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Foot and Ankle Injuries

Foot and Ankle Injuries

and Injuries Today’s lecture can be viewed at Learning in Athletics the following URL address: We most likely will not get “All of life should be a through all these slides today, learning experience, not Thomas W. Kaminski, PhD, ATC, http://sites.udel.edu/chshowever the presentation- atep/lectures/is just for the trivial FNATA, FACSM, RFSA thorough and complete and will reasons but because by Professor make for an excellent study continuing the learning Director of Athletic Training Education guide for the BOC process, we are challenging our brain University of Delaware examination! Good Luck! and therefore building brain circuitry” Arnold Scheibel

Athletic Training & Sports Laboratory Manual UD is located here! A First State to accompany Fact! Health Care: The Journal for the Rehabilitation Techniques in Sports Medicine Delaware is 96 miles Practicing Clinician and Athletic Training long and varies from th 9 to 35 miles in 6 Edition width.

http://www.healio.com /journals/atshc

https://www.healio.com/books/athletic- training/%7b927168ac-1da2-422c-b98e- ae9013d4e15b%7d/rehabilitation-techniques-for- sports-medicine-and-athletic-training-sixth-edition

Perhaps ATC’s Need to Incorporate Lower Extremity ~ Foot this Into Their Assessment Scheme? Anatomical Review

Cyriax- “Diagnosis is only a matter of applying one’s anatomy”

1 Clinical PEARL: Lower Extremity ~ Foot Navicular Palpation Lower Extremity ~ Foot

• Palpated 2-3 cm anteroinferior to the medial • More prominent with foot adducted

Radiographically Viewed The Ankle Mortise Articulations Ankle Joint (Medial View)

1. 2. 3. Ankle jointChallenge 4. Promontoryyourself of tibia to 5. Trochlear surface of talus 6. Talus identify the 7. Posterior anatomicaltubercle of talus 8. Calcaneusstructures? 9. Sustentaculum tali 10. 11. Navicular 12. Cuneiforms 13. Cuboid

Major Lateral Ligaments The Medial “Deltoid” Complex Ankle Syndesmosis

IOM = Interosseous membrane IOL = Interosseous ligament AITFL = Anterior inferior Tibiofibular Ligament PITFL = Posterior inferior Tibiofibular Ligament

2 The The Ligaments of the Subtalar Joint

WOW! Compartments of the Leg

• Anterior Anterior Medial (Tibial ) Muscular Anatomy Lateral (Peroneal/Fibularis Region) Posterior Superficial Deep

Lower-Leg Compartment Lower Leg Musculature Tibialis Anterior Contents Anterior Posterior

3 At what bony Can you tell Extensor Digitorum Longus landmark do they Posterior Compartment (S) bifurcate? Peroneals which one?

Plantaris

Posterior Compartment (S) Posterior Compartment (D) Posterior Compartment (D)

TOM HARRY

Note we have excised the T&D Soleus DICK

Talocrural and HAS ANYONE Selected Injuries Involving the Subtalar Joint Motion SEEN FERRIS??? Can Ankle Region anyone Talocrural Joint Subtalar Joint name this voice?

Ben Stein!

Circa 1986

4 Ankle Sprain - Risk Factors Inversion/Lateral Sprains Real-time Ankle Sprain Caught on Door Cam!

• 85-95% of all ankle sprains – lateral malleolus extends further • medial acts as a fulcrum – weaker lateral ligs • MOI: – inversion (CF lig) – inv + pf (ATF/CF/TibFib ligs) • most common mechanism • R/O: – “push-off” fx’s of medial malleolus – other associated fx’s & nerve injury

Consequences of an Acute Ankle Sprain Recommendations • Most commonly injured structures in 547 patients with soft tissue • Most common clinical The purpose of this position statement is to injuries due to an acutely twisted presentations ankle – ATFL + CFL = 34% – Presented to emergency room or present recommendations for certified athletic occupational medicine clinic – ATFL + CFL + PTFL = 31% – ATFL only = 16% trainers and other allied health professionals – Other = 14% • “Injury” based on pain at site of structure – PTFL only = 2% in the conservative management and – CFL only = 1% – Anterior Talofibular Lig. (83%) prevention of ankle sprains in athletes. Our – Calcaneofibular Lig. (67%) • Most common primary diagnoses – Posterior Talofibular Lig. (34%) – Grade 1 sprain = 71% recommendations will be reinforced by – Deltoid Lig. (32%) – Other = 15% – Ankle joint capsule (32%) – Grade 2 sprain = 10% relevant scholarly evidence currently available – Dorsum of foot (20%) – Grade 3 sprain = 3% – Sinus tarsi (16%) – Syndesmotic sprain = 1% in peer-reviewed publications and graded – Peroneals (15% – Bifurcate Lig. (8%) according to the Evidence Category Taxonomy – Syndesmosis (6%) Fallet et al, J Foot Ankle (SORT) Evidence Based Scale. Surg, 1998

Recommendations from Five Current State of AT Practice (5) Different Categories What is Evidence-Based Practice • Diagnosis • Treatment and Rehabilitation Best Research • Return-to-Play Considerations • Prevention Clinical Experience

• Special Considerations Patient Values

5 Evidence Categories Evidence Categories Made Simple Implementing the Position SORT Taxonomy Level of SORT Grade Clinical Practice Statement Recommendations Evidence Recommendation

A Based on No brainer! You consistent and should be doing this good evidence in clinical practice B Based on Should probably inconsistent or include in our limited-quality clinical practice! evidence C Based on Flip a coin --- it is up consensus or to you to decide! usual practice https://www.nata.org/news- publications/pressroom/statements/position

Clinical Diagnostic Assessment International Ankle Consortium Clinical assessment of acute lateral ankle Rehabilitation-Oriented ASsessmenT sprain injuries: consensus (ROAST) statement and recommendations of the International Ankle Consortium • The International Ankle Consortium ROAST will help Authors: clinicians identify mechanical and/or Delahunt E 1,2, Bleakley CM 3, Bossard DS 1,2, Caulfield BM 1,4, Docherty CL 5, sensorimotor impairments that are associated with Doherty C 4, Fourchet F 6, Fong DT 7, chronic ankle instability (CAI). Hertel J 8, Hiller CE 9, Kaminski TW 10, McKeon PO 11, Refshauge KM 9, Remus A 4, Verhagen EA 12, Vicenzino BT • This consensus statement from the International Ankle 13, Wikstrom EA 14, Gribble PA 15 Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

Eamonn Delahunt et al. Br J Sports Med doi:10.1136/bjsports-2017-098885

Helpful Resource

• Section I Risk and ROAST Risk Reduction of Ankle Sprains Infographic • Section II Diagnosis • Section III Treatment ROAST and Rehabilitation • Section IV Surgical Considerations

https://www.healio.com/books/athletic-training/%7b43034553-4c8b- 472d-98d2-aca4eefd4c48%7d/quick-questions-in-ankle-sprains- expert-advice-in-sports-medicine

6 Did This 2012 JAT Article Make You Stop and Think About Current Ankle Sprain An Management? Interesting Take on an Old Practice

POLICE = Protection, Optimal Loading, Ice, Compression, and Elevation

An Even Newer Treatment Paradigm

BJSM 2016

The Future of Acute Ankle Sprain Footbeat in Action Treatment Intervention?

7 The Anti-ICE Age via The Evolution of RICE ACTIVE recovery • Developed to reduce the use of unnecessary • Active recovery with non- radiographs in the diagnosis of acute foot fatiguing muscle activation, flushing out waste, and and ankle injuries in emergency What if RICE is wrong? delivering nourishment to the departments Newer evidence is target area suggesting that both ICE • Estimated only 15% of foot/ankle injuries and REST may actually delay recovery! Does this presenting to emergency departments are turn an ATC’s life into fractures peril? • Use of these diagnostic rules have significantly reduced unnecessary x-rays

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OTTAWA ANKLE RULES Clinical PEARL: Ankle Instability Ottawa Ankle Rules Palpation Points

• Medial • Lateral

Updated CAI Model (Hertel & Corbett, JAT 2019) Overview – Ankle Instability Now This Takes Some Coordination! • Inversion ankle sprains are a frequent orthopedic injury

• The majority of appropriately rehabilitated ankle sprains will do well . . . , but saying “they all do well” is a misnomer!

• Symptoms: – pain – feeling of giving way – swelling – recurrent injury

8 Ankle Instability (Mechanical) LigMaster Stress with Musculoskeletal Telos Stress X-Ray Ultrasound Imaging • Definition: – lateral ligament laxity (Freeman et al. - 1965) – joint motion that exceeds physiologic motion B A (Tropp - 1985) FIBULA • Assessment Tools: TALUS – anterior drawer test A represents Talofibular – talar tilt Interval from MSUS – roentgenographic studies (Telos Stress) image

A fancy name for x-ray!

Instrumented Ankle Arthrometry Ankle Instability (Functional) Ankle Instability (Functional) • Assessment • Definition: Tools: – disability to which patients refer when they say the foot tends to “give way” (Freeman et al. - – muscular 1965) strength • isometric – joint motion beyond voluntary control, but not • isokinetic necessarily exceeding physiologic ROM (Tropp - 1985) – stabilometry – peroneal reaction times

Cumberland Ankle Instability Tool (CAIT) The Cumberland Ankle Instability Tool: A Report of Validity and Reliability Testing Claire E. Hiller, MAppSc, Kathryn M. Refshauge, PhD, Anita C. Bundy, ScD, Rob D. Herbert, PhD,Sharon L. Kilbreath, PhD Arch Phys Med Rehabil Vol 87, September 2006 • Designed to measure functional ankle instability • 9 questions related to subjects’ perception of ankle stability during various activities • Shown to be valid and reliable • How do you score? – Maximum score = 30 – Scores < 25 = ankle instability

9 Eversion/Medial Ankle Sprains Syndesmotic Ankle Sprains Syndesmotic Ankle Sprains

• less common (5 - 15% • uncommon injury, the “high • Sx: prevalence) ankle sprain” – point tenderness and swelling localized over the – strong deltoid complex • more disabling with anterior + posterior tibiofibular ligaments prolonged recovery time – bilateral compression increases pain – bony structure of ankle • MOI: mortise – forced df – walk on toes • talus located between – inability to push off • MOI: malleoli forces apart – damage to syndesmosis • Tx: – eversion + df (ruptures (fibrous sheath) deltoid + tibfib ligs.) – forced rotation with a fixed – POLICE vs Marc Pro Therapy? foot • R/O associated fx’s – immobilization usually for a period of 2-3 weeks • shape of the talus acts as a – rotation + eversion (fx 17% - 74% of ankle injuries fulcrum forcing the tibia and • depends on the severity of mortise separation fibula apart fibular shaft + sprain of among young athletes! – NSAID’s deltoid complex)

Clinical PEARL: Ankle Fractures Syndesmosis Palpation Radiological View

Radiograph showing widening of the tibiofibular Alecia Bell UD "clear space" WBB Player 11- (arrows) as a result 2014 of disruption of the syndesmosis. The clear space is normally less than 5 • Anterior Inferior • Interosseous • Posterior Inferior mm wide. Tibiofibular Membrane Tibiofibular Ligament Ligament

Tibial Plafond - the Did this really happen? Ankle Fractures articular surface of the distal end of the tibia. Posterior Malleolar Fracture • Ankle fractures are usually defined as single malleolar, bimalleolar, or trimalleolar

Trimalleolar involves med/lat and posterior tibial malleolus • Isolated fibular fractures are the most common type of fracture and, without displacement, usually requires 4-6 weeks to heal

10 Ankle Dislocation Acute Ankle Dislocation • Ankle dislocation results from complete disruption of articular elements in the ankle • An isolated ankle dislocation without associated fracture is quite rare

England’s Physiotherapist (Gary Injuries Triceps Surae Lewin) Dislocates Ankle during • common tendon of the triceps surae (2 heads of 2014 World Cup --- Ughhhh! gastrocnemius & soleus) inserting into the • receives its greatest stress during extension/ankle dorsiflexion Can you think of a MOI? • Tendinitis (aka tendonitis) – most common form of tendinitis seen in athletics – Et: • overuse – Sx: • crepitus (Landed on a water bottle celebrating a goal!) • inflammatory rxn

Clinical PEARL: Achilles Tendon Injuries Achilles Tendon Injuries Gastrocnemius/Soleus Stretch • Tendinitis (con’t) • Ruptures (con’t) – Tx: – Sites: • calcaneal insertion • Cryotherapy vs Marc Pro therapy • 2-6 cm above insertion pt • NSAID’s (poor vascularity) • lifts – most common site of • decrease/modify activity injury • M-T junction • stretching/strengthening of gastroc/soleus – MOI: • orthotics • forced pf during knee • gradual return to activity extension – common move during • Ruptures propulsion activities Side View of Ruptured Achilles' Tendon. Notice – 75% seen in males 30 - 40 yr. old who participate in • sudden, forced df of an depression at site of rupture (red circle). intermittent activities Gastrocnemius Stretch Soleus Stretch already pf foot – return from a jumping https://www.instagram.c (Straight Knee) (Bent Knee) movement Chauncey Billups NBA ---- om/p/BJqyDOphcnT/ https://www.youtube.com/watch?v=qGwnFAbDOZ8 – most common mechanism

11 Os Trigonum Syndrome (Posterior Achilles Tendon Injuries (Repaired!) Ankle Impingement) • Ruptures (con’t) – Factors Contributing to Ruptures • Os Trigonum - D bone, posterior stylus of • microtrauma/inflammation the talus • dominant extremity ? – 7% of population has a free os trigonum (non- • age • steroid usage union) – Signs/Sx: • Path: • painful, swollen calf • ecchymosis – traction apophysitis during early childhood • palpable deformity caused the separation • pf MMT = weakness – Tx • FHL irritates the bone as it passes by • pf splint 10°-15°, NWB, • PF motions impinge the posterior process transport, surgery

Os Trigonum Syndrome Differential Diagnosis Distal Fibular Fracture • Sx: – painful & limited pf A Shepherd's – pain on great toe flexion fracture • Dx Tests: (avulsion – bilateral x-rays (feet pf) fracture of the posterolateral – bone scans or MRI process of • Tx: talus), which is – symptomatic therapy often difficult to (conservative) differentiate – surgical intervention in radiographically some cases from an os trigonum.

Lower 1/3 Fibular Fracture Proximal Tibia Fracture (UD MLAX Player Fall 2019) Foot Injuries

12 Every Athletic Trainer’s Arch Injuries Morton’s Neuroma Worst Nightmare • Definition - a type of • Longitudinal Arch metatarsalgia (pain in the – know anatomy metatarsals) associated – sprain - intertarsal ligaments with a localized thickening (neuroma) at – pes planus - flat foot the point where the medial – – high arch & lateral branches of the • Transverse Arch plantar nerve join between the 3rd & 4th metatarsal – know anatomy heads – sprain - intertarsal ligaments – Sx • pinpoint tenderness between • look for callosities under 2nd 3rd & 4th metatarsal heads metatarsal head • decreased sensation in 3rd http://teachmeanatomy.info/l and 4th toes ower-limb/misc/foot-arches/

Morton’s Neuroma Plantar Fascitis Clinical PEARL: • Definition - • Hx Palpation – complain of sprained inflammation of the transverse arch, sharp- fascia covering the shocklike pain during plantar aspect of the activity that is relieved foot, most common • Passively when the shoe is removed, extend hallux numbness in the 3rd & 4th site is from the • Palpate toes attachment off the starting at the • Tx medial tubercle of the – transverse arch pad medial – proper shoes calcaneus tubercle of *Note – the long plantar ligament – NSAID’s calcaneus is found laterally and connects to – Cryotherapy vs Marc Pro the cuboid is part of the plantar therapy? fascia (Slide #16)

Turf Toe Turf Toe Lisfranc Injury • Definition - • The injury is named after Jacques Lisfranc de St. • graded according to sx’s (I, II, III) Martin a French surgeon and gynecologist who – sprain of plantar capsuloligamentous complex of the great toe • Sx: described the injury in 1815. • MOI: – inflammatory signs • Lisfranc Ligament – hyperextension – ecchymosis – ligament between the 2nd metatarsal and the medial cuneiform (oblique fashion) – hyperflexion + valgus stress (uncommon!) – tenderness • MOI: • Predisposing Factors: • Tx – axial load of pf foot – artificial turf – Cryotherapy vs Marc Pro • usually traumatic – flexible footwear therapy • Sx: – pes planus – rigid foot insole – swelling & tenderness midfoot – decreased ankle or MP joint motion – taping – restricted activity – ecchymosis late – crutches NWB in severe cases – pain on stress of 1st/2nd metatarsal bases

13 Lisfranc Fracture Lisfranc Injury Foot Fractures • Tx: • neck of talus (forced DF) – no flattening of long. arch • NWB cast 6 wks • calcaneus (crush injury/compression) AP radiograph of the forefoot. There is • walking cast 2 wks Open Reduction • avulsion of base of 5th metatarsal (strong homolateral Lisfranc and Internal – flattening of long. arch Fixation contraction of ) fracture-dislocation. • ORIF • metatarsal fractures (direct trauma) • poor prognosis • Jones fracture (just distal to the base of the • 14.5 wks return to sports on average! 5th metatarsal)

5th Metatarsal 5th Metacarpal Fracture Calcaneal Fracture Tuberosity Fracture • most common • “tennis fracture” Lateral • MOI: radiograph of – inversion force with pull by lateral plantar fascia the ankle. • Tx: There is a – undisplaced hatchet injury • wooden shoe to the • symptomatic care calcaneus. • union in 8 wks – > 2 mm displacement = ORIF

Jones Fractures Classification Scheme • 1902 Sir Robert Jones described Jones Fracture 4 cases • Definition - – transverse fx @ the junction of the diaphysis and metaphysis • intraarticular fx (between 4th & 5th) • distal to base of 5th – @ a pt. between insertions of peroneus brevis & tertius • MOI: – pf ankle with a large adduction force to forefoot Lateral radiograph of the foot. A patient • Tx: stepped off a curb and sustained a fracture of – SLC for 6-8 wks. the proximal aspect of the fifth metatarsal. – ORIF in competitive athletes

14 Jones Fracture – UD Soccer Ouch – Sports Related Concusion?? Neuropathies and Player Fall 2017 Compartment Syndromes

Definitions LE Neuropathies – Foot Lacinate LE Neuropathies – Foot mean rough • Neuropathy - any disorder affecting the nervous • Tarsal Tunnel Syndromeedges!: • Tarsal Tunnel Syndrome: – Tunnel formed by the flexor – Uncommon in athletes system. retinaculum (lacinate ligament), medial wall of – Etiology: • Radiculopathy - disorder of the spinal nerve roots the calcaneus, posterior • Vascular compromise of • Compartment Syndrome - condition in which talus, distal tibia and medial the nerve (sensory) malleolus • Direct compression increased intramuscular pressure in a confined – Structures include: neuropathy (sensory + anatomical space brought on by overactivity or • Posterior motor) • PT tendon – Abnormalities of the trauma impedes blood flow and function of tissues tunnel • FDL tendon – Extrinsic factors that within that space. • FH tendon compress • & vein

Clinical PEARL: Tarsal Tunnel Palpation LE Neuropathies – Lower Leg LE Neuropathies – Lower Leg

• Passively dorsiflex the • Entrapment of the • ankle and extend the SPN: Entrapment: toes th – Etiology: – Secondary to 5 met fx’s • Palpate between the • Facial impingement as medial malleolus and it exits the deep fascia – Recurrent sprains Achilles tendon approx. 6 cm above the (PF/inv) lateral malleolus • Tinel’s Sign – tapping – Ganglions • Chronic ankle sprains – Extrinsic compression over the tarsal tunnel subject the nerve to (tight ski boot) recurrent stretching

15 Review of the Thank You Wake Up! Clinical Foot and Ankle Assessment

Former VP Joe Joe Flacco – QB Baltimore Ravens Biden

Bill Prentice – Principles of Athletic Training

Our Famous Former NJ Governor – Chris Christie Delawareans!

Ankle/Foot Anterior Talofibular Ligament (ATF) Anterior Talofibular Ligament (ATF) Pain Diagram

Anterior Talofibular Ligament (ATF) (CF) Range of Motion Testing

• AROM • PROM • RROM – MMT – “Break Test”

16 AROM AROM AROM

• Plantar Flexion • Dorsiflexion • Inversion

Note that PF is two words!!

AROM Weight Bearing AROM Weight Bearing AROM Plantar and Dorsiflexion Inversion and Eversion • Eversion

Any UNF students in RROM the audience? RROM RROM Who is this? • Plantar Flexion • Dorsiflexion • Inversion

17 Special Tests for Ligamentous RROM Show Me the Evidence! and Capsular Laxity • Eversion • Sensitivity – those people correctly identified by the test as having the condition of interest (Positive (+) Predictive Value)

• Specificity – those people BOC correctly identified as NOT having the condition of interest (Negative (-) Predictive Value)

Anterior Drawer Test Anterior Drawer Schematic Anterior Drawer Schematic

Anterior translation is > when the ankle is in 15° of plantar flexion

Sensitivity 32% - 80%

Anterior Drawer Test Talar Tilt Talar Tilt Schematic

(variation) I (Inversion Stress) n v e r s i o n

E v e r s i o n Sensitivity 52%

18 Talar Tilt Ankle Syndesmosis (Eversion Stress) Medial Subtalar-Glide Test

Used to assess laxity of the subtalar joint resulting from lateral ligament injury

Test is performed by translating the calcaneus medially on the talus in the transverse plane --- excessive laxity is a (+) test

Ankle Syndesmosis Risk Factors for Syndesmotic Ankle Sprains Mechanism of Injury • Prospective cohort (USMA) study examining the causes of SAS and – Ice Hockey Video medial ankle sprains (11.8% of all ankle sprains) over a 4 yr. period • Gender – ♂ more medial sprains vs. ♀ – ♀ longer recovery time vs. ♂ • Sport – FB, soccer, team handball, basketball • Level of Competition – Intercollegiate > intramural • Body Mass Index (BMI) – > BMI is associated with more SAS and medial sprains

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Palpation Assessment Considerations Assessment of Pain • Evidence of swelling? – Severe swelling usually not • Patient complaints of present, if it is may take on a • Evaluation usually “rectangular” appearance! involves: pain include: • Tenderness between fibula – Anteriorly between distal and tibia (AITFL and PITFL) – Location and extent of fibula and tibia (AITFL) pain • Tenderness over the medial – Posteromedially at level of malleolus – Anatomic palpation the ankle – Isolated syndesmotic – Various stress tests – Pain with WB and ligamentous injury is rare, may “pushing-off” have lesions of – Differential diagnosis: too – Some may complain of pain • Depends on evaluators ability • Medial (Deltoid) ligament extending proximally to find ligament/IM involvement (interosseous membrane?) • Pain on palpation is the most • Associated fractures of • The “”! frequent positive test either the tibia or fibula – Alonso- JOSPT,1998 • Lateral ankle sprain – Nussbaum, AJSM 2001

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19 Palpation – “Tenderness Length” Hopping Assessment Gait Assessment • Term coined by Nussbaum et al. Am J Sports Med 2001 • Perform a single-leg hop • Normal heel-toe walking pushing off from the toes – Measure length of tenderness gait may be replaced by a from distal tip of fibula to the – Performed only after R/O most proximal portion of heel-raise gait. evidence of fracture tenderness – Used to avoid excessive ankle – 10 reps? – Made along anterior portion of DF and pain during “push- • Inability to perform the hop off” interosseous membrane (space or hopping with extreme pain between lateral palpable • Antalgic gait with short is indicative of SAS. border of tibia and the medial duration of “stance” phase palpable border of fibula – Rising on the toes produces on the injured foot may – “Tenderness Length” can be hindfoot inversion which used to predict time lost from also be present stresses the syndesmosis competition (> the distance = Days Lost = 5 + (0.93) x tenderness length more time lost) in cm ± 3.72 days

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Special Tests: Kleiger Test Kleiger Test (aka External Rotation Test) (External Rotation Test) Special Tests: Squeeze Test • Described by Hopkinson et al. • Described by Hopkinson et al. Foot Ankle, 1990 Foot Ankle, 1990 & Boytim et al. • Compress /”cup” tibia/fibula Am J Sports Med 1991 together at mid calf moving • Externally rotate the foot while upward proximally – Can also be performed seated holding the ankle in a neutral • Causes separation of distal position (can be performed either tibiofibular syndesmosis seated or supine) – Teitz & Harrington Foot Ankle Int,1998 – Doesn’t measure instability • Not sensitive to minor or partial injuries of the syndesmotic ligs. – If (+) in the early stages (first few – 20/60 - Nussbaum et al. AJSM weeks) indicative of damage to 2001 syndesmotic ligaments – Interrater reliability is low (0.50) – Best interrater reliability (0.75) • (+) Test correlates w/ longer • Alonso, JOSPT, 1998 return • Hopkinson 1990, Taylor 1992, – 55/60 patients in Nussbaum et al. Nussbaum 2001 (2001) study had (+) tests

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Special Tests: Cotton Test Special Tests: Special Tests: Point Test (aka Lateral Talar Glide) Fibular-Translation Test (aka Palpation Test) • Described by Cotton, • Described by Ogilvie- Dislocations and Joint- Harris et al. • Described by Boytim et Fractures, 1910. Arthroscopy,1994 al. Am J Sports Med 1991 • Used to evaluate lateral • Performed by translation of the talus in the • Supine or sitting ankle mortise translating the distal • Pressure with finger • Performed with the patient fibula anteriorly and directly over the anterior supine posteriorly on the tibia aspect of the distal • Stabilize the distal leg but do not • (+) test results when tibiofibular syndesmosis compress syndesmosis while pain is produced at the opposite hand cups the calcaneus • ↑ pressure gradually syndesmosis or when and talus • (+) test involves a report fibular displacement is • (+) Test is ↑ lateral translation of of pain by the patient the talus relative to the opposite > the uninvolved limb uninjured limb and ↑ PAIN!

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20 Special Tests: Dorsiflexion Maneuver Special Tests: Crossed-leg Test Special Tests: Heel Thump Test

• • First described by Ward, J Kiter E. Foot Ankle Int. • Described by Lindenfeld & Manip Phyiol Ther, 1994. 2005 Parikh, Foot Ankle Int. 2005 • Performed to force the wider • Mimics the squeeze test and • Performed to force the talus into anterior portion of the talar attempts to induce the ankle mortise dome into the ankle mortise, separation of the distal thus inducing separation of the syndesmosis • Patient is seated distal tibia and fibula • Resting point should be • Examiner applies a gentle but • Patient is seated, passive mid-calf! firm thump on the heel with movement into DF • Pt applies a gentle force on their fist • (+) test is pain experienced in medial knee • Force applied at center of heel and in line with long axis of tibia the distal tibiofibular • (+) test is pain in distal syndesmosis syndesmosis • (+) test is pain in distal • Interrater reliability is low syndesmosis (0.36)

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What Does the Evidence Suggest? Special Tests: Stabilization Test Special Tests: Malleolar Compression/Rebound Test • None of the syndesmotic stress tests could • Williams et al. Am J distinguish which ligaments were sectioned. Sports Med. 2007 – Compress malleoli Furthermore, the small displacements measured during the stress tests (with the • Apply several layers of and look for pain with tape (tightly) above the exception of the external rotation test) ankle joint to “stabilize” rebound suggest it is unlikely that the displacement the distal syndesmosis – Hard, frequently very induced in injured syndesmoses can be • Patient is then asked to clinically differentiated from normal stand, walk, perform a toe sore syndesmoses. Therefore, pain, rather than raise, and jump – Not well publicized or increased displacement, should be considered • (+) test if these maneuvers investigated yet. the outcome measure of these tests. are less painful with the – Beumer A, van Hemert WL, Swierstra BA, Jasper tape in place LE, Belkoff SM. A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability. Foot Ankle Int. 2003 Apr;24(4):358- 63. Athletic Training Research Laboratory Athletic Training Research Laboratory Athletic Training Research Laboratory

Ankle Joint Swelling Weight-Bearing Lunge Test

??? ???

21 Ankle Joint Strength Testing Ankle Joint Strength Testing Ankle Joint Strength Testing

Assessing Dynamic Ankle Assessing Dynamic Ankle Stability: Kin Com 125 AP Stability: Isotonic Strength Isokinetic Strength Isokinetic Dynamometer Isokinetic Concept introduced in Isotonic activities re Dynamometry 1967 by Hislop & dynamic and involve Perrine (Hislop, HJ, both ECC and CON – objective Perrine, JJ (1967). Phys muscle actions – quantifiable Ther. 47, 114-117.) – quasi-CKC Contemporary PrimUs System 1 RM is commonly dynamometers enable used a measure of assessment the researcher to strength in larger – reliable gather both CON and muscle groups, Capable of ECC data however rarely used in measuring both Allows for the the ankle. examination of Some examples of ECC and CON reciprocal muscle isotonic exercises are muscle actions group ratios (knee, shown here. shoulder, ankle)

BESS Testing One Leg Stance Testing Y-Balance Testing

Developed & described by: – Functional Movement Systems – Plisky et al. Reliable dynamic balance assessment tool Cut-off = 89.6% for the composite score, relative to limb length – Sensitivity of 100% and specificity of 71.7% – Males < 89.6% are 3.5X more likely to obtain a noncontact lower extremity injury – Female < 94% are 6.5 times as likely to sustain a musculoskeletal injury In the ANT reach, a difference > 4 cm between the limbs is associated with an elevated risk of injury

22 Assessing Activity Levels Assessing Foot/Ankle Function (FAAM) Special Tests - Fracture Identification

Squeeze Test Bump Test Special Tests - (Potts Compression Test) (Heel Tap or Percussion Test) Thompson Test (Achilles Tendon Rupture)

Pott’s Fx = fx distal fibula and medial malleolus, Sir (-) (+) Percival Potts identified this compound fx in 1756

Special Tests - Special Tests - Thompson Test Homan’s Sign On-Field Assessment Review (Achilles Tendon Rupture) • History – MOI, location, pain – Unusual sounds/sensations – Information from others • Observation/Inspection – Deformity, swelling, ecchymosis – Positioning Dr. Homan (of "Homan's sign" fame) discredited his own test as being useless in the – Skin color evaluation of DVT and admitted he was sorry he ever published its description.

23 On-Field Assessment Review On-Field Assessment Review Today’s lecture can be viewed at • Neurovascular the following URL address: • Palpation – Dorsalis pedis pulse – Tenderness, – Sensation over foot crepitation, deformity: (dorsum and lateral http://sites.udel.edu/chs-atep/lectures/ border), calcaneus • distal tibia • Special Tests • distal fibula THANK • ligamentous structures – Pott’s Compression • syndesmosis Test • Achilles tendon – Anterior Drawer Test • foot region • AROM Tests

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