All right, so now we'll jump into the
examination of the foot and the ankle,
and we'll start off by just doing a quick
review of some of the gross anatomy here
and doing some inspection at the same time.
So we've got the medial malleolus
and the lateral malleolus.
This is our first MTP,
metatarsal pharyngeal joint.
And then on the other side is our 5th MTP,
which if you bring your thumb down the
lateral margin of the foot, you'll feel a
prominent, a little bony prominence there.
And that's the 5th MTP, which is an important
structure to identify, as we'll see later on.
The posterior calcaneus is back here and
we'll be taking a closer look at that as well.
And of course, you've got PIPs and DIPs and MTPs
just like we do with the hand for all of the digits.
So let's just take a look at strength testing first.
So I'm going to have you just dorsiflex your foot.
Now, remember, back with our neuromuscular exam,
that dorsiflexing the foot is the L4 nerve root,
So a person who has an L4 radiculopathy may
have weakness with dorsiflexion of the foot
and end up having what's called a foot
drop or the foot kind of drags behind them
when they're walking.
And then in contrast, I want
you to push down with your foot.
So that's testing L5 and S1 nerve
roots and essentially the integrity
of the Achilles tendon posteriorly.
In addition, we can do strength
testing by doing inversion of the foot.
Inversions that way, and
I'm going to resist you.
So resisted inversion of the foot is going
to involve the inverters of the foot.
And in particular we're talking about
the posterior tibial tendon back here.
If a person has tendinopathy
involving the posterior tibial tendon,
it's going to hurt when we
do have resisted inversion.
In contrast, push your foot out.
Resisted eversion is testing the peroneus
longus, also called the fibular tendons.
And again, a person will have
discomfort by doing resisted eversion.
Similarly, I can stress the posterior tibial
tendon simply by stretching that tendon so I could,
this is passive eversion and passive
inversion to accomplish the same thing.
So let's move on to taking a look at the
Achilles tendon and the other structures
that are on the back of the foot.
Now we're going to move in to talking
about ankle sprains versus ankle fracture,
which is, both of which are relatively
common, certainly ankle sprains are.
And the bedside physical exam is really effective
at distinguishing between those two possibilities.
Remember that a ligamentous strain, a strain
of a ligament is actually a micro tear.
There are tendons or I should say there are
fibers within that ligament that have been torn
when you quote, sprain your ankle.
A more severe example, though, is
a complete tear of that ligament.
And usually when a ligament is completely torn,
there's significant instability at that joint.
So what we're doing on the exam is distinguishing
between ligamentous laxity because it's torn
ligamentous discomfort because it's sprained
versus an actual fracture where the ligament
has typically also been cut but also there's
been some evulsion of the ligament from the bone
or even a potentially a break higher
up on the fibula or the tibia.
So I'm going to quickly remind you guys
of the ligaments that stabilize the ankle.
And I'm going to draw your
attention in particular to this one.
This is the interior talofibular ligament.
This is the most commonly sprained ligaments.
Then we have our calcaneofibular here and
then the posterior talofibular ligament here.
This is where most ankle sprains
happen, it's this guy right there.
And on the other side, on the medial
aspect is the deltoid ligament
and you can even tell on this model that
that is a ligament that does not kid around.
It is a very thick, very strong membrane.
People rarely sprain their ankle medially.
It's really the lateral aspect with an
inversion injury that is most common.
So orienting ourselves back to Shayla
here, this would be the deltoid ligament.
It's a very strong ligament here, ligamentous
attachment that's stabilizing this.
So I'm unlikely to cause an eversion injury.
In contrast, on this side of the
foot, her ATFL is basically right here.
Here's her lateral malleolus and it's attaching
here on her, basically her tarsal bones.
That's where the ATFL is,
the CFL, calcaneofibular ligament
and then the posterior
talofibular ligaments back here.
So to strain that ligament, I can
simply do what's called a talar tilt.
I'm tilting her ankle in this way.
I'm going to compare one side to the other.
When a ligament is completely
torn, you'll have a soft end point.
It's the phrase that we would use
because there's no ligament there
so I can basically just
continue to invert her foot
and it would only stop when some other
ligaments started to get involved.
If somebody has an intact ligament,
there will be a hard stop.
And I can feel that in her case
right there, I can't go any further.
It came to a hard stop.
And whenever we're assessing ligaments,
as we'll do for other joints,
you're looking for a hard stop to
make sure that ligament is intact,
I t's like the tether has reached
its length and that's that's it.
They don't really stretch very much.
The other thing you can do to assess
for the integrity of particularly the
ATFL and the calcaneofibular
ligament is called a 'drawer test'.
Well, we have a knee anterior drawer
and we also have an ankle anterior drawer.
And I'm pushing down on her tibia
and pulling forward with her heel
to test the integrity of the ATFL
in particular, because the ATFL
again here is preventing anterior translocation
of the foot relative to the tibia.
So if a person has tenderness in that area
and also has pain when I do talar tilt
whether or not they have laxity or not,
that suggests a typical sprain of the ATFL.
So now that we've reviewed the
different types of ligamentous sprains,
we're now going to look at the possibility of a
fracture that could be occurring along with the sprain.
Fortunately, there's a very well validated
instrument that has been designed
called the Ottawa Ankle Rules.
They were made up in Ottawa, Canada, and they
are designed to be a simple examination tool
that allows us to eliminate or dramatically
reduce the possibility that there's a fracture.
So we don't need to get plain films
to do any further investigation.
It's composed of four specific
points that I'll show on this model.
Two in the midfoot and
then two in the hind foot.
The two in the midfoot are here, the 5th MTP.
Here is the navicular bone,
and then it's the posterior distal 6
centimeters of the tibia and the fibula.
Not the anterior portion,
just the posterior portion.
And that's important because you can
imagine if somebody has an ankle sprain,
well, guess what, they're going to have
tenderness here because that's where the ATFL is.
So it really has to be posterior tenderness that
would precipitate a positive Ottawa ankle rule
test that would lead you to getting an X-ray.
So let's demonstrate those
sections on our patient.
All right, Shayla.
So again, this is the navicular bone.
There's a bony prominence that you could feel about
halfway between the calcaneus and the first MTP.
Here is her 5th MTP and all I'm doing
is palpating the back of the malleoli
because those malleoli are
the fibula on this side,
I'm sorry, the tibia on this
side and the fibula on this side.
So just the posterior aspect.
If a patient has any one of those things,
that's positive, and then one more criteria.
If the patient was non-weight
bearing at the time of the injury
and when they present to the emergency room.
If they're not able to weight bear and
any one of those points is positive.
Get some plain films and see what you find.
All right, so that's everything
about sprains and fractures.
Let's look at some other
common diseases of the foot.
We'll start with plantar fasciitis.
So the plantar fascia is the fascia, which
is a very fibrous tendinous structure,
that connects the front, the metatarsals
here all the way with the calcaneus
and the insertion of the plantar fascia
is right here at the base of the calcaneus.
Let me just take a quick look
at our model here to show this.
So, again, this is actually a
right foot, not a left foot.
Here's the plantar fascia and it connects here.
You can see this little red area here,
which marks the insertion of the calcaneus
or into the calcaneus and you'll note
that it's somewhat medial on the calcaneus.
And this little part of the calcaneus
is called the calcaneal tubercle.
So that's the most likely sensitive
spot for plantar fasciitis.
So you're going to want to push on that area
and see if it reproduces the patient's pain.
And lastly, since it's this structure
that is causing the patient's pain
by trying to tense that structure, by stretching
it, you'll hopefully reproduce their symptoms
and make it more clear as to
what's causing their pain.
So that's called the 'Windlass mechanism test',
where I simply pull up on the great toe,
so I'm dorsiflexing the toe and
if that reproduces their pain,
that would support the
diagnosis of plantar fasciitis.
Next up, we're going to look at the tarsal tunnel,
so I'm going to pull out my model yet again.
The tarsal tunnel is on the medial aspect of the
foot, and it describes similar to the carpal tunnel.
It's a small area where a number of
structures are running through it,
including your posterior tibial artery.
We already talked about your
tibialis posterior tendon.
There are veins running through there and in
particular there's the posterior tibial nerve.
Now, patients who have neuropathy
involving the posterior tibial nerve
similar to a carpal tunnel type
neuropathy, a median nerve neuropathy
are essentially having an ischemic neuropathy.
There's a problem with a blood supply to that
nerve because there's too much inflammation
in a very tight space called the tarsal tunnel.
That nerve is then diving down underneath
the foot and innervating other parts of the
on the plantar surface of the foot and
so patients with tarsal tunnel syndrome
report a burning sensation or
paresthesias, numbness, tingling, etcetera
on the bottom of the foot.
Well, just like with carpal tunnel syndrome
where we tapped on that called the 'Tinel's sign',
you can also do a Tinel's
sign on the tibial tunnel.
It's running just posterior
medial to the medial malleolus
and you're just going to tap on that area to
see if that reproduces this patient's pain.
So here's the insertion of her gastrocnemius
tendon, forming her Achilles tendon
and plugging into the top of the calcaneus.
Take note that in this area, patients can
have pain for three different reasons.
It could be Achilles tendinopathy and so they should
really have pain on the Achilles tendon itself,
or they could have pain at the insertion.
And when there's discomfort or even swelling and
warmth in that area, we think about enthesitis,
which is a manifestation potentially of reactive
arthritis and some of the other spondyloarthritides
or it could be just retrocalcaneal bursitis.
There is a Bursa that lies just deep to
the insertion of the Achilles tendon.
And when the bursa gets inflamed, oftentimes
by wearing shoes that are too tight
or shoes that have a very firm rage
posteriorly or wearing high heels,
those kinds of things,
the bursa can get inflamed
and simply wearing flip flops for a
week will typically make that go away.
But the patient would have tenderness
right there over the retrocalcaneal bursa.
The last thing I just wanted to highlight
is patients who do have suspicion
for an Achilles tendon tear, Achilles
tendon rupture sometimes we say.
There's a quick bedside test for that as well,
it's just called the 'calf squeeze test'.
Since the gastroc essentially
plantar flexes the foot.
If I just squeeze the gastroc, you'll note that her
foot dorsiflexes or plantarflexes on the left.
As long as it looks the same on
the right, you can confidently say
this patient does not have
a ruptured Achilles tendon.
You can do that in this position or
you can have the patient lying prone
and have their knee up in the air as well
to get an even more grossly visual result.