Download The Approach To Examination of an Ankle and Foot Injury

The Approach to Examination of an Ankle and Foot Injury
I.
History
A. Was it a twisting injury?
B. Was it a fall? If so, how high was the patient off of the ground when s/he fell?
C. Are there any associated injuries such as knee, hip, back, upper extremity, neck or head
injuries?
II.
Physical Examination
A. Inspection
1. Swelling- Where is it?
2. Deformity- Are any parts of the foot or ankle in an abnormal position in relation to the
other parts?
3. Color - Is it abnormal?
a. Is there erythema? (Erythema is abnormal redness of the skin resulting from
dilation of blood vessels, as in inflammation, infection, or sunburn.)
b. Is there cellulitis? (Cellulitis is erythema that is due to bacterial infection.)
4. Open vs. Closed Injury- Is the injury open or closed? Is there a laceration extending
to the injured tendon or bone?
5. Evaluation of active motion
a. Tendon function- Do manual tests to see if the following tendons are
functioning normally.
i. Achilles tendon  Palpate the Achilles tendon.
 Perform the Thompson test- This test shows whether the Achilles
tendon is intact. It is performed with the patient lying prone with the
foot over the edge of the table or bed. The large muscle belly in the midcalf region (gastrocsoleus mass) is squeezed gently while the examiner’s
other hand is placed on the plantar aspect of the foot. If the foot strongly
plantar flexes when the examiner is squeezing the muscle mass, one can
rule out an Achilles laceration or rupture (a complete tear of the tendon).
The response of plantar flexion following the squeeze of the calf shows
that the Achilles tendon is intact.
ii. Tibialis posterior – This tendon actively and forcibly inverts the foot. The
posterior tibial tendon starts in the calf, stretches down behind the medial
malleolus, and then attaches to bones on the underside of the foot.
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Check for swelling of the tendon sheath- This indicates injury or
inflammation.
Check for tenderness of the tendon – This also indicates pathology.
Too Many Toes Sign- This sign shows whether the tendon is
ruptured. The patient stands facing away from the physician;
observation is from the back. With this condition, the front of the foot
starts to slide to the outside (valgus position). From behind, it looks
like there are “too many toes” showing, as compared with the opposite
side.
Check for the inability of the heel to invert actively when the
patient stands on his toes on the side of the injured tendon. Normally,
a single heel raise results in inversion of the heel. With a rupture of
the tibialis posterior, the heel does not invert.
iii. Peroneus longus and brevis -The peroneus longus and brevis tendons are
located behind the lateral malleolus at the ankle. The peroneus brevis extends
behind the lateral malleolus and then distally into the foot to insert on the base
of the fifth metatarsal (small toe). The peroneus longus extends behind the
lateral malleolus and then extends beneath the mid foot, across the mid foot,
to insert on the base of the first metatarsal (great toe).
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Palpate the peroneus brevis tendon- Active eversion of the foot
makes the tendon visible for palpation.
 Check to see if the peroneus longus is intact- Active contraction of
the peroneus longus tendon plantar flexes the first metatarsal (the great
toe). The examining physician tests its function by asking the patient
to “step on the gas.” The physician puts his finger beneath the MP
(metatarsal phalangeal) joint of the great toe and asks the patient to
step on the gas. If the tendon is intact, the physician can feel the
metatarsal head compressing his/her finger forcibly. (Use caution so
no injury occurs to the examining finger.)
Note: There are additional tendons, including the Tibialis anterior, Extensor
digitorum and flexor digitorum, Extensor and flexor hallucis, that are not
relevant here.
4. Evaluation of patient’s ability to walk- The patient is asked to walk if s/he is able to,
depending on how much pain is present. The type of gait is then evaluated if the patient
is able to walk.
a. Observe whether the patient is able to walk and bear weight. The inability
to bear weight indicates a more severe injury.
b. Observe the patient’s gait while walking. Does the patient have a limp? The
patient may be able to walk, but he/ she may have an abnormal gait. There are
many types of abnormal gait (limps). Check to see if the patient has any of the
following abnormal gaits:
i. Antalgic gait – With this gait, the patient spends very little time on the foot
and gets off of the foot within a fraction of an instant after stepping on it. In a
normal gait, there is “push-off” during gait--the patient moves weightbearing
from the heel to the toes and forefoot. If there is no active plantar flexion, the
patient walks in a peg-legged fashion without progressing from heel to toe.
Gait with lack of push-off indicates potential injury to the Achilles tendon or
triceps surae muscle.
ii. Trendelenburg gait- This gait is caused by the presence of a weak hip
abductor muscle (gluteus medius). The absence of gluteus medius causes an
inability to abduct actively the hip on that side. The patient in this situation
leans over the foot and shifts his body weight over onto the foot, to
compensate for the lack of action of the gluteus medius muscle.
iii. Gluteus maximus gait- This gait is caused by a weak gluteus maximus
muscle. The gluteus maximus extends the hip and is the muscle that propels
you as you walk up stairs, when you bear weight on that foot. If the gluteus
maximus is weak, the patient will extend the trunk while bearing weight on
that side. If the patient lies on his belly, a hip with an intact gluteus maximus
muscle can actively raise the leg backwards off of the surface with good
strength. One can palpate the active contraction in the gluteus maximus
muscle at that time.
c. Evaluate the strength of the muscles. Strength of muscles is evaluated as
follows:
Grade 0 Strength:
Grade I Strength:
No active contraction is palpable in the muscle.
The muscle can be palpated to contract, but the joint is not
moved by the muscles because of severe weakness.
Grade II Strength: The muscle can move the joint fully with gravity
eliminated.
Grade III Strength: The muscle can move the joint fully against gravity.
Grade IV Strength: The muscle can move the joint against gravity and against
an additional amount of weight.
Grade V Strength: The muscle can move the joint fully against gravity and a
normal weight.
(http://www.hawaii.edu/medicine/pediatrics/pemxray/v3c03.html)
B. Palpation
1. Tenderness – Where is it located? How severe is it?
a. Palpate the sites of common injuries to the ligaments and tendons.
Palpation is carried out over:
i. the anterior talofibular ligament (ATF ligament, or ATFL), both on
the talus and the fibula
ii. the calcaneofibular ligament (CF ligament, or CFL) both on the
calcaneus and the fibula
iii. the distal anterior tibiofibular ligament which connects the tibia
and fibula, just above the ankle joint.
b. Palpate over any suspected fracture site. Note any significant
tenderness. A usual place to palpate is the base of the fifth metatarsal
(metatarsal of the small toe). You can also palpate at the insertion of any
tendon; for example, if you suspect an injury to the tibialis posterior
tendon, you should palpate the insertion of the tendon on the navicular
tuberosity as well as palpating the adjacent bones.
2. Fluctuation -Is there an accumulation of fluid in a closed space?
3. Pulses- Can you feel the presence of a pulse? Some important blood vessels with
pulses in the ankle and foot are the dorsalis pedis over the dorsum of the foot and the
posterior tibialis behind the medial malleolus.
4. Temperature to touch- Warmth or coolness of the injured area as a sign of
inflammation or impaired circulation respectively.
C. Function -Evaluation of active and passive joint motion by evaluating the function of the joint
motors. It should be noted that many of the tests are overlapping. For example, active ankle
motion depends on the joint itself as well as the anatomical structures involved in moving the
joint (e.g., muscles and tendons).
1. Active motion – The following motions are carried out by the patient while the range of
motion is measured and the strength evaluated. The intactness and strength of the various
tendons which move the foot and toes can also be evaluated.
a. Ankle dorsiflexion and ankle plantarflexion (Normal range of motion would allow
the patient to raise or lower the toes 40 degrees.)
b. Foot inversion and eversion (Normal range of motion is 40 degrees inversion, 5-10
degrees maximum eversion.)
Forefoot and toe flexibility might be part of a comprehensive exam, but they won’t be
addressed in this document.
2. Passive motion- The following motions are carried out by the physician, who moves the
foot with his/her hands. The patient does not work at moving the foot.
a. Foot inversion and eversion
b. Forefoot abduction and adduction
c. Toe flexion and extension
3. Stability- When a ligament is ruptured (Grade III injury), abnormal increased motion of
a joint occurs; the joint becomes unstable.
a. Upon manual testing, the joint will either move in a normal direction but with
increased range, or in an abnormal motion because of loss of resistance of the ligament.
b. Stress tests for instability- There are tests for instability of the ankle where an x-ray is
used to measure the amount of abnormal motion present between the tibia and the talus.
The ankle is forced into different positions and x-rays are taken with the ankle in those
positions.