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.
With the foot, you’re not gonna
hold it all the way forward
but you’re still gonna
turn it inward and upward.
Pronation is going to be
the opposite direction.
ABduction is when you move
the foot away from the body.
ADduction is when you
move it towards the body.
And eversion and inversion of the foot:
similarly, eversion - away, inversion - towards.
And dorsiflexion is when
you pull the foot up
and plantarflexion is when you
plant the foot down into the ground.
That’s the motion of the ankle and foot.
One test you want to do when you
first start examining the ankle
is called the anterior drawer test.
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.
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.
If you squeeze the gastrocnemius
and the foot doesn’t move,
then there’s been an interruption
in the achilles tendon.
And Klieger’s test which test external
rotation when you rotate the foot lateral
and you test for
deltoid ligament sprain.
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.
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.
You'll also get some eversion to evaluate
for the integrity of the deltoid ligament.
Ankle sprains are a
very common problem.
More than 25,000 sprains occur
every day in the United States.
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.
It also causes instability,
problems with walking, loss of balance
and can lead to other
problems later in life.
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.
You're gonna have the tenderness but you're
not gonna have a floppiness in the ankle.
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.
And grade 3 is a complete tear with a
complete opening on movement of the ankle.
The Ottawa ankle rules and the Ottawa
foot rules tell you when to get an x-ray.
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.
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.
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.
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.
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.
For a fracture, there'll be an
immediate inability to bear weight.
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.
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.
Ankle sprains are generally treated symptomatically
with awareness of the injury, protection of the injury.
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.
An ar or gel-filled cast
will help protect it.
NSAIDS will help limit inflammation.
And analgesics like tylenol and OMM
will be a benefit as well.
Exercise to maintain
a range of motion.
and to enhance lymphatic
drainage can also be helpful.
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.
Another topic I want to introduce
is the high ankle sprain.
These are an injury to the tibiofiibular
syndesmosis or the interosseus ligaments.
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.
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.
So if you see a laxity or a
separation, or you notice more movement
in the tibial-fibular region -
consider a high ankle sprain.
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.
so it's a distinct type of strain that's
much less common than the others.
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.
You also may want to consider
podiatry or orthopedic consult
You can get OMT for some
other symptoms around it.
T is functioning and comfort but it's
not gonna be the treatment or cure.
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.
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.
If there is any compromise,
the neurovascular compartment,
if you have numbness and tingling or
weakness, you want to get a consult.
If there's a tendon that's been ruptured, a positive
Thomson test - get help and get this person referred.
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.
And if you have an injury to the syndesmosis
to the joint, then you can consider referring.
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.
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.
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.
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
Cuneiform dysfuncton is also
amenable to manipulation.
phalangeal dysfunction are all areas
that can be treated with
osteopathic manipulative medicine.
That is the end of my ankle talk.