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Examination of the Ankle and Foot Flashcards

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1
Q

Define a dor no pé/tornozelo.

A

Foot pain is an unpleasant sensory and emotional experience following perceived damage to any tissue distal to the tibia or fibula; including bones, joints, ligaments, muscles, tendons, apophyses, retinacula, fascia, bursae, nerves, skin, nails and vascular structures.

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2
Q

Quais as funções do tornozelo e pé?

A
  • Mobility
  • Allows shock absorption
  • Allows loose adaptation during stance
  • Acts as directional torque transmitter during stance
  • Stability
  • Acts as a rigid lever during push-off
  • Dynamic support of the foot, evenly distribute weight.
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3
Q

Quais os 5 mecanismos envolvidos na função do tornozelo/pé?

A
  1. The lower leg
  2. Talocrural mechanism
  3. Subtalar joint
  4. Midtarsal complex
  5. Metatarsophalangeal mechanism.
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4
Q

A articulação tibiofibular superior pertence ao joelho ou ao tornozelo?

A
  • Anatomically belongs to the knee but functionally belongs to the ankle/foot
  • Oval synovial joint
  • Joint moves in response to movement in the talocrural joint and limitations here can create end-range limitations and possible pain in the anterior ankle with weightbearing.
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5
Q

Qual a função da membrana interóssea da perna?

A
  • Spans between tibia and fibula
  • Functions as a divider of the lower leg compartments with only 2 openings for the passage of nerves and vessels
  • Transfers up to 30% of weightbearing load from tibia to fibula
  • Mortise is stabilized at end-range dorsiflexion.
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6
Q

Quais as propriedades da articulação talocrural?

A
  • Consists of the talar dome resting within the rigid roof of the mortise or distal tibiofemoral joint
  • Allows tibia to move over the foot
  • Primary constraint is the architecture followed by ligamentous stability
  • Provides 30 degrees of DF and 50 PF passively.
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7
Q

Explica o mecanismo da articulação subtalar.

A
  • Primarily adds stability but also for shock absorption
  • Talus functions as a torque converter between the internally rotating tibia and the everting calcaneus
  • Anterior and posterior STJ covered by fibrous capsule and synovial membrane
  • Triplanar joint
  • Predominant source of inversion/eversion and abduction/adduction in the entire ankle/foot region.
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8
Q

Resume o Midtarsal Complex.

A
  • 3 joint compartments – Calcaneocuboid joint, Talonavicular joint, Cubonaviculocuneiform joint.
  • Functionally the 3 compartments are seen as a single ball and socket joint
  • Accounts for 25% of dorsiflexion of the ankle/foot complex
  • 45% of total plantarflexion
  • MTJ is locked with inversion, mobile with eversion.
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9
Q

Além das estruturas musculotendinosas e articulares, que outras estruturas compõem o calcanhar?

A
  • Plantar surface of the heel is covered by skin and a subcutaneous fat pad
  • Fat pad consists of a meshwork of fibroelastic septae whereby imposed loads are distributed over the entire region of contact
  • The septal chambers consist of a significant blood and nerve supply
  • Thickness of the pad is paramount to compressive load tolerance and reduced fat pad height is consistent with increased incidence of heel pain
  • Shock absorbing capacity of the fat pad decreases with age.
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10
Q

O que é a fáscia plantar?

A
  • Dense fibrous connective tissue originating from the calcaneal tuberosity
  • Tissue fans and thins out attaching to the plantar fibrous digital sheaths of thelateral four toes and the sesamoids of the great toe
  • Serves as a functional windlass in the foot complex helping support the foot’s longitudinal arch contributing as much as 25% to the stiffness of the foot and carrying as much as 14% of the total load imposed on the foot during weightbearing.
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11
Q

Lateral ankle sprains account for up to what percentage of all injuries in sports?

A

Lateral ankle sprains account for up to 38-45% of all injuries in sports.

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12
Q

Which structure is responsible for transferring up to 30% of weightbearing load from the tibia to fibula?

A

The interosseous membrane transfers up to 30% of weightbearing load from tibia to fibular.

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13
Q

The subtalar joint is primarily responsible for which movements of the ankle/foot?

A

The subtalar mechanism is the predominant source of inversion/eversion and abduction/adduction in the entire ankle/foot region.

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14
Q

Which of the following structures serves as the main eccentric stabilizer of the subtalar complex during pronation in weightbearing?

A

The tibialis posterior serves as the main eccentric stabilizer of the subtalar complex during pronation in weightbearing.

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15
Q

Como podemos avaliar a irritabilidade dos sintomas?

A

Aggravating and relieving factors:
– What activities make your symptoms worse? (Running, shoes, hopping, walking);
– What is the pain level during these activities?
– Does it worsen immediately or over time?
– After stopping the activity, how long before your pain level returns to normal?

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16
Q

How can we get the history of the present illness?

A
  • When and how did this start? – Mechanism of injury may assist in determining presence of a fracture
  • How long have you been suffering from these symptoms?
  • Do you have a previous history of these symptoms?
  • Have you undergone any imaging?
  • Course of symptoms – Are you better, worse, or the same?
  • Have you undergone any previous treatment? – Was it effective?
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17
Q

O que é importante perceber a nível social?

A

• Are you currently working? – What are your occupational demands?
• Look for yellow (Factors that may affect treatment plan), blue (Features of work generally associated with
increased rate of symptoms), and black flags (Established policy concerning work conditions)!
• What is your current living situation? – Do you have stairs in your home, rugs?
• Do you have family support? – How much help does this patient have in the home?

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18
Q

Que questões especiais poderão ajudar a identificar um problema de origem não mecânica?

A
  • Do you notice any feelings of numbness or pins and needles bilaterally?
  • Have you suffered any recent weight loss?
  • Do you ever feel as though you are stumbling while walking?
  • Have you suffered any recent bowel/bladder changes?
  • Do you suffer from any pins/needle like feelings in the inner groin area?
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19
Q

Qual o outcome measure mais apropriado para avaliar as disfunções funcionais em casos com instabilidade do tornozelo?

A

The FOOT AND ANKLE DISABILITY INDEX (FADI) can be considered as the most appropriate, patient assessed tool to quantify functional disabilities in patients with chronic ankle instability.

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20
Q

Nomeia alguns instrumentos com evidência para o seu uso relativo.

A
  • Sports Ankle Rating System QOL measure;
  • FAAM;
  • FFI;
  • FHSQ;
  • LEFS.
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21
Q

Refere algumas das fraquezas da utilização de medidas de resultados de auto-preenchimento.

A
  • Do not always differentiate between whether or why a specific task is not done or can’t be done
  • Do not accurately characterize or quantify the impact of the health condition nor a change in that impact
  • Errors in memory or judgment, impaired cognition, willingness and ability to answer accurately
  • Poor correlation between self-report and PPM
  • Appear to be highly reflective of changes in pain (and what the patient is experiencing) and less reflective of changes in function.
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22
Q

Porquê administrar self-reported e physical performance measures para ajudar a compreender a condição clínica?

A
  • Because assessment of function is multidimensional, indexes of functional disability have been considered misleading without considering the patients’ values and preferences, thus reflecting the important role of self-report measures
  • The patient’s subjective evaluation serves to represent patient perception, an essential aspect to consider when determining functional change
  • Self-report used in isolation may overestimate patients’ functional status due to the high correlations with pain.
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23
Q

Exemplifica uma questão que nos permita avaliar a taxa de recuperação do paciente na altura da alta de fisioterapia.

A

• “Taking into account all the activities you have during your daily life, your level of pain, and your functional impairment, do you consider that your current state is
satisfactory?”
• Basically, this helps to identify whether the patient is good versus are they better
• Better does not always equal satisfied

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24
Q

Jeff Grant is a 20 year old male who presented to physical therapy with complaint of left ankle pain and requesting crutches. The patient was an intercollegiate football player who had sustained a combination forced-dorsiflexion and external rotation injury to his left ankle, getting tackled while returning a punt during a game on the previous Saturday evening. He stated that he heard an audible “pop” but was able to limp off the field and did not return to the game. He was treated with ice and elevation that evening and the next day he iced his ankle several times and was able to walk to the dining facility several times. Given what we know about Mr. Grant’s history, which could be considered as potential outcome measures to distribute?

A

Both the foot and ankle ability measure and the foot and ankle disability index would be good options as they are both validated, reliable, and have sport specific subscales which would be important in this patient.

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25
Which of the following statements is FALSE with regards to self-report measures? • There is a poor correlation between self-report and physical performance measures of function • There is a strong correlation between self-report measures of function and performance measures of function • Self report measures of function appear to be highly reflective of changes in pain and less reflective of changes in function
There is a strong correlation between self-report measures of function and performance measures of function - Several studies have shown low correlations between self-report measures of function and performance measures given self-report tends to be highly dependent upon pain and patient perceived ability.
26
The minimal clinically important difference (MCID) is the same as the minimal detectable change?
False. The minimal clinically important difference is determined by the patient whereas the minimal detectable change is based upon statistics and sample distribution.
27
The MCID is dependent upon which factors?
The MCID is not a fixed attribute and will vary based upon the patient’s age, acuity of symptoms, disease specific state, and other.
28
Quais os três critérios a avaliar durante a observação do pé e tornozelo?
1. Inspection of the foot and ankle during standing 2. Gait evaluation 3. Skin and Nail Inspection.
29
Define algumas informações chave que devemos ter em consideração na inspeção da posição do pé e tornozelo.
* Abnormal alignment of the forefoot and hindfoot that is associated with a concordant pain during stance may require specific intervention such as orthotics or stabilization * Fallen longitudinal arch increases pronation during static stance; also known as “too many toes” * A greater risk for stress fractures in the tibia, fibula, and foot has been associated with high longitudinal arch and excessive forefoot varus in runners. * Elevated first ray, hypermobile first ray and long second metatarsal have been linked with the development of first metatarsophalangeal joint OA, hallux valgus, and midfoot OA, respectively.
30
Quais os valores de referência para o ângulo do arco longitudinal do pé? Como podemos medir?
* High arch = or sup 150 degrees * Medium arch = 130-150 * Low arch =or inf 130 degrees. Pode ser medido com um goniómetro. A tuberosidade navicular é o eixo; e o maléolo medial e a cabeça do primeiro metatarso são os braços do goniómetro.
31
Para que serve o naviculum drop test? E quais os valores representativos de um teste positivo?
• Naviculum drop test for hyperpronation – Normal drop test less than 3-5mm – Positive test sup 10mm
32
What do we assess during gait?
* Footwear Assessment * Forward/backward walking * Walk on toes/heels * Look for stride length * Stance phase – Shortened? * Foot rotation – Externally rotated? * Often, a gait evaluation will identify a concordant abnormality in the ankle/foot complex.
33
What should we look in footwear assessment?
* Length/width * Heel cup? * Arch support? * Torsional/Toebreak flexibility * Patterns of wear
34
O que devemos verificar na inspeção da pele e unhas?
* Trophic changes may be indicative of peripheral vascular disease * Pigmentation may be associated with venous insufficiency * Significant callus formation may be a consequence of abnormal gait or increased pressure during WB * Toenail disorders may be a result of psoriasis, poor blood flow, and/or infection * Edema.
35
Que tipo de movimentos dinâmicos podemos solicitar? E o que devemos procurar?
* Deep Squat – Point of pain or weight shift; Heel rising from floor earlier than opposite side leads to suspicion of TCJ hypomobility. * Unilateral squat * Single leg hop – Pain reproduction * Ascend/Descend Stairs – Which foot do they lead with; Pain reproduction.
36
How to perform o navicular drop test?
The patient stands and places the patient in subtalar neutral. Subtalar neutral is found by palpation of the patient’s tali in which both the medial and lateral aspects are felt equally by the examiner. The most prominent aspect of the navicular bone is palpated and marked with a pen. The examiner marks the height of the “neutral” position on a 3x5 note card. The patient is then instructed to stand normally. A repeat measure of the navicular height is again measured. A difference of greater than 10mm is considered a positive finding.
37
Upon physical examination, a patient was antalgic gait with his left lower extremity externally rotated. Left leg stance time and stride length was decreased approximately 50%. The left ankle demonstrated moderate edema laterally and medially, and ecchymosis present laterally. When testing the longitudinal arch angle, the arch height was recorded at 145 degrees. This would place the patient in which category?
Medium arch height (between 130 and 150 degrees).
38
The “too many toes” signs refer to what?
A fallen longitudinal arch or increased pronation.
39
What type of questions could be done to screen any patient?
* Medical history * Surgical history * Weight loss * Medications * Other tests (radiographs, blood work, etc) * Stress
40
Quais as red flags específicas para o tornozelo e pé?
* Foot and Ankle Fractures * Stress fracture * Morton’s Neuroma * DVT (deep vain trombosis) * Peripheral Neuropathy * Lumbar radiculopathy * Lumbar myelopathy.
41
Quais os critérios das Ottawa ankle rules para presença de fratura no tornozelo?
History of trauma or fall. A series of ankle x ray films is required only if there is any pain in malleolar zone and any of these findings: • Bone tenderness at posterior edge or tip of lateral malleolus - 6 cm • Bone tenderness at medial edge or tip of lateral malleolus - 6 cm • Inability to bear weight both immediately and in emergency dept. (Sn 100 ; Sp 62)
42
Quais os critérios das Ottawa ankle rules para presença de fratura no pé?
History of trauma or fall. A series of x ray films is required only if there is any pain in mid-foot zone and any of these findings: • Bone tenderness at base of fifth metatarsal • Bone tenderness at navicular • Inability to bear weight both immediately and in emergency department. (Sn 100 ; Sp 62)
43
Explain the tuning fork test for stress fracture.
The patient lies supine. The examiner places a stethoscope on the fibular head and the tuning fork on the lateral malleolus. A positive test is a change in “tone” (sound) during the assessment. (Sn 83; Sp 80)
44
Quais os testes para o neuroma de Morton? Descreve-os.
* Foot Squeeze Test (Sn 88 ; Sp NT). The patient assumes a supine or sitting position. The examiner applies a squeeze to the metatarsal heads from lateral to medial toward midline. A positive test is reproduction of patient symptoms. * Web Space Tenderness (Sn 95 ; Sp NT). The patient assumes a supine position. The examiner applies a force between the 2nd and 3rd metatarsals using the end of his or her thumb. A positive test is reproduction of patient symptoms.
45
Describe Well’s Criteria for Deep Vein Thrombosis.
``` Major Criteria • Active cancer within last 6 months • Paralysis • Recently bedridden • Localized tenderness • Thigh and calf are swollen • Strong family history of DVT. ``` ``` Minor Criteria • History of recent trauma • Pitting edema • Dilated superficial veins • Hospitalized within last 6 months • Erythema. ``` A positive test is sup 3 of the major criteria and sup 2 of the minor criteria.
46
Que teste pode ajudar a descartar neuropatia periférica? Descreve-o.
Position sense of the Great Toe (Sn 88,2 ; Sp 68,8). The patient is positioned in a seated position. The examiner stabilizes the MTP joint and with the opposite hand grasping the distal phalanx laterally, begins to move the distal phalanx up and down. With eyes closed, the patient verbally reports in which position the toe is being moved. Inability to correctly identify movement may suggest abnormal position sense and possible spinal cord lesions of the dorsolateral portion of the spinal cord.
47
How can we rule out lumbar spine?
* Rule out referred pain (Lumbar flexion; extension; lateral flexion; extension quadrant; flexion quadrant). * Perform with overpressure to clear.
48
Que teste podemos fazer para detetar possível envolvimento de mielopatia ou radiculopatia lombar?
Achilles Deep Tendon Reflex (Sn 12 ; Sp 89) – Hyperreflexia indicative of myelopathy; hyporeflexia indicative of radiculopathy. (testar o reflexo pelo menos três vezes, para verificar se é mantido ao longo do tempo).
49
Qual o teste para Lumbar Radiculopathy (L4/5)?
Ankle Dorsiflexion (Sn 60 ; Sp 89). (Pedir para andar alguns metros apenas com os calcanhares).
50
Existe algum teste que ajude a detetar o envolvimento de Lumbar Radiculopathy (L4) – L4-5 Disc Herniation?
Sensation and dermatome testing (Sn 59; Sp 87,5). (Verificar se eles sentem o toque; comparando com o lado contralateral, a sensação é a mesma?; ou se o paciente sente uma sensação diminuída).
51
Que sinal podemos procurar em caso de suspeita de mielopatia?
Clonus (Sn 11; Sp 96).
52
The Ottawa ankle rules are best used to rule IN a fracture of the foot/ankle. True or False?
False. The Ottawa ankle rules are highly sensitive and better utilized as a screen for ruling OUT a fracture with a sensitivity of 100 and specificity of 62.
53
When performing the achilles deep tendon reflex, a hyperreflexive response is indicative of a lumbar radiculopathy. True or False?
False. Hyperreflexia is indicative of lumbar myelopathy whereas hyporeflexia is indicative of lumbar radiculopathy.
54
The web space compression tenderness test is best utilized as a screen for which of the following conditions? Lumbar radiculopathy; Lumbar myelopathy; Deep Vein Thrombosis; Morton’s Neuroma.
Morton’s Neuroma. The web space compression test has a sensitivity of 95 making it a useful test for ruling out a morton’s neuroma when the test is negative for pain.
55
Para que servem os testes funcionais?
* Functional tests are designed to provide a glimpse of pain provocation with various activities * Also, these tests serve as a “reassessment sign” to determine response to treatment.
56
Quais os testes funcionais mais utilizados para avaliar o pé e tornozelo? O que procurar aquando da realização destes movimentos?
* Gait assessment * Unilateral Step-Up/Down * Single leg hop * Bilateral squat * Unilateral squat. Look for heel lift, foot rotation, leaning away from painful side.
57
How to apply passive physiological plantarflexion (whole foot, midfoot, forefoot)?
The patient is placed in a prone position with the knee flexed. Resting pain is assessed. The examiner places the posterior hand on the postero-plantar calcaneus and the anterior hand on the dorsal forefoot. The foot and ankle are then passively plantarflexed to the first point of concordant pain (if present). Repeated movements or sustained holds are applied to determine if the symptoms increase or decrease. Differentiation of whole foot and midfoot can be made with hand placement changes. The clinician stabilizes the hindfoot and passively applies a plantarflexion force on the midfoot. The same is true for the forefoot by stabilizing the midfoot and forcing the forefoot into plantarflexion. A comparison of the patient’s reaction to pain with the various positions implicates which anatomical region is the likely source of the pain.
58
Describe the application of passive physiological dorsiflexion (whole foot, midfoot, forefoot).
The patient is placed in a prone position with the knee flexed. Resting pain is assessed. The examiner places the posterior hand on the postero-dorsal calcaneus (over the calcaneal tendon) and the other hand on the palmar surface of the foot. The foot and ankle are then passively dorsiflexed to the first point of concordant pain (if present). Repeated movements or sustained holds are applied to determine if the symptoms increase or decrease. Differentiation of whole foot and midfoot can be made by stabilizing the hindfoot and promoting dorsiflexion of the midfoot. Differentiation of the forefoot from the midfoot is made by stabilizing the midfoot and applying a dorsiflexion force to the forefoot.
59
Quais as amplitudes fisiológicas de flexão plantar e dorsal do tornozelo, inversão, eversão; e flexão dorsal e plantar do primeiro metatarso?
* Normal plantarflexion 50 degrees * Normal dorsiflexion 20 degrees * Normal whole foot inversion 35 degrees * Normal whole foot eversion 15 degrees * Normal first MTP flexion 30 degrees * Normal first MTP extension 70 degrees.
60
List the movements we should apply when testing ankle and foot.
* Passive physiological plantarflexion (whole foot, midfoot, forefoot). * Passive physiological dorsiflexion (whole foot, midfoot, forefoot). * Passive physiological inversion (whole foot, midfoot). * Passive physiological eversion (whole foot, midfoot). * Passive physiological first MTP flexion and extension * Anterior to posterior; posterior to anterior; caudal and cephalic passive accessory glide of the inferior tibiofibular joint. * Anterior to posterior glide; posterior to anterior; medial and lateral; and longitudinal distraction of the talocrural joint. * Posterior to anterior glide; anterior to posterior; medial and lateral rotation; medial and lateral glide of the subtalar joint. * Horizontal flexion and extension of the forefoot. * Anterior to posterior glide; adduction and abduction; medial and lateral rotation; compression and distraction of the MTPs joints.
61
Que tipo de problemas identificam os movimentos acessórios passivos?
Passive accessories are movements that cannot be accomplished by the patient alone and help to isolate intra-articular pathology.
62
What are the main structures we should palpate in the anterior aspect of ankle and foot, searching for pain tenderness?
* Syndesmosis * AITFL (anterior inferior tibio filularis ligament) * TC joint space * Head of talus * Sinus Tarsi * Dorsalis Pedis pulse * Superficial peroneal nerve * Extensor digitorum longus * Extensor hallucis longus.
63
What structures should we palpate in the posterior region of ankle and foot?
* Achilles tendon * FHL (flexor hálux longus) deep to Achilles * Fat pad * Calcaneal tuberosity * Plantar Fascia on medial tubercle.
64
Quais as estruturas que devem ser palpadas a nível lateral no pé e tornozelo?
* Styloid process 5th metatarsal * Peroneal tubercle of the calcaneus * Lateral malleolus * ATFL (anterior tibio fibular ligament) * CFL (calcaneo fibular ligament) * Peroneal tendons * Peroneal retinacula * Extensor retinaculum * Cuboid.
65
A nível medial, quais as estruturas do pé e tornozelo que devemos palpar em busca de reprodução da dor?
* Head of Talus * Navicular Tubercle * Medial Malleolus * Posterior Tibial Artery * Posterior Tibial Tendon * Flexor retinaculum * First metatarsal head * Deltoid ligament
66
How we perform the ankle dorsiflexion strength test?
The patient is positioned supine. The examiner passively moves the ankle into maximal dorsiflexion and the patient is asked to hold against resistance for 3-5 seconds.
67
Where is the palpation site for the deltoid ligament?
The deltoid ligament is on the medial aspect of the ankle.
68
Should the tibialis posterior tendon be injured, in which directions would you expect to find pain with resistance?
The tibialis posterior performs plantarflexion and inversion, so we should find pain when it contracts in that direction.
69
Que tipo de testes diagnóstico (SN vs. SP) é mais útil no início vs. fim do exame clínico?
* In the beginning of the exam as a screen – SNnOUT | * At the end of an exam as the “icing on the cake” – SPpIN.
70
Quais as características ideais de um teste especial?
* No fatal flaws in design * LR+ of 5.0 or higher * LR- of 0.2 or lower * Sensitivity of .90 or higher * QUADAS of 10 or higher * A test that matters.
71
Qual o teste e suas características psicométricas mais indicado para averiguar um entorse com envolvimento do ligamento tibiofibular anterior? Descreve-o.
Anterior Drawer Test – Lateral ankle sprain affecting the ATFL. The patient lies in a supine position. The ankle is prepositioned into slight plantarflexion. The examiner applies an anterior glide of the calcaneus and talus on the stabilized tibia. A positive test is excessive translation of one side in comparison to the opposite extremity (SN 78; SP 75; LR+ 3,1 ; LR- 0,29).
72
Qual o outro teste, além do teste de inversão passiva, que ajuda a diagnosticar entorse da tibiotársica?
Medial Subtalar Glide Test – Lateral Ankle Sprain. The patient lies in a supine position. The examiner stabilizes the talus superiorly while gripping the calcaneus at the plantar aspect of the foot. The examiner applies a medial glide of the calcaneus on the fixed talus. Excessive laxity in affected side in comparison with contralateral side is a positive sign (SN 78; SP 75; LR+ 3,1 ; LR- 0,29).
73
Quais as características (SN, etc.) do medial talar tilt stress test para diagnosticar entorse da tibiotársica?
Medial talar tilt stress test – Inversion ankle sprain. The patient is positioned in supine or sitting. The examiner grasps the ankle of the patient at the malleoli. The examiner applies a quick medial thrust to the calcaneus. A positive test is excessive laxity when compared to the opposite side (SN 67; SP 75; LR+ 2,7 ; LR- 0,44).
74
Quais as propriedades do teste de eversão para testar entorse medial da tibiotársica?
The test wasn't studied in the literature, but it still sometimes useful. The patient is positioned in supine or sitting. The examiner grasps the ankle of the patient at the malleoli. The examiner applies a quick lateral thrust to the calcaneus. A positive test is excessive laxity when compared to the opposite side.
75
Como testar high ankle sprain?
Fibular Translation Test – High Ankle Sprain. The patient lies in sidelying. The examiner applies anterior and posterior forces on the fibula at the level of the syndesmosis. Positive test if displacement to the fibula than the compared side or reproduction of symptoms (SN 86; SP 88; LR+ 6,8 ; LR- 0,2).
76
Além da fibular translation test, refere outro teste que ajuda a descartar high ankle sprain.
Squeeze Test – High Ankle Sprain. The patient lies supine or sidelying. The examiner applies a manual squeeze, pushing the fibula into the tibia, applying a force at the midpoint of the calf. A test is considered positive if the proximal force causes distal pain near the syndesmosis (SN 100; SP 63; LR+ 2,68). (Com a compressão na articulação superior, ocorre um afastamento na articulação inferior).
77
Identifica um teste que possa ajudar a diagnosticar uma lesão do tendão de aquiles?
Thompson Test. The patient lies in a supine position. The examiner applies a squeeze to the calf of the patient’s affected leg. Failure to see a plantar flexion when the test is applied is considered positive (SN 40; SP NT; LR+ NA).
78
Refere um teste que permita averiguar anterior ankle impingement.
Forced Dorsiflexion Test. The patient assumes a seated position. The examiner stabilizes the distal aspect of the tibia and places his or her thumb on the anterolateral aspect of the talus near the lateral gutter. Pressure is applied. The examiner applies a forceful dorsiflexion movement. A positive test is reproduction of pain at the anterolateral aspect of the foot during forced dorsiflexion (SN 95; SP 88; LR+ 7,9 ; LR- 0,06).
79
Qual o teste para o sindrome do túnel társico?
Tinel’s Sign. The patient begins in sidelying. The examiner applies a tapping force to the posteromedial aspect of the ankle. A positive finding is reproduction of tingling during the test (SN 58; SP NT; LR+ NA). Teste de fraco valor, mas muito utilizado clinicamente.
80
Apresenta os testes utilizados para identificar uma fratura por stress ou neuroma interdigital.
* Web Space Tenderness (SN 95; SP NT; LR+ NA). * Morton’s Test (SN 85; SP NT; LR+ NA). * Tuning Fork (SN 83; SP 80; LR+ 4,2 ; LR- 0,21).
81
What are the criteria of Well's clinical prediction rule to deep vein thrombosis (DVT)?
``` Major Criteria - Must present with > 3 of the following: – Active cancer within last 6 months – Paralysis – Recently bedridden (acamado) – Localized tenderness – Thigh and calf are swollen – Strong family history of DVT. ``` ``` Minor Criteria - Must present with > 2 of the following: – History of recent trauma – Pitting edema – Dilated superficial veins – Hospitalized within last 6 months – Erythema. ```
82
What are the specific tests to deep vein thrombosis?
* Calf Swelling - Positive test is a difference of 15mm for men and 12mm for women side to side (SN 90; SP 92; LR+ 11,3 ; LR- 0,11). * Calf Tenderness (SN 82; SP 72; LR+ 2,9 ; LR- 0,25).
83
What are the psychometric characteristics of Ottawa Ankle Rules for foot and ankle fractures?
(SN 100; SP 62; LR+ 2,59).
84
Describe the Web Space Tenderness test and the Morton’s Test.
* The patient assumes a supine or seated position. The examiner applies a force between the 2nd and 3rd metatarsals using the end of his or her thumb. A positive test is reproduction of patient symptoms * The patient assumes a supine or seated position. The examiner applies a squeeze to the metatarsal heads from lateral to medial toward mid-line. A positive test is reproduction of patient symptoms.
85
You have suspicions that a patient may have a high ankle sprain. Which of the tests is the best test to diagnose a high ankle sprain?
The fibular translation test demonstrates both high sensitivity and high specificity with a +LR of 6.8. The squeeze test can be used for diagnosing a high ankle sprain although it is probably better used as a screening tool with a sensitivity of 100 and a specificity of only 63 giving it a +LR of 2.68 as compared to the fibular translation test with a +LR of 5.8.
86
In terms of calf swelling for diagnosis of DVT, what is considered a positive test for women?
A positive test is a difference of 12mm for women side to side to suggest DVT.
87
Which of the following statements is false with regards to highly sensitive tests? • A highly sensitive test is best utilized as a screen at the beginning of the exam because it can help rule OUT specific diagnoses • A highly sensitive test best helps rule IN a specific diagnosis • A highly sensitive test will have few false negatives • A highly sensitive test may have a high number of false positives.
A highly sensitive test best helps rule IN a specific diagnosis. This is false because a highly sensitive test most commonly is less specific therefore you may find a number of false positive tests.
88
``` In all cases with our patients, we would focus on tests that have high value in clinical practice. Which of the following is NOT included in the guidelines for best special tests? • LR+ of 2 or higher • LR- of 0.2 or lower • QUADAS of 10 or higher • A test that matters ```
LR+ of 2 or higher. This is not included in the guidelines, the best special tests are those with LR+ values of 5 or higher.
89
Refer some performance measures we can use in examination of foot and anke.
* T-Test * Star Excursion Balance Test * Y Balance Test * Hop Tests.
90
What is the value of T-test? Explain how the test is done.
* Reliability – ICC = .76-.98 * Validity – Worse scores with chronic ankle instability * Responsiveness – Scores improve after treatment. Participants are asked to sprint forward to the center of the arm for a distance of 10 yards, then facing forward he/she sidesteps to one end of the horizontal arm without crossing feet and continues to the other end. To finish, they sidestep back to the center of the horizontal arm and run backward down the longitudinal limb to the starting position. The activity is timed.
91
Describe the Y Balance Test.
* Reliability – Intra .85-.91 ; Inter 0.991 * Validity – Worse scores with chronic ankle instability * Responsiveness – Scores improve after treatment. The test is performed with the patient standing on one leg at the center of the “star”. While maintaining single leg stance, the patient reaches with the free limb in 3 different direction (anterior, posteromedial, and posterolateral) in relation to the stance foot.
92
What is the reliability of the hop tests? Refer their names.
* Reliability – ICC = .76-.92 * Validity – Valid in Functional Ankle Instability Single hop for distance; 6m timed hop; triple hop for distance; crossover hop for distance.
93
How to perform the triple hop test?
The patient is asked to perform the test bilaterally. The first is run as a practice trial and the 2nd as the formal test for distance. The patient is asked to jump 3 consecutive jumps for distance while not touching the opposite lower extremity down and the landing must be maintained for a total of 2 seconds. The total distance for 3 consecutive hops is recorded and compared to the opposite side. Distances should be within 90% of each other.
94
How to do 6m timed hop and crossover for distance tests?
* The patient is asked to jump a distance of 6 meters and the activity is timed. * The patient is asked to hop forward 3 times while alternately crossing over a marking. The total distance hopped forward is recorded.
95
Which of the following is most accurate with respect to physical performance tests? • It allows one to test what one can do, not what they think they can do • Physical performance tests are designed to only test endurance • Physical performance tests are only designed to test physical ability.
It allows one to test what one can do, not what they think they can do. This statement is correct. Often, there is variation between what one states they can do and what they can. A physical performance test directly evaluates what one can do.
96
What are the most common pathologies of the foot and ankle?
* Tendinopathies * Ankle Sprains * Foot/Ankle fracture * Impingement * Exercise-related lower leg pain * Plantar Fasciitis * Turf toe * Hallux Rigidus.
97
Refer the most comon tendinopathies of foot and ankle.
* Achilles Tendinopathy * Posterior Tibialis Dysfunction * Flexor Hallucis Longus * Peroneal Tendon.
98
List some of the features present in achilles tendinopathy.
* Mean age 30-50 years * Athletic – Running, Jumping * Local tenderness of the Achilles 2-6cm proximal to its insertion * Tendon thickening * Decreased PF strength * Decreased PF endurance * Pain and stiffness after inactivity, lessens with activity and returns after activity * Pain with eccentric DF (walking down stairs).
99
Quais os pontos chave que ajudam a diagnosticar tendinopatia do aquiliano?
* Symptoms located to the midportion of the Achilles tendon * Intermittent pain related to exercises or activity * Stiffness upon weight bearing after prolonged immobility such as sleeping * Stiffness and pain at the commencement of an exercise training session that lessens as exercise continues * Achilles tendon tenderness.
100
Refer other differential diagnosis in achilles tendinopathy.
* Acute Achilles tendon rupture * Partial tear of Achilles * Retrocalcaneal bursitis * Posterior ankle impingement * Os trigonum syndrome * Calcaneal stress fracture * Posterior talar fracture * Sural nerve * Lumbar radiculopathy.
101
What is the clinical presentation to posterior tibialis dysfunction?
* Pain and swelling posterior to the medial malleolus * Female sup male * Age sup 40 * Pain worse with weightbearing and with inversion and plantarflexion against resistance * “Too many toes” sign * Pain with single-leg toe raise * Lacks normal heel varus when rising up on toes * Ache after walking long distances.
102
What two characteristics help to diagnose posterior tibialis dysfunction?
Medial pain or swelling behind the medial malleoli AND change in foot shape (SN 100).
103
Que outras condições se podem apresentar de forma semelhante a tendinopatia do tibial posterior em diagnóstico diferencial?
* Deltoid ligament sprain * Flexor digitorum longus sprain * Flexor hallucis longus injury * Navicular stress fracture * Tarsal Tunnel Syndrome.
104
A football player who had sustained a combination forced-dorsiflexion and external rotation injury to his left ankle, getting tackled while returning a punt during a game. Given the mechanism of Mr. Grant’s injury, what pathologies are on your hypothesis list?
Forced dorsiflexion with external rotation is the mechanism of injury most commonly associated with both high ankle sprains and deltoid ligament sprains.
105
Patients with chronic ankle instability typically present with greater inversion during toe- off while jogging when compared to controls. True or false?
True. Research has shown that individuals with chronic ankle sprains present with more inversion during toe-off and through the gait cycle when compared to controls.
106
Chronic ankle instability can lead to translation of the ankle mortise in which direction?
Posteriorly. Chronic lateral ankle instability with lack of an ATFL allows the mortise to translate posteriorly when the ankle/foot is in weightbearing resulting in anterior impingement of the anterior inferior tibiofibular ligament.
107
Which of the following clinical findings helps differentiate a stress fracture from medial tibial stress syndrome (shin splints)? • The patient presents with anterolateral cramping and burning in the leg • Pain increases with warm-up • The patient presents with deep, nagging, focal point pain • Normal pulse
The patient presents with deep, nagging, focal point pain. Stress fractures typically presents with focal point pain with pain present even at rest versus shin splints present with diffuse medial pain of at least 5cm.
108
What is the cluster of signs and symptoms suggested for the diagnoses of cuboid syndrome secondary to lateral ankle sprains?
Subjective findings: • Mechanism of injury (plantar flexion/inversion) • Pain location (lateral midfoot/ankle) Objective findings: • Pain on palpation of the cuboid • Positive midtarsal mobility testing (symptom reproduction) • Positive dorsal/plantar and/or plantar/dorsal mobility testing (pain) • Antalgic gait (most prominent during push-off phase) • Manual muscle tests – resisted inversion/eversion (pain and possible weakness) • Functional testing (heel/toe raises or single leg hop testing) Differential diagnoses • Radiological/Imaging studies to rule out other pathologies.

Examination (11 decks)

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