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Diagnosis of the Feet

by Sheldon C. Yao, DO

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    1:00:01 Osteopathic evaluation of the foot and ankle.

    1:00:05 So when evaluating the foot and ankle, we want to start with look-feel moves.

    1:00:08 So starting with observation, we're gonna look at the feet, check for any swelling.

    1:00:13 Sometimes, the joints could be swollen.

    1:00:15 In case of gout, sometimes you might see redness of the skin or you might see swelling.

    1:00:20 Someone sprained their ankle, there might be visible deformities, swelling in the regions.

    1:00:25 So start with observations, observe the feet.

    1:00:28 Look for any deviations, any callouses that might be present in the feet.

    1:00:34 After observation, we're gonna perform some palpation.

    1:00:38 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.

    1:00:56 You have your metatarsals here and you have your distal metatarsal here.

    1:01:00 You have your styloid process, so the 5th metatarsal.

    1:01:03 You could check your tarsal bones and check the toes here for any sort of pain, tenderness or any area.

    1:01:13 Most of the foot is ligaments, so the ligaments provide structural stability to the foot.

    1:01:20 You also want to check the foot when they're weight bearing to check for any sort of flat feet that might be possible.

    1:01:26 Patients may have inflammation and complaints of pain at the heel.

    1:01:31 You want to see if you could palpate a possible tenderness or heel spur in the region.

    1:01:36 Or plantar fasciitis, the inflammation of that plantar surface of the foot.

    1:01:40 So, palpation could sometimes elicit tenderness or you could feel swelling or increased warmth in different regions of the foot and ankle.

    1:01:49 So motion testing the ankle and foot.

    1:01:52 When we motion test the ankle, what we're looking for is the amount of motion available in the different planes.

    1:02:00 So for the ankle joint in the saggital plane, we could have flexion and extension.

    1:02:07 But it it's not called that at the ankle joint, what we have is dorsiflexion and plantar flexion.

    1:02:14 So this is the dorsal surface of the foot, so this is considered dorsiflexion and plantarflexion.

    1:02:19 So you wanna check the amount of range of motion in both of those motions.

    1:02:24 In the ankle, you also have inversion and eversion in the coronal plane.

    1:02:29 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.

    1:02:43 Whereas the deltoid ligament on the medial aspect of the ankle is really strong.

    1:02:48 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.

    1:02:59 So that prevents the ankle from everting as much.

    1:03:02 So most of the time when we do twist our ankle.

    1:03:06 The twisting motion is usually inversion as opposed to eversion injury.

    1:03:12 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.

    1:03:27 So the main motions the ankle include the dorsiflexion,plantar flexion, inversion and eversion.

    1:03:33 with a more limited external and internal rotation.

    1:03:38 Going into the foot, you have different articulations but the foot joint is pretty much stabilized by the ligaments between the bones.

    1:03:49 so there's not as much motion but you can have some forefoot flexion and extension, inversion and eversion.

    1:03:57 And so this is the joint between the metatarsals and the tarsal bones.

    1:04:03 At the toes also, you can have motion here with flexion-extension, less so AB-, ADduction or internal-external rotation.

    1:04:12 So most of our tendons come and attach to the distal phalanx giving us ability to extend and flex our toes.

    1:04:22 If I have a restriction of motion, then I could name the dysfunction in terms of its freedoms.

    1:04:30 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.

    1:04:41 If I could invert the ankle and cannot evert, then that's an inversion somatic dyfunction of the ankle.

    1:04:49 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.

    1:05:00 So in the ankle joint, there could be several injuries and we could perform some tests to narrow down the potential pathologies.

    1:05:11 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.

    1:05:34 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.

    1:05:58 So the first test we could perform is the anterior drawer test.

    1:06:02 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.

    1:06:12 and we're gonna try to pull the calcaneus anteriorly compared to the rest of the leg.

    1:06:19 and so if I have increased joint play or laxity as I pull anteriorly, that would be a positive test.

    1:06:28 So a positive anterior drawer test would tell me that there is disruption of the anterior talofibular ligament.

    1:06:37 The calcaneofibular ligament attaches the distal fibula to the calcaneus.

    1:06:43 This ligament tends to prevent inversion and so we could perform an inversion stress test.

    1:06:50 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.

    1:07:00 So we're gonna take the ankle by the heel and support the lower leg and just invert the ankle.

    1:07:08 and as you invert the ankle, you're gapping and stressing the region where the calcaneofibular ligament lies.

    1:07:15 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.

    1:07:35 On the medial aspect of the ankle, we have the deltoid ligament.

    1:07:40 So to test the integrity of the deltoid ligament, we could perform an eversion test.

    1:07:46 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.

    1:07:54 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.

    1:08:07 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.

    1:08:19 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.

    1:08:31 So the squeeze test is assessing whether or not someone has a high ankle sprain.

    1:08:35 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.

    1:08:54 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.

    1:09:18 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.

    1:09:29 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.


    About the Lecture

    The lecture Diagnosis of the Feet by Sheldon C. Yao, DO is from the course Osteopathic Diagnosis of the Ankle and Foot Region.


    Included Quiz Questions

    1. Inferior or distal
    2. Posterior
    3. Superior or proximal
    4. Anterior
    1. Deltoid ligament
    2. Anterior talo-fibular ligament
    3. Calcaneo-fibular ligament
    4. Posterior talo-fibular ligament
    5. Achilles tendon
    1. Inversion
    2. Dorsiflexion
    3. Plantarflexion
    4. Eversion
    5. Extension
    1. Anterior talo-fibular ligament
    2. Calcaneo-fibular ligament
    3. Posterior talo-fibular ligament
    4. Deltoid ligament
    5. Achilles tendon

    Author of lecture Diagnosis of the Feet

     Sheldon C. Yao, DO

    Sheldon C. Yao, DO


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