Physiotherapy Ankle and Foot Ax

 Keywords: Subjective Ax, objective Ax, Ankle assessment, Foot pain, Passive ROM, Active ROM, ankle pain, Strength Tests,  Special tests, Differential Diagnosis, Red flags.

Physiotherapy Foot and Ankle Assessment (Ax)

 

The Foot and Ankle Assessment  is vital in the diagnosis of lower limb pain. The common saying “No foot no horse” in the veterinary world can be applied to humans. Foot and ankle pain can be particularly debilitating and its sometimes difficult to protect and rest due to its role it weight bearing.

Any assessment should include a thorough subjective and objective examination with use of special tests to aid differential diagnosis. The best way to learn good assessment skills is through hands on practice and watching experts. Try to spend a day with a consultant or extended scope practitioner to see how they perform an assessment. Visit the student room to  find preparation notes for work experience days.

Useful tip  “One way to get better at assessing is by practicing. Organizing small groups and role playing the clinical environment is useful so that someone can observe and give you constructive criticism. You will feel more confident with your questions, handling techniques and tests if you have practiced them on a friend five times before.”

Areas to focus on:

  • Communication
  • Question asking
  • Hand holds
  • Professionalism

This page includes: Subjective Ax, objective Ax, Passive ROM, Active ROM, Strength Tests, Special tests, Differential Diagnosis.

Subjective Ax

The subjective examination aims to gain valuable information on how the symptoms have come about and what is causing them.

  • Locking/Popping/giving way
  • Type of shoes and their wear patterns.
  • Functional limitations
  • Does the pain presentation lie within a dermatomal region?
  • How does walking on different terrain affect swelling?
  • If runners ( What is the surface/distance/frequency/level-ie competitive or recreational)
  • Mechanism of injury –This gives you clues as to which structures may have been stressed.
  • Gym- type/intensity/duration.

 

What does this tell you?

Knowing the history gives clues as to the structures affected. Mechanism of injury is extremely important. If you can work out the force of the injury this gives you clues on likely stretched/ damaged structures (Inversion injury may suggest damage to tissue on the lateral aspect of the ankle and perhaps the lateral ligament complex. Eversion injury may suggest medial tissues may be affected and large direct trauma may suggest fracture).
Make sure you consider back referral too. If there was no history of trauma to the ankle and it has FAROM look closer at the site of pain. Does the patients pain lie in a dermatomal pattern? Are reflexes and myotomes normal?  Immediate swelling and bruising usually indicates significant trauma and may require X-Ray to rule fractures, bone bruises or an MRI to investigate integrity of the ligaments.

Mechanism Of Injury and Differential Diagnosis

 

Achilles tendonopathy(chronic)

  • Coming on gradually over time. Continuing to undergo exercise despite discomfort.
  • Repetitive loading, athletic and non athletic population.

 

Achilles tendinitis (acute)

  • Crepitis and/or tenderness in the achilles tendon region.
  • Increased symptoms with increased load (ie running/jumping/climbing stairs).
  • Rest decreases symptoms.
Achilles tendon rupture
  • H/o rapid eccentric loading (ie running/jumping/sprinting/stair climbing)
  • Severe pain in TA.
  • May report hearing “pop” or feeling posterior impact.
  • Positive thompson test/unable to heel raise. Tenderness over rupture site/gapping between ends of ruptured tendon.

 

Plantar fasciitis

  • Pain Am, eases witha  few steps.
  • Insidious onset, gradually worsening.
  • Change of shoes (ie long walk in wellies)

Ankle Sprain

  • H/O trauma (Inversion/eversion injury)
  • Variable pain (depending on severity) and function.
  • Excessive movement in complete rupture of ligaments.
  • Immediate bruising/ swelling.

 

Stress fracture

  • Insidious onset of symptoms.
  • Over use injury.
  • Intense training program with high milage ++
  • Specific localised tenderness over bone.
  • Eases with rest.

 

Compartment Syndrome (Can be chronic or acute)

  • Acute Muscle weakness/ paraesthesia/vascular compromise/ disproportionate pain to a passive stretch (Immediate And E referral needed).
  • Chronic – Symtoms ease with rest. Same symptoms as acute but less intense/dramatic, nil vascular compromise.
Syndesmosis Sprain
  • External rotational force or hyper dorsiflexion force to foot/ankle.
  • Pain on tibial tuberosity.
  • Tenderness over posterior tibiofibular ligament and ATFL.
Also consider:
  • Turf Toe
  • Tarsal Tunnel syndrome
  • Morton’s neuroma
  • DVT

RED FLAGS –

 

These are the special questions which may indicate that something more sinister may be going on. Patients should be referred immediately back to the GP with your concerns noted. Ask a seniors advice on the severity of these symptoms and whether and A and E referral is more appropriate. Mechanism of Injury is important here, what force was exerted through the leg? Was it enough for a tibia/femur fracture? Loss of pulses in the foot may indicate vascular compromise due to  a fracture. Fractures can lead to fatty embolisms therefore warrant immediate A and E referral.

  • Bilateral pins and needles or numbness in the LL.
  • Problems with bowel and bladder function where the patient is unable to feel themselves going to the toilet.
  • Incontinence.
  • Paraesthesia in the groin region.
  • Loss of pulses in the LL (Vascular compromise).
  • Obvious deformity.

Video Assessment

Objective Examinations

 The objective examination gives you quantifiable measures to rule out what structures are involved and to reassess after treatment to determine improvement/deterioration. For example documenting that a lady has 50 % ankle inversion will allow you to re-assess at her next treatment session and monitor improvement or deterioration. This should help guide you on whether a treatment has been effective and  can help confirm a diagnosis.

  • Observation ( Gait, Posture, heel walking(L4-S1), toe walking((s1-S2), Heel raise)
  • Posture (fore foot/rear foot/valgus/varus)
  • AROM – Ankle DF(10-15 degrees), ankle PF(45-55 degrees), Ankle Inversion(30-40 degrees), ankle Eversion(15-25 degrees).
  • Measure swelling/effusion (tape measure)
  • PROM
  • Myotomes
  • Reflexes (Patella; L3-4, Ankle Jerk; S1, Babinski, Clonus).
  • Sensation (Dermatomes)
  • Palpation (Dorsal pedal and posterior tibial artery pulses, soft tissue, bony landmarks)
  • PA Spinous processes (To r/o back pathology)
  • PA Tranverse processes (To r/o back pathology)
  • Strength (PF/DF/INV/EVE)
What does this tell you?

 

  • Try to establish the structure involved. Pain at the end of the day after work may suggest structures that are stressed as the day goes on. Pain in morning could be due to inflammation (ie OA) however if the pain is easier in the morning this could be due to reduced swelling  due to rest and elevation overnight .
  • Does it ease with a few steps? Is it due to tight fascia/muscles which ease as they warm up?
  • Poor Quality of movement – Is the muscle jerking or shaky which could indicate pain inhibition or fatigue.
  • Throughout movements where does the patent feel their pain? Is the patient weak in a specific range or does the pain increase with soft tissue impingement ie end of range DF?
  • Does the patient present with significant guarding, apprehension and unwillingness to move.
  • Pins and needles of paraesthesia (numbness) in the lower limb? This normally suggests a neural element which maybe coming from the lumbar spine or compression of the nerve somewhere along its course.
  • If you press on a structure and this reproduces the patients symptoms this may suggest referred pain is occurring.

 

Special Tests

 

When to X-Ray??

 Check your anatomy and improve skills by reading X-Rays and completing a self directed image interpretation course, brought to you by Heidi Nunn DCR (D) Pgcert.

 

References

Daniels L, Worthingham C: Muscle Testing: Techniques of Manual Examination, 5th ed. philadelphia, WB Saunders. 1986.

Magee DJ: orthopaedic Physical assessment, 4th ed. Philadephia. WB Saunders, 2002.

Hopkinson WJ, st. pierre P. Ryan JB, Wheeler JH: Syndesmosis sprains of the ankle. Foot ankle 10(6): 325-330,1990.

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