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Download B t t kl B t t kl Bony structures : ankle B t t f t B t t f t Bony structures
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ANKLE AND FOOT FOOT = THE TERMINAL ORGAN OF THE LEG FUNCTION = WEIGHT BEARING Ankle examination and common problems Tanawat Vaseenon,MD Orthopaedic surgeon CMU Courtesy from KORKU CHIENGTHONG M.D. B Bony structures t t : ankle kl B Bony structures t t : foot f t Lisfranc joint Talocrural joint j plantarflexion midfoot dorsiflexion Chopart’s joint forefoot eversion inversion S bt l joint Subtalar j i t Joint = the place of union between 2 or more bone hindfoot Li Ligamentous t structures t t L t l ankle Lateral kl ligaments li t Ligament = the band of tissue that connects bones anterior t i talofibular t l fib l ligament li t Resist inversion ,internal rotation of talus and anterior displacement calcaneofibular l fib l ligament li t Resist inversion and anterior displacement M di l ankle Medial kl ligaments li t M di l ankle Medial kl ligaments li t D lt id ligament Deltoid li t S d Syndesmotic ti ligaments li t interosseous ligament A t i tibiofibular Anterior tibi fib l liligamentt Resist eversion ,external rotation of talus and anterior displacement P t i tibiofibular Posterior tibi fib l liligamentt Transverse ligament Resist external rotation Anterior dynamic stability Medial dynamic stability Flexor retinaculum Tibialis anterior dorsiflexion of the ankle Extensor digitolum longus Tibialis posterior Flexor hallicis longus invert the midfoot lock the transverse Tarsal joint Flexed big toe Extend toes E t Extensor hallicis h lli i llongus Extend big toe Flexor digitolum g longus g Extensor retinaculum Flexed toes Posterior dynamic stability Lateral dynamic stability Gastrosoleus muscle ……….. Plantar flexion ……….. peroneal tendons active eversion and assist with plantar flexion Hi t History foot position i inspection ti g g, y degree and location of swelling,ecchymosis continue bear weight Sound ‘‘pops’’ onset swelling, swelling locking, locking catching, catching or giving way? What improves the pain? What makes it worsen? palpation l ti B Bony palpation l ti bony y structures Proximal head of the fibula ligamentous structures Fibula Lateral malleolus Medial malleolus Proximal fifth metatarsal Li Ligamentous t palpation l ti R Range off motion ti ROM DEGREE PRIMARY MUSCLES TESTED Anterior talofibular ligament g Dorsiflexion 20 Tibialis anterior Calcaneofibular ligament Plantar flexion (knee bent) 50 Soleus Posterior talofibular ligament Plantar flexion (knee straight) 50 Gastrocnemius Anterior tibiofibular ligament Eversion 20 Peroneal tendons D lt id li Deltoid ligamentt Inversion 20 Tibialis posterior special i l tests t t Anterior A t i d drawer test t t > 5 mm compared with opposite side SPECIAL TEST Knee bent Anterior drawer test Anterior talofibular ligament g Talar tilt test Calcaneofibular ligament Squeeze test Syndesmotic ligaments Plantar flexion Thompson test Achilles tendon degree of laxity compared with the uninjured side Positive = complete tear of the anterior talofibular ligament T l tilt test Talar t t Squeeze S test t t > 5 degree compared with opposite side Neutral or slightly dorsiflexion degree of lateral talar laxity (opening up) is assessed and d compared d with the noninjured side stability of the calcaneofibular ligament Thompson Th test t t negative positive Squeeze calf muscle Knee bent 90 degree integrity of the Achilles tendon assesses integrity of the syndesmosis (anterior tibiofibular ligament and the interosseus ligament and membrane) Vascular examination I Innervation ti Ott Ottawa rules l I Innervation ti nerve sensation Tibial muscle root action plantar Gastrosoleus Medial p heel TP FDL FHL S1-S2 L5-S1 L5-S1 L5-S2 L5 S2 Plantar flexion Foot adduction&inversion Lateral toe flexion Great toe flexion Sup. Pero. Dorsum L4-S1 Foot eversion Deep pero. 1st L4-S1 L4-S1 L4-S1 Foot inversion&dorsiflexion Toe extension&foot dorsiflexion Great toe extension Peroneus web space TA EDL EHL Radiographic examination Foot : AP,oblique and lateral Ankle : AP,mortise and lateral Foot AP oblique and lateral Ankle AP mortise and lateral Hallux valgus C Common ffoot and d ankle kl problems bl lateral deviation of the great toe Hallux valgus Plantar fasciitis Pain with the first few steps in the morning Point of tenderness Surgery in patients who have increasing pain arising from the medial eminence of the widened forefoot Shoe inserts and stretching exercises, other treatments Plantar fasciitis Haglund syndrome Excessively prominent superior calcaneal processes Pump bump Sh iinserts Shoe t and d stretching t t hi exercises, i other th ttreatments t t Haglund syndrome Change of footwear Change in patient’s patient s activity Prescription of NSAIDs Achillis tendon rupture Risk factors • Quinolone antibiotics (ciprofloxacin) • systemic corticostcroid use • mechanical abnormalities of the foot • Gout • SLE S Achillis tendon rupture Ankle sprain Conservative (casting) • No risk of surgery • Higher rate of rerupture Surgery g y • Lower rate of rerupture • Risk of surgery rolling over of the ankle with an inversion A kl sprain Ankle i Grading G di grade ligament I swelling tenderness stability bearing ATFL stretch minimal mild stable comfort II ATFL torn CFL intact moderate moderate stable difficult III ATFL torn CFL torn severe diffuse unstable difficult Treatment T t t grade ligament initial few week rehabilitation I ATFL stretch RICE g Bandage 1 week II ATFL torn CFL intact RICE Active ROM Normal Proprioceptive training return to Stretching peroneus function III ATFL torn CFL torn RICE Brace 3 weeks Key y is bandaging g g 6-8 weeks Thank you Tanawat Vaseenon,MD Orthopaedic surgeon CMU hospital
