Motions of the Foot and Ankle

by Tyler Cymet, DO, FACOFP

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    00:01 So when you look at foot motion, we're gonna talk about pronation and supination Typically, supination is when you turn your hand palm upward toward the ceiling.

    00:10 With the foot, you’re not gonna hold it all the way forward but you’re still gonna turn it inward and upward.

    00:16 Pronation is going to be the opposite direction.

    00:21 ABduction is when you move the foot away from the body.

    00:24 ADduction is when you move it towards the body.

    00:28 And eversion and inversion of the foot: similarly, eversion - away, inversion - towards.

    00:33 And dorsiflexion is when you pull the foot up and plantarflexion is when you plant the foot down into the ground.

    00:41 That’s the motion of the ankle and foot.

    00:44 One test you want to do when you first start examining the ankle is called the anterior drawer test.

    00:49 and as to assess the stability of the talofibular ligament and you hold the calcaneus, pull it forward, seeing if the foot is held tightly in the ankle mortise.

    00:59 Thompson’s test as we mentioned earlier, is a test for the achilles tendon being intact which runs from the gastrocnemius tendon to the calcaneus.

    01:09 If you squeeze the gastrocnemius and the foot doesn’t move, then there’s been an interruption in the achilles tendon.

    01:16 And Klieger’s test which test external rotation when you rotate the foot lateral and you test for deltoid ligament sprain.

    01:24 the deltoid ligament is a strong medial ligament It can get torn, as it is on the inside, it is less common than a lateral ligament tear, but if you can rotate the foot lateral and you feel a tenderness or a gap by the deltoid ligament - that is a positive Klieger’s test.

    01:47 The talar tilt is when you invert the foot and evaluate for the integrity of the calcaneofibular ligament, the middle ligament and seeing how bad a sprain or strain was.

    01:59 You'll also get some eversion to evaluate for the integrity of the deltoid ligament.

    02:04 Ankle sprains are a very common problem.

    02:07 More than 25,000 sprains occur every day in the United States.

    02:11 10-30% of sports related injuries that occur in young athletes are ankle sprains and 40% of these patients will have some residual symptoms Sometimes it resolves in a day, a week, 2 weeks sometimes it can last years depending on the severity.

    02:26 It also causes instability, problems with walking, loss of balance and can lead to other problems later in life.

    02:33 When we look at ankle sprains, we generally classify it to 1 of 3 grades, Grade 1 is a ligament that's stretched but no instability, you're gonna have the swelling.

    02:42 You're gonna have the tenderness but you're not gonna have a floppiness in the ankle.

    02:49 Grade 2 is a partial tear of the ligament with some instability, generally if you can feed your finger and there and you feel the space, that's generally gonna be a grade 2 because it means that with you having that much freedom to palpate that deeply, the potential for instability is there.

    03:05 And grade 3 is a complete tear with a complete opening on movement of the ankle.

    03:13 The Ottawa ankle rules and the Ottawa foot rules tell you when to get an x-ray.

    03:19 For the Ottawa ankle rules - pain at the medial malleolus or along the distal 6 centimeters of the bone will tell you you need to get an x-ray.

    03:28 For the Ottawa foot rules - pain in the midfoot, if you palpate and push, particularly at the base of the fifth metatarsal gets you worried.

    03:40 Other aspects you may wanna look for before deciding whether or not to get an x-ray, for the ankle - pain at the lateral malleolus or along the 6 centimeters again gets you worried about a fracture.

    03:51 or pain in the midfoot in a navicular bone - if you can touch the navicular bone and people jump, you want to get an x-ray.

    04:00 And the last thing is inability to bear weight immediately after an injury typically, it takes up to an hour or two for a full swelling to occur for an ankle sprain.

    04:10 For a fracture, there'll be an immediate inability to bear weight.

    04:13 So if somebody says, "I was able to walk a litte bit but it hurt and I couldn't afterwards", then you're generally safe not getting an x-ray.

    04:21 For the foot, if you're unable to bear weight for 4 steps immediately after something happens, that's a good sign that you need an x-ray for you to rule out a fracture.

    04:33 Ankle sprains are generally treated symptomatically with awareness of the injury, protection of the injury.

    04:39 We've debated on and off when you start moving the ankle and more and more, we're saying it's okay to move it right away and to get a full range of motion wth the ankle but you want to protect them from further injury, you want to rest it somewhat with full range of motion, you use ice to limit swelling, compress with an ace wrap to help with return of lymph system, and maintain some elevation.

    05:02 An ar or gel-filled cast will help protect it.

    05:05 NSAIDS will help limit inflammation.

    05:08 And analgesics like tylenol and OMM will be a benefit as well.

    05:12 Exercise to maintain a range of motion.

    05:15 and to enhance lymphatic drainage can also be helpful.

    05:18 Now we talk about functional rehabilitation, making sure people can walk on uneven surfaces, walk up steps and eliminate the risk for further injury because of instablity.

    05:28 Another topic I want to introduce is the high ankle sprain.

    05:32 These are an injury to the tibiofiibular syndesmosis or the interosseus ligaments.

    05:39 And just something to be aware of: with bad sprains, you're gonna have the separation of those membranes and you can have other problems develop.

    05:47 So we just need to be aware of the anterior inferior tibiofibular ligament and the posterior inferior tibiofibular ligament as well as the interoseous membranes.

    05:58 So if you see a laxity or a separation, or you notice more movement in the tibial-fibular region - consider a high ankle sprain.

    06:08 And there's usually a different mechanism of injury, it's not a fall off of a step, it's generally more severe and with a lateral rotation of the foot and internal rotation of the tibia.

    06:22 so it's a distinct type of strain that's much less common than the others.

    06:28 If you are worried about it being different or being a high ankle sprain, you probably want to get more imaging, and consider bracing it and protecting the foot until you have full information.

    06:38 You also may want to consider podiatry or orthopedic consult You can get OMT for some other symptoms around it.

    06:45 T is functioning and comfort but it's not gonna be the treatment or cure.

    06:49 And you want to treat with pharmacotherapy and consider physiotherapy to help with healing When do you refer somebody wth an ankle sprain to a specialist? If there is a fracture or a fracture is suspected, if they're not getting better.

    07:05 If you have a full dislocation of the ankle or subluxation, if something is out of joint, it's likely that it's fallen out of joint again, and just treating it symptomatically is not gonna be enough.

    07:14 If there is any compromise, the neurovascular compartment, if you have numbness and tingling or weakness, you want to get a consult.

    07:23 If there's a tendon that's been ruptured, a positive Thomson test - get help and get this person referred.

    07:30 If you noticed a penetrating wound to the joint, this is no longer just an ankle sprain and further evaluation is needing And if you have a locking of the joint, then there's a piece of tissue in there or something broken off that's preventing it, it may need to be treated more than just locally, so I would refer to a surgeon at that point.

    07:50 And if you have an injury to the syndesmosis to the joint, then you can consider referring.

    07:55 From an osteopathic dysfunction, it's very common for the talar head of the fibula to get stuck, to not move adequately, and that's when you may want to treat or focus on.

    08:08 Calcaneal inversion/eversion injuries - these are things that are easy to test if you dont have inversion a everson, a loss of motion should be restored.

    08:18 If you have cuboid dysfunction, occasionally there's a curse with the cuboid comes out of place, it's exquisitely tender and it can be pushed back into place.

    08:27 Fifth metatarsal dysfuncton that does not result in a fracture is another thing that can be treated osteopathically with manipulation Navicular dysfunction again once you rule out fracture, if it's a mild tenderness are things you can treat with osteopathic manipulation.

    08:43 Cuneiform dysfuncton is also amenable to manipulation.

    08:47 and phalangeal dysfunction are all areas that can be treated with osteopathic manipulative medicine.

    08:53 That is the end of my ankle talk.

    About the Lecture

    The lecture Motions of the Foot and Ankle by Tyler Cymet, DO, FACOFP is from the course Osteopathic Diagnosis of the Ankle and Foot Region. It contains the following chapters:

    • Motions of the Foot and Ankle
    • Special Tests
    • Ankle Sprains
    • Treatment of Ankle Sprains
    • High Ankle Sprain

    Included Quiz Questions

    1. Deltoid ligament or distal tibiofibular syndesmosis sprain
    2. Achilles tendon rupture
    3. Anterior talo-fibular ligament and posterior talo-fibular ligament sprain
    4. Distal fracture of the tibia
    5. Navicular bone fracture
    1. A partial tear to the ligament with mild to moderate instability indicated by partial opening of the joint on stress maneuvers
    2. A stretched ligament, but no instability or opening of the joint on stress maneuvers
    3. A complete tear with complete opening of the joint on stress maneuvers
    4. An incomplete tear of the ligament with complete opening of the joint on stress maneuvers
    1. Injury to the distal tibiofibular syndesmosis ligaments
    2. Injury to the Achilles tendon only
    3. Injury to the deltoid ligament only
    4. Injury to the anterior talo-fibular ligament
    5. Injury to the posterior talo-fibular ligament

    Author of lecture Motions of the Foot and Ankle

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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