Evaluation

1
Evaluation Treatment of Foot/Ankle Injuries

• Ross Brakeville, PT, DPT STC
• Woodstock Physical Therapy Performance Institute

2
Evaluation Strategies

• Test, dont guess!
• George Davies

3
MD

• Limited clinical evaluation
• Specificity 85
• Sensitivity 90
• X-ray
• Bone versus tissue
• MRI
• Specificity 85
• Sensitivity 59
• Liu SH, et al. AJSM 24(2) 149-154, 1996

4
Foot Ankle

• Ankle - Anatomy

5
Foot Ankle

• Anatomy

6
Subjective Exam History(Goal to confirm PE
with SE)

1. Onset
2. Etiology (Macro vs. Micro trauma)
3. Past treatments and tests with results
4. Current c/o
5. PMHx
6. Review of systems
7. Subjective Score with limitations
8. Pain levels
9. Patient Goals

7
Physical Exam

• Inspection
• Gait
• Weight Bearing
• Discoloration
• Swelling
• Deformity
• Pronated vs. Supinated
• Skin

8
Ankle Injuries

• Inversion injury
• Most common sports injury

9
Evaluation

• History
• what happened
• when did it happen
• trauma/self imposed

10
Evaluation

• Inspection
• Gait
• Swelling
• Ecchymosis

11
Evaluation

• Palpation does it reproduce symptoms? If so,
  how
• severe?
• ATF
• CFL
• PTF
• TF
• Lateral malleolus
• Base of 5th metatarsal
• Medial malleolus
• Talar dome

12
Evaluation

• Stress tests
• Inversion
• Rotation
• Compression
• Anterior drawer
• Fibular mobility

13
Evaluation

• ROM
• Dorsiflexion - Supination
• Plantarflexion - Pronation
• Hallux Extension

14
Evaluation

• Muscle Tests
• Dorsiflexion
• Plantarflexion
• Inversion
• Eversion

15
Injuries

• Ankle Sprain

16
Injuries

• Growth Plate

17
Injuries

• Growth Plate

18
Injuries

• Severs Disease - Squeeze sign

19
Injuries

• LisFranc

20
Injuries

• Ankle Talar Dome

21
Injuries

• Stress fracture

22
Treatment

• In sports medicine and orthopedics, treatment is
  an active process. Rare is the case in which
  rest or inactivity is desirable.
• Instead, relative rest through management is
  recommended. The goal is to return to activity
  prepared. As tissue healing matures Wolfs
  Law and the S.A.I.D. principles should be
  instituted so there are minimal risks of
  recurrence.
• Physical Therapists are well trained in tissue
  physiology and the art of healing. Therefore,
  physical therapy is the best resource for
  management of the healing process.

23
Treatment

• Ankle Sprain
• Grade I Brace, NSAIDS, Ice, Physical Therapy
• Grade II Brace, NSAIDS, Ice, Crutches, Physical
  Therapy
• Grade III Immobilization, Ortho, NSAIDS,
  Physical Therapy management with Ortho

24
Treatment

• Growth Plate
• Mild Pain NSAIDS, Ice, Physical Therapy
  management
• Moderate Pain X-ray, NSAIDS, Ice, Physical
  Therapy management/Immobilization
• Severe Pain Ortho/Immobilization, NSAIDS, Ice,
  Physical Therapy management with Ortho
• Physical therapy management based on decreasing
  stress from the involved growth plate.

25
Treatment

• Fractures/Dislocations
• Immobilization, Ortho, and physical therapy
  management with Ortho

26
Case Report

• History
• 14 year old male inversion injury to right ankle
  trying to change directions playing soccer
• Immediate swelling lateral malleolus region that
  over next 24 hours continued to increase but only
  on lateral aspect of foot/ankle
• Pain moderate to severe and unable weight bear

27
Case Report

• Rule Out
• Fracture to lateral malleolus fibular growth
  plate
• Jones fracture/base of 5th metatarsal growth
  plate
• Medial malleolus compression fracture
• Syndesmosis injury
• Osteochondral fracture

28
Case Report

• Exam
• Admits with help from parents non weight bearing
• Moderate swelling lateral malleolus and
  ecchymosis lateral calcaneus
• Palpation
• distal fibula at growth plate mild moderate
• ATF moderate
• CFL moderate
• PTF mild
• - base of 5th metatarsal
• - deltoid ligament
• - medial malleolus
• anterior tibfib ligament minimal

29
Case Report

• X-ray
• A/P - negative
• Lateral - negative
• Mortise View negative
• If suspect instability of syndesmosis may order
  Talar tilt Anterior drawer stress views but
  usually done if complications with physical
  therapy.

30
Case Report

• Stress Tests
• Inversion moderate severe at ATF and CF
  ligaments
• Rotation minimal at anterior TF ligament
• - Compression
• - Drawer
• - Fibular mobility

31
Case Report

• ROM Strength
• ROM limited all planes secondary to pain lateral
  ankle
• Strength limited eversion gt inversion,
  dorsiflexion gt plantarflexion

32
Case Report

• DX
• Lateral Ankle Sprain Grade II II
• High Ankle Sprain Grade I
• Working DX
• Ligament damage ATF CF
• Pain
• Loss of Motion
• Decreased Strength
• Decreased Proprioception
• ? Core stability risk factor
• ? Pronation risk factor

33
Case Report

• Plan of Care
• Ankle brace
• Crutches WBAT
• NSAIDS after 48 hours
• Ice, Compression, Elevation
• Physical Therapy started immediately and daily
• Modalities - electrical stimulation
• Non-impact CV activities bike
• Open chain strength for lower leg and foot
• Closed chain activities
• Proprioception work
• Return to function
• Reduce risk of recurrence
• Core Stabilization
• Orthotics

34
Case Report

• Physical Therapy - Started 2 days after insult
• Day 1
• Electrical Stimulation
• Non-impact CV activities Bike
• Gait training WBAT
• Open chain lower leg ankle strengthening
  PNF
• Core Strengthening
• Emphasize throughout rehabilitation that there
  should be no pain!!

35
Case Report

• Day 2
• Bike
• Gait training WBAT progress to independent
• ROM work in pain free range
• Progress open chain strength pain free
• Foot Ankle
• Entire LE
• Progress Core Stabilization
• Start close chain work with emphasis on
  balance/proprioception
• Electrical stimulation with ice
• 1 crutch left arm with ankle brace

36
Case Report

• Day 3-5
• D/C crutch as able to ambulate normal with brace
• Continue with Day 2 treatments increasing
  intensity of loads
• Add step-ups
• Add ambulation on side of feet (supination
  walking)

37
Case Report

• Day 6
• Patient now has strength, full motion
• Patient limited with balance.
• tender ATF, CF mild-moderate.
• tender distal fibula minimal
• - PTF, and anterior tibfib ligament
• Treatment progress with day 5 activities and
  started low level plyometrics in linear plane

38
Case Report

• Day 7-8
• Progression with day 6 activities and increase
  plyometric work to include rotational and lateral
  activities.

39
Case Report

• Day 9
• Testing
• ATF minimal to moderate
• CF minimal
• - distal fibula
• Squat 2/3 pain
• Lunge 3/3 pain
• MMT 4/5 all planes pain
• Balance testing 4 4/5 pain
• Plyometric liner movements compared to L LE
  pain or apprehension
• Plyometric lateral and rotational movements
  ?20 with slight apprehension and pain along
  ATF and CF lig.
• Treatment same as Day 8 and allowed to
  practice drills but not scrimmage in brace.

40
Case Report

• Day 10 and 11 Progressed with full LE and core
  program as per above.
• Day 12 Retest with a Functional Score of 98
  to include a Subjective Score of 99.
  Therefore, patient D/C and allowed to return to
  full sport with brace X 6 weeks.

41
Case Report

• Two week and two month follow up is without
  complaints and negative palpable tenderness.
• Patient instructed, at two month follow up, to
  D/C brace during practice but can wear in games
  if desired.

42
(No Transcript)