00:01
Osteopathic evaluation of the foot and ankle.
00:05
So when evaluating the foot and ankle, we
want to start with look-feel moves.
00:08
So starting with observation, we're gonna
look at the feet, check for any swelling.
00:13
Sometimes, the joints could be swollen.
00:15
In case of gout, sometimes you might see
redness of the skin or you might see swelling.
00:20
Someone sprained their ankle, there might be
visible deformities, swelling in the regions.
00:25
So start with observations,
observe the feet.
00:28
Look for any deviations, any callouses
that might be present in the feet.
00:34
After observation, we're gonna
perform some palpation.
00:38
So you want to palpate the ankle and check
the lateral malleoli, the medial malleoli
Check the tendons that run behind it.
The talus, the calcaneus posteriorly
You want to check the lateral foot and
check the different bones and landmarks.
00:56
You have your metatarsals here and you
have your distal metatarsal here.
01:00
You have your styloid process,
so the 5th metatarsal.
01:03
You could check your tarsal
bones and check the toes here
for any sort of pain,
tenderness or any area.
01:13
Most of the foot is ligaments, so the ligaments
provide structural stability to the foot.
01:20
You also want to check the foot
when they're weight bearing
to check for any sort of flat
feet that might be possible.
01:26
Patients may have inflammation and
complaints of pain at the heel.
01:31
You want to see if you could palpate a possible
tenderness or heel spur in the region.
01:36
Or plantar fasciitis, the inflammation of
that plantar surface of the foot.
01:40
So, palpation could sometimes elicit
tenderness or you could feel swelling
or increased warmth in different
regions of the foot and ankle.
01:49
So motion testing the ankle and foot.
01:52
When we motion test the
ankle, what we're looking for
is the amount of motion available
in the different planes.
02:00
So for the ankle joint in the saggital
plane, we could have flexion and extension.
02:07
But it it's not called that at the ankle joint,
what we have is dorsiflexion and plantar flexion.
02:14
So this is the dorsal surface of the foot, so this
is considered dorsiflexion and plantarflexion.
02:19
So you wanna check the amount of range
of motion in both of those motions.
02:24
In the ankle, you also have inversion
and eversion in the coronal plane.
02:29
So inversion,
I'm turning the heel medially,
This is relatively increased because the ligaments
on the lateral aspect is a little bit more lax.
02:43
Whereas the deltoid ligament on the medial
aspect of the ankle is really strong.
02:48
So as I try to evert, you are more limited
so you have more inversion that eversion
You also have the lateral malleoli, it's a
little bit more inferior than the medial.
02:59
So that prevents the ankle
from everting as much.
03:02
So most of the time when
we do twist our ankle.
03:06
The twisting motion is usually inversion
as opposed to eversion injury.
03:12
The ankle joint has a little less play in
terms of internal and external rotation,
pretty much because the malleoli
locks down into the talus
and you don't have as much
internal-external rotation.
03:27
So the main motions the ankle include the
dorsiflexion,plantar flexion, inversion and eversion.
03:33
with a more limited external
and internal rotation.
03:38
Going into the foot, you have different
articulations but the foot joint
is pretty much stabilized by the
ligaments between the bones.
03:49
so there's not as much motion but you can
have some forefoot flexion and extension,
inversion and eversion.
03:57
And so this is the joint between the
metatarsals and the tarsal bones.
04:03
At the toes also, you can have motion here with
flexion-extension, less so AB-, ADduction
or internal-external rotation.
04:12
So most of our tendons come and
attach to the distal phalanx
giving us ability to
extend and flex our toes.
04:22
If I have a restriction of motion, then I could
name the dysfunction in terms of its freedoms.
04:30
So if I was dorsiflexing the foot and I could not
fully dorsiflex but I could fully plantarflex,
then that is a plantar flexion
somatic dysfunction of the ankle.
04:41
If I could invert the ankle
and cannot evert, then
that's an inversion somatic
dyfunction of the ankle.
04:49
So, naming of a somatic dysfunction is naming,
first finding a restriction of motion
and naming it for the freedom of
motion in the opposite direction.
05:00
So in the ankle joint, there could be several
injuries and we could perform some tests
to narrow down the potential pathologies.
05:11
So, when a patient sprains their ankle,
they're at risk of tearing the ligaments,
so if you have a severe inversion injury that could
tear the ligaments surrounding the lateral malleoli
So, you have your anterior talofibular
ligament, the calcaniotalofibular ligament
and the posterior
talofibular ligament.
05:34
So, these 3 ligaments help to support the lateral
ankle and if you have a severe inversion injury
that could potentially tear those ligaments
starting with the anterior talofibular ligaments
So that's why we call the anterior talofibular
ligament the ATF or "Always Tears First"
To check the integrity of the ligaments
here, we can perform a couple of tests.
05:58
So the first test we could perform
is the anterior drawer test.
06:02
So with the anterior drawer test,
what we're doing is we're stabilizing
the calcaneus with one hand and with the
other hand, we're stabilizing the lower leg.
06:12
and we're gonna try to pull the calcaneus
anteriorly compared to the rest of the leg.
06:19
and so if I have increased joint play or laxity as
I pull anteriorly, that would be a positive test.
06:28
So a positive anterior drawer test
would tell me that there is disruption
of the anterior talofibular ligament.
06:37
The calcaneofibular ligament attaches
the distal fibula to the calcaneus.
06:43
This ligament tends to prevent inversion and
so we could perform an inversion stress test.
06:50
So in inversion stress test, what we're
doing is we're inverting the ankle
to see if the ligament,
the calcaneofibular ligament is intact.
07:00
So we're gonna take
the ankle by the heel
and support the lower leg
and just invert the ankle.
07:08
and as you invert the ankle, you're
gapping and stressing the region
where the calcaneofibular
ligament lies.
07:15
And so, what you're looking for,
is if there's any sort of increased
range of motion, lack of end
feel, increased joint play
or pain as you're doing this, severe pain as
you're doing this, then there may be disruption
of the calcaneofibular ligament
at the lateral aspect of the ankle.
07:35
On the medial aspect of the ankle,
we have the deltoid ligament.
07:40
So to test the integrity of the deltoid
ligament, we could perform an eversion test.
07:46
So here, we're gonna be everting the ankle.
And when you evert the ankle,
you're gapping the medial
aspect of the ankle here.
07:54
So the deltoid ligaments, the deltoid ligaments
do tend to be stronger so it's less likely
that you tear them plus the lateral aspect of the
distal lateral maleolli helps to prevent eversion.
08:07
But to assess whether or not the deltoid
ligaments are intact, what we could do is
we could support the calcaneus and support
the lower leg and evert the ankle
thus gapping this region.
08:19
And if there is a disruption of
the tendons and the ligaments,
in this region, you're gonna
have increased eversion
Another test that we could
perform is the squeeze test.
08:31
So the squeeze test is assessing whether
or not someone has a high ankle sprain.
08:35
High ankle sprains are usually due
to such a severe injury at the ankle
that it damages the ligament between the fibula and
the tibia. So the fibula and tibia has a ligament
the syndesmosis between the two.
and what we wanna do is we want to
squeeze the proximal portion which
will splay out the distal portion.
08:54
So to perform the test, I'm gonna put
my palms along the fibula and the tibia
near the proximal portion and
as I squeeze this together,
it splays out the distal portion and
the patient has pain as I do that,
then that's indicative of damage to the
syndesmosis and indicative of a high ankle sprain
The Thompson test checks for
Achilles tendon integrity.
09:18
So if we have a suspicion that
the Achilles tendon is ruptured,
what we're going to do is to test to see if the
foot will plantarflex when we squeeze the gastroc.
09:29
So the gastrac attaches to the achilles
which then attaches to the calcaneus
So I'm going to very gently
squeeze on the gastroc muscle
and as I squeeze on the gastroc muscle,
it's gonna pull on the achilles tendon
which is connected to the
calcaneus and cause plantar flexion
If I squeeze and there's no plantar
flexion, then I would have to reassess
and see if the tendon
here has been ruptured.