Musculoskeletal Physiotherapy Assessment & Treatment Get Active Educational Video Presentation 3. The Ankle & Foot 02/08/2006 Subjective Assessment Current History Establish the kind of disorder involved

Determine Areas involved & Subjective Symptoms

Pain or discomfort / Stiffness Acute Injury Determine body area

Giving Way & Instability Recurrent Instability

Inversion Injuries Recurrent lateral instability Length of history - Acute, recurrent or chronic, Frequency

Clicking & Impingement Area / Pain Painful or non painful click

Weakness Unable to hop / run Left vs right

Loss of function How rapidly or gradual it developed

Swelling / Effusion / Tenderness Area involved Extent and Time frame

Parathesiae / Anaesthesiae Constant / Intermittent Area

Body chart Record all symptoms Asterisk and number

Related Sites of pain or symptoms Knee, Lumbar Spine, Muscle Trigger point referral Mechanism of injury Type / Symptoms Indications / Implications

Sudden ? Immediate

Acute injury Sprain of joint Strain of soft tissue Sudeck’s Atrophy

Gradual or insidious Time frame – how long into run?

Inflammatory Degenerative biomechanical Wear / tear

Onset of pain / symptoms

Patient demonstration Rolling Ankle

Visual demonstration more concisive Inversion injury

Trauma Multiple forces Impact / Falls

Multiple areas of damage Soft tissue types / Fractures Osteochondral fractures / Heel

Ripping feeling / sound Muscle tear Minor ligament tear

Popping sound +/- intense sharp pain Ligament rupture Tendon rupture Audible

Crepitus or creaking Swelling in joint Tendon Sheath swelling

Exercise or Training Determine type of training Intensity, frequency

Running / Squash / Tennis or Swimming / cycling / X-Trainer Social or competitive? Hills or flat?

Change in direction / Rotary Complex ligament sprains External Forces

Inversion / contact involved LCFL / ATFL Avulsion Injury

(c) PhysioProfessor.com

Eversion / contact involved Avulsion fractures

Overuse or Abuse

Marathon training Excessive cardiovascular impact Overtraining Sustained postures

Old or incorrect footwear Business shoes vs running shoes Orthotics, Biomechanics Age and level of patient Standing or sitting long periods

Misuse Incorrect exercises Poor technique

Technique observation Local and global strength

Disuse Training after long period of inactivity Poor strength or coordination Glut and VMO bulk and strength

New Use

New to exercise / too long exercise Too strenuously Beyond capacities of structures Poor strength or coordination

Glut and VMO bulk and strength Biomechanics Gym program Use of personal trainer

Symptom behaviour Type / Symptoms Indications / Implications

Dull aching / Throbbing Inflammation / Bleed Pain referral Tarsal Tunnel syndrome

Sharp / Burning Tearing/ pulling or pressure on sensitive or injured structures

Constant Intermittent

Inflammation or continual pressure on injured / sensitive structures Mechanical / Activity dependant Referred pain – Lumbar / Tibial

Pain or symptom type

Stiffness Swelling / Muscle spasm / Tissue contractures

Severity / Irritability Onset / time to ease Changes during day Becoming better / Worse / ISQ

Immediate Slow Determine activity at time of onset

Aggravating factors Activities involved Effect of weigthbearing Effect of Exercise Determine forces involved

Easing Factors Activities involved Effect of rest / night’s sleep Ice Medications

24 hours Am / Day / Pm Determine possible factors Relationship of work postures AM: Plantar Fascitis

Night Inflammatory Osteoarthritis Medications taken / needed

Previous History Type Type / Questions Indications / Implications

Previous episodes Amount Area similarity Severity

Related areas Effect of multiple episodes Integrity of structures

Previous injuries Type Level (e.g. tear I, II or III) Diagnosed?

Previous # / Ligament Injuries Related areas (eg. Tibial #) Level of rehabilitation achieved Hypomobility of the Subtalar joint Synovitis of subtalar joint

Surgery Trauma Fractures

Current Previous Surgeon name

Ankle Reconstructions - lateral Related areas – Knee / Foot Talar dome fractures Chondral surface damage Dislcocation = Post TFL Tear + ATFL/CFL Stage of recovery

(c) PhysioProfessor.com

Previous treatment Type Dates For current or previous episodes

Effect of rehabilitation Level of rehabilitation

Social History Type Type / Questions Indications / Implications

Occupational Standing / Sitting Stairs / Lifting / Driving Amount of day?

Possible causes of symptoms Loading Time available for rehab

Sports Type Intensity / Frequency / Duration Competitive / Level or Social

Return to sport need Training through injury Level of rehabilitation needed Acute / chronic ant tibial synd. Mid foot loading / Stress Fractures

Exercise Gym based Outdoor based Intensity / Frequency / Duration

Training through injury Level of rehabilitation needed

Youth Sports played Intensity / Frequency / Duration Competitive / Level or Social

Coordination level Abuse or degenerative loading Tissue conditioning

Medical History Medical Type Implications / Questions asked

Medications NSAID’s Painkillers (Analgesics) Muscle relaxants

How long? Dosage? For this condition?

Investigations

X-Ray MRI Ultrasound Bone scan

Result? Photocopy radiographer’s report Mark NAD

Weight loss / gain Recent illness Red flags (Cancer) Diabetes Weight

Current weight Underweight / overweight / obesity Effect on ankle and foot loading / muscle control

Biomechanics

Pronation Rear foot Varus Pes Planus / Cavus Shoe type / Age of Shoe Already have orthotics? Acute / chronic ant tibial synd. / Tibailis Anterior Tendonitis

Predisposing Factors

Genetic / Familial Hereditary arthritic conditions Gout

Recent / chronic illness Virus Slow Healer

Effect on healing rate Infections Malignancy

Pregnancy Weight gain Relaxin component Will impact on treatment options General Health

Diabetes Tuberculosis Asthma Blood conditions Epliepsy

Degeneration of structures Will impact on treatment options

Doctor Surgeon

Name Recent check up? Diagnosis / Surgery notes

Referral script - photocopy Contact – letter & communication Medication prescription

(c) PhysioProfessor.com

Physical Assessment Observation Area / Signs / Structure Determine / Action Indications / Implications

Gait Anterior / Posterior Swing / Stand phase

Dynamic pronation Heel strike Limping / ability to weight-bear Compensation

Deformities Posture Biomechanics

Expose body part Note abnormal movements Standing vs Dynamic (1 foot) Fractures

Genu-varum / Genu-valgus - knee Q angle Static pronation / Dynamic Arch height Pes planus / cavus Toes / Clawing / Hammer / Hallux Valgus / Bunion

Swelling / Effusion Expose body parts Extent and location Localised or generalized

Location will determine structures involved / injured / stress loaded Achilles thickening/Haglin’s deformity Achilles tendonitis / osis / rupture Calcaneal bursae Chronic thickening, Focal degeneration, Bursitis Sinus Tarsi

Muscle bulk / wasting

Relative to opposite side Hypertrophy Atrophy As result of injury

Previous or current injury Glut / VMO Calf / L vs R

Bruising Global / Localised Extent / Colouration Tracking

New or old Tearing of structures / degree of injury

Quick Tests Type Determine / Structure Indications / Implications

Functional movements Calf Raise / Single Leg Injuring movement

Movement rhythm Forces involved

Squat

Full or partial Technique Hip Intenal rotation Foot pronation Ankle DF

Effect of load Knee movement vs Hip movement Core stability / Hip dissociation Weak VMO / gluteals / biomechanics Previous injuries / Biomechanics

Single leg Balance / Hop

Trendelenberg /Compare sides Knee movement vs Hip movement Hip internal rotation Foot pronation Balance / Clawing of toes

Pain / Coordination level Weak gluteals / VMO Weightbearing / control side Left / Right footed Tarsal tunnel Interosseous ligament

Pelvis Ax SIJ Posterior Rotation? Level of PSIS Effect on Hip stabilizers and gait

Palpation Type / Structure Determine / Structure Indications / Implications

Fluid Localised / Tenderness Global

Ligament sprain Tenosynovitis

Tissue thickening Chronic Synovial Thickening Old injuries / Scarring Surgery

Previous injuries Not artoscopic and suture lines Tendon Sheaths – posterior malleoli & anterior Extensor Retinaculum Recurrence rate

(c) PhysioProfessor.com

Length of chronic swelling / inflammation Extent / changes / time frame

Heat / Warmth Direct comparison opposite leg Inflammation Infections Malignancy

Swellings Confirm prescence from Observation Differentiate from synovitis

Effusion Sinus Tarsi Joint Sprains Ligament Sprains Gastrocnemius tears / Calf Cysts Rheumatoid Arthritis

Tenderness

Local or global Fractures – point tenderness Joint lines Tendons Ligaments Bursae Specific to particular structure

Malleoli Fractures Lateral Calcaneofibular ligament tear / Avulsion Post Talofibular ligament tear Tibilais posterior / anterior tendonitis Peroneus Longus/ / brevis tendonitis Extensor / Peroneus Tertius Tendons Biomechanical stress loading Acute / Chronic post comp synd. Heel Spurs / Fat Pad irritation / Bruised Heel Plantar Fascitis Flexor muscle strains

Crepitus Creaking or crunching Painful snaping or clicking

Synovitis Elderly: Osteoarthritic instability

Muscle Spasm / Tightness Calf Peroneals

Acute Ligament ruptures Acute Tendon injuries Protective

Muscle Trigger Points Tib Posterior Peroneals / Tib Anterior

Pain referral Stress Sydnromes

Sensation Swelling Dermatones

Compression of nerves Lateral compartment – Peroneal nerv Lumbar spine

Active ROM Movement Type / Activity Indications / Implications

Ànkle Motion

Dorsi-Flexion Plantar flexion Walk on toes / Walk on heels

Hypermobility Stiffness / Loss of movement Neural motor loss ATFL Tear

Circumduction Circling of foot Pain / Loss of movement / Spasm

Subtalar Motion Inversion / Eversion

Stiffness / Spasm Laxity / Excessive ROM Calcaneofibular ligament tear Deltoid ligament tear - Rare

Midtarsal motion Forefoot adduction Forefoot abduction

Toe motion Flexion Extension

Passive ROM / Flexibility Movement Indications / Implications

Ankle Dorsiflexion

Supine ROM Pain during movement / EOR pain Effect of Overpressure Normal: 20 deg

Pain inf tib fib joint anterior: High Ankle Sprain (tibiofibular ligament) Anterior block / Pain anterior T/C: Bony impingement – exotoses / Capuslar impingement

(c) PhysioProfessor.com

Anterior Talofibular ligament tears, Recurrent anterior instability Posterior pain / sharp / tightness: Posterior capsulitis Contracture of joint capsule

Ankle Plantarflexion

Supine ROM Pain during movement / EOR pain Effect of Overpressure Normal: 50 deg

Posterior pain: Bony impingement – exotoses / Capuslar impingment Anterior Pain / loss of ROM Anterior Ankle joint sprain / ATFL Joint Stiffness / swelling Contracture of joint capsule

Subtalar Inversion Overpressure / ROM Left compared to right Normal 20 deg

Hypermobility / Instability ATFL and CFL tears Capuslar / Ligament restriction

Subtalar Eversion Overpressure / ROM Left compared to right Normal 10 deg

Hypermobility - pronation

Midtarsal Forefoot add / abduction Tarsometatarsal F/E

Overpressure / ROM Left compared to right Mid Tarsal: Normal 5 deg

Cuboid syndrome / sprain Joint sprains / Intertarsal Ligaments Anterior metatarsalgia Peroneus brevis tendinitis Inversion + Adduction = “Pronation” Eversion + Abduction = “Supination”

1st MTP Flexion / Extension Flexion 45 deg Extension 70-90 deg

Hallux Rigidis Mortons syndrome – short 1st ray Normal toe off requires 35-40 deg

Intertarsal & IP / DIP motion Flexion Extension

Interossei strains Fractures Extensor tendon ruptures Mortons Neuroma – 3rd / 4th MT heads Dropping of Metatarsal Heads Anterior metatarsalgia

Calf and Peroneal tightness / spasm Severity Muscle tear / protection Accessory ROM Inferior Tibiofibular Joint Notes Indications / Implications Anteroposterior (AP) Posteroanterior (PA) Rotation

Test with and without compression Prone and supine

Gr. I-IV Note range, pain, resistance, spasm and behaviour

Ankle Joint Notes Indications / Implications Anteroposterior (AP) Posteroanterior (PA) Rotation Medial and Lateral Longitudinal Movement Caudad Longitudinal Movement Cephalad

Test with and without compression Prone and supine

Gr. I-IV Note range, pain, resistance, spasm and behaviour

Subtalar Joint Notes Indications / Implications Medial Glide (MG) Lateral Glide (LG) Anteroposterior (AP) Posteroanterior (PA)

Also: Add / Abd / MR / LR / LCa / LCe

Gr. I-IV Note range, pain, resistance, spasm and behaviour

Mid Foot Notes Indications / Implications

Transverse Tarsal joint Talonavicular joint Calcaneocuboid joint

AP / PA / MG / LG / Sup / Pro / LCa / LCe / Add / Abd

Cuneifrom navicular joint

Gr. I-IV Note range, pain, resistance, spasm and behaviour

(c) PhysioProfessor.com

Tarsometatarsal Joint Forefoot Notes Indications / Implications

AP / PA / HF / HE Intermetatarsal Joints Phalangeal Joints

Gr. I-IV Note range, pain, resistance, spasm and behaviour

Special Tests Test Notes Indications / Implications

Ankle Dorsiflexion Decrease in DF angle 15cm to wall

Ankle stiffness / loss of ROM in DF Previous sprains / #

Calf Squeeze Prone – look for foot PF Achilles complete rupture

Anterior Draw ATFL tear Look for clunk

Subtalar (calaneus) Inversion Rocking in mortise = ATFL + CFL tear instability

Post TFL Tear Gross trauma - dislocation

Ankle Joint Instability

Eversion Deltoid tear

Rigid or supple flat feet Observe sitting and standing Sitting – flat = rigid Sitting – arch = supple

Tibial Torsion Children – toeing in Locate fixed bony points Normal 15 deg external

Internal tibial torsion – malleolar line faces anteriorly

Video Analysis

Foot strike Stance phase

Heels / Toe Knee extension Pronation Valgus Trendelenberg Early heel lift Length of stride

Neurological Examination Muscle Testing Notes Indications / Implications

Tibialis Anterior Deep Peroneal Nerve L4 (L5) Dorsiflexors Extensor Hallicus Longus

Extensor Digitorum Longus Deep Peroneal Nerve L5

Peroneus Longus and Brevis Supeficial Peroneal Nerve S1 Gastrocnemuis and Soleus Tibial Nerve S1,2

Plantar Flexors Flexor Hallicus Longus Flexor Digitorum longus Tibialis posterior

Tibial Nerve L5

Knee joint & Medial side of leg L4 Lateral side of leg, dorsum of foot L5 Sensation Testing Lateral side of foot S1

Reflex Testing Achilles Tendon S1

(c) PhysioProfessor.com

Treatment Techniques Local Treatment Objective Area Technique

Decrease Inflammation & Swelling

Ultrasound Deep Tissue Massage / Effleurage Compression bandage NSAID’s / Gel Elevation / RICE

Decrease Pain & Sensitisation STM Acupuncture Ice / Heat

Decrease Muscle spasm STM Acupucnture Stretching

Manual Techniques Objective Area Technique

Ankle joint AP Talus F/E Gr I-IV PA F/E Gr I-IV Caudal Glide / Gr V Manip

Sub Talar Joint MG / LG / AP / PA Inferior Tibiofular joint AP/ PA +/- DF / PF Cuboid MG / AP / Gr V Manip

Increase Joint ROM

Mid Tarsal / Intertarsal / / Forefoot Mobs as per accessory section above Soft Tissue release

Tendons Ligaments Retinaculum

DTF STM

Muscle Flexibility and release Calf, Peroneals, Tibalis Muscles

DTM Stretching Muscle Energy Technique Trigger point Release, Acupucnture

Tendon Loading Peroneals / Tibalis Posterior Achilles

Theraband Inversion / Eversion Calf Raises - Eccentric

Neural Mobilisation Common Peroneal Tibial

SLR in knee extension Inversion / Dorsiflexion

Ligament / Joint Stabilisation ATFL / CFL

Taping Muscle Re-education Wobble Board / Balance Theraband Inv / Eve

Biomechanical correction Subtalar Joint Arch / MT / Foot

Low dye Taping Orthotics Shoes

Exercise Rehabilitation Objective Muscle Group Exercises (CAPITALS ON SHEETS) Early Mobilisation Muscle Activation & Control Increase muscle strength & balance Post-Operative Protocols See separate protocol Reconstruction Rehab Protocol See separate protocol Treatment Progression Exercise Rehabilitation Sheets Training Diaries Sports Specific / Return to Sport Reassessment

(c) PhysioProfessor.com