Extremities -- Ankle & Foot

What are 2 DDx for a Bunion?

Hallux Rigidus

Fusion of MT-P joint

What would you visualize with a Bunion? (2)

Lateral (valgus) deviation of toe

Callus formation at MT-P joint

What is the static pain point of a bunion?

MT-P joint

What is the decreased ROM for Bunion?

All may be decreased

What is the decreased fluid motion for Bunion?

All may be decreased (MT-P & I-P jts)

What are 2 DDx for Calcaneus L?

Inversion sprain

ATFL tear

Calcaneofibular ligament tear

Facture of distal fibula or neck of fibula

What is visualized with Calcaneus L?

Swelling over lateral aspect of jt

WHat is the static pain point for Calcaneus L?

Lateral jt space

What is the Decreased ROM for Calcaneus L?

Decreased eversion

What is the orthopedic done for Calcaneus L?

Lateral Stability Test

What is the decreased fluid motion for Calcaneus L?

Medial Stability Test (loss of motion)

What are 2 DDx of Calcaneus M?

Spine subluxation

Eversion Sprain

Deltoid ligament tear

What is visualized with Calcaneus M?

Swelling over medial aspect of jt space

What is the static pain point of Calcaneus M?

Medial jt space

What is the decreased ROM for Calcaneus M?

Decreased inversion

What is the orthopedic test for Calcaneus M?

Medial stability test

What is the decreased fluid motion for Calcaneus M?

Lateral stability test (loss of motion)

What are 2 DDx of Cuboid AL?

Calcaneus L

T-MT A (4th/5th)

Pulled calf muscle

Fractured 5th metatarsal

Inversion sprain

What is the visualization for Cuboid AL?

Pillow like shaped edema over cuboid

What is the static pain point for Cuboid AL?

Over cuboid & Deep in calf

What is the ROM decreased with Cuboid AL?

Possibly eversion

What is the Orthopedic for Cuboid AL?

Lateral stability test

What is the decreased fluid motion for Cuboid AL?

A-P

What are 2 DDx for Cuneiform P?

Plantar fasciitis

T-MT A

Pes Planus

Fallen Arch

Flexible Foot

Navicular AM

What do you visualize with Cuneiform P?

Fallen Arch

What is the static pain point for Cuneiform P?

Over post cuneiform (plantar surface)

What is the orthopedic for Cuneiform P?

Strunskey's

What is the decreased fluid motion for Cuneiform P?

P-A

What are 2 DDx of I-P Jt?

Stubbed toe

Claw toe

Hammer toe

Mallet toe

Hallux Rigidus

DJD

Fracture

What is the static pain point for I-P Jt?

I-P jt

What is the decreased ROM for I-P Jt?

Plantar flexion

What is the orthopedic test for I-P Jt?

Strunskey's may cause pain at joint

What is the decreased fluid motion for I-P Jt?

Some or all

What are 2 DDx for MT-P P?

T-MT A

Hammer Toe

DJD

Dislocation

Bunion

Bunionette

What is the visualization for MT-P P?

Heavy Callus under joint

What is the static pain point for MT-P P?

MT-P jt

What is the decreased ROM for MT-P P?

Plantar flexion

What is the orthopedics for MT-P P? (2)

Strunskey's

Morton's

What is the decreased fluid motion for MT-P P?

P-A

What are 2 DDx of Navicular AM?

Talus A

Deltoid ligament tear

Cuneiform P

What is the static pain point for Navicular AM?

Over navicular

What is the decreased fluid motion for Navicular AM?

Decreased rotation (pronation)

What are 2 DDx for Talus A?

ATFL tear

Fracture distal tibia

Navicular AM

Fibula L

Calf muscle tightness

What is the pain point for Talus A?

Anterior talus

What is the decreased ROM for Talus A?

Dorsiflexion

What are the orthopedics for Talus A? (2)

Draw sign (ankle)

Lateral stability test

What is the decreased fluid motion for Talus A?

A-P

What are 2 DDx for T-MT A?

MT-P P

Metatarsal fracture

Metatarsalgia

Cuboid AL

Cuneiform P

What is the static pain point for T-MT A?

Anterior T-MT joint and possibly along shaft of MT

What are the orthopedics for T-MT A? (2)

Strunskey's

Morton's

What is the decreased fluid motion for T-MT A?

A-P

What is a positive Draw Sign (Drawer Test at ankle)?

Excessive P-A motion at ankle

What does a positive Draw sign at ankle indicate?

Instability of Anterior Talofibular ligament

How would you verify an anterior talofibular ligament tear?

Utilize Lateral Stability Test

What is a positive Lateral Stability Test?

Excess motion at lateral aspect of ankle upon inversion

What does a positive Lateral Stability test MOST OFTEN indicate? (3)

Ligament tears form front to back

1) anterior talofibular ligament sprain / tear / instability

2) calcaneofibular ligament sprain / tear / instability

3) posteiror talofibular ligament sprain / tear / instability

What ROM does the Dr stress the pt ankle in for the Lateral Stability Test?

Inversion

How would you verify an anterior talofibular ligament tear?

Draw sign of ankle

What is a positive Medial stability test?

Excessive motion at medial aspect of ankle upon Eversion

What does Medial Stability test positive indicate?

Instability / tear of Deltoid ligament

What ROM does the Dr stress the Pt ankle in for Medial Stability Test?

Eversion

T/F: During Lateral or Medial Stability test, if there is pian in the ligaments then they are still attached, if there is no increase in pain then there is a complete tear

TRUE

How do you perform Talus A fluid motion?

One hand underneath distal end of tibia for stabilization & other hand on anterior aspect of talus

-- Press A-P no talus to feel for loss of motion

NOTE: the hand used should correspond to the foot being palpated

How do you perform fluid motion of Calcaneus L?

Medial stability test, loss of motion upon EVERSION

How do you perform fluid motion of Calcaneus M?

Lateral Stability test, loss of motion upon INVERSION

How do you perform fluid motion of Navicular AM?

Stand on lateral side of foot and reach across to medial aspect, grasping navicular

Stabilize segments around navicular (talus and cuneiforms) and attempt to rotate navicular in relationship to those segments

NOTE: opposite of Cuboid

How do you perform fluid motion of Cuboid AL?

Stand on medial side of foot & reach across to lateral aspect of cuboid

Stabilize segments around cuboid (calcaneus & 4th/5th metatarsals) and attempt to rotate cuboid in relationship to those segments

NOTE: Opposite of Navicular

How do you name the Cuneiforms?

Listing them 1st, 2nd, and 3rd according to metatarsals they articulate with

How do you perform fluid motion of Cuneiforms?

Stabilize surrounding bone (metatarsals & navicular) one at a time

Shear them P-A and A-P past each other

T/F: If a Cuneiform is subluxated it will have a loss of motion A-P

FALSE

Loss of motion P-A

Which ankle adjustments MUST have 3rd party stabilization? (3)

Talus A

Navicular AM

Cuboid AL

Which ankle adjustments MAY have 3rd party stabilization? (2)

Talus traction

Cuneiform posterior

The following indicates what adjustment is needed?

- Hx of inversion ankle sprain

- Pain / tenderness across anterior aspect of ankle

- Edema at anteiror ankle

- Loss of dorsiflexion ROM

- Loss of A-P fluid motion

Talus Traction

(follow up w/ Talus A if txn unsuccessful)

How do you know when to perform Talus Traction or Talus A?

Only if there is failure of talus traction to improve fluid motion

--> do talus traction first!

The following indicates what adjustment is needed?

- Hx of inversion ankle sprain

- Tenderness below lateral malleolus

- Loss of eversion ROM

- Restricted fluid motion for medial stability test

- Edema below lateral malleolus

Calcaneus L

What is the CP for Calcaneus L?

Thenar of hand opposite side of involvement

What does the SH do to the ankle for Calcaneus L?

Dorsiflex & Evert

The Calcaneus L has restricted fluid motion during which orthopedic?

Medial Stability Test

The following indicates what adjustment is needed?

- Hx eversion ankle sprain

- Tenderness below medial malleolus

- Loss of inversion ROM

- Restricted fluid motion on lateral stability test

- Edema below medial malleolus

Calcaneus M

What is the CP for Calcaneus M?

Thenar of hand corresponding to side of involvement

What does the SH do to the ankle for Calcaneus M?

Dorsiflex & Invert

The Calcaneus M will have restricted fluid motion during which orthopedic test?

Lateral stability test

The following indicates what adjustment is needed?

- Hx kicking injury

- Pain / tenderness over navicular tuberosity

- Edema & loss of fluid motion over this bone

Navicular AM

What is the LOD of the thrust for the Navicular AM?

A-P & M-L

The following indicates what adjustment is needed?

- Loss of fluid motion

- Point tenderness over this bone & deep in the calf (2 pain points!)

- Dull ache referred deep in posterior calf musculature

Cuboid AL

Where should the thumbs be for Cuboid AL?

One under 4th & 5th metatarsals and one under cuneiforms & navicular

What is the CH for the Cuboid AL?

CH hand opposite side of involvement

The following indicates what adjustment is needed?

- Visualize Fallen Arch

- Pain & swelling on plantar surface of the foot (plantar fascitis0

- Loss of fluid motion P-A

Cuneiform P

Where should the stabilization fingers be for the Cuneiform P?

On dorsum of foot

-- over proximal end of metatarsals, navicular, & cuboid

How do you perform part 1 of Morton's Test?

Palpate between metatarsal heads and shaft

What is a positive Morton's Part 1 test and what doest this indicate?

+ = palpable mass / cyst (gummy worm)

Indication = Morton's neuroma

How do you perform part 2 of Morton's Test?

Compress medial & lateral sides of the metatarsal heads together

What is a positive Part 2 Morton's Test and what does it indicate?

+ = Pain between metatarsal heads

Indicates Morton's neuroma

Where is Morton's Neuroma most commonly found?

Between 3rd & 4th metatarsal heads

(however can be located between any of them)

What would you want to differentiate Morton's Neuroma from? (3)

Stress fracture

Subluxation (MT-P)

Plantar fasciitis

What orthopedic test is rapid plantar flexion of the metatarsal phalange joints?

Strunsky's Test

What is a positive Strunksy's test and what does this indicate?

+ = pain in metatarsal arch

Indicates metatarsalgia

How do you perform fluid motion of T-MT A?

One hand holds under distal Tibia for stabilization

Other hand (corresponding to foot palpated) on anterior aspect of talus

Press A-P

How do you perform MT-P P fluid motion?

One hand stabilizes metatarsals while other hand grasps phalange

Move phalange through all motions and rotation

How do you perform I-P fluid motion?

One hand stabilizes proximal phalange while other hand grasps distal phalange

Move phalange through all motions and rotation