AH 325

Ankle, Foot, & Lower Leg Injuries Laboratory

1. History
   1. Mechanism of Injury
      1. Overstretch
         1. Inversion - common cause of sprains to anterior talofibular, anterolateral capsule, calcaneofibular, posterior talofibular ligaments, lateral malleolus fx, medial malleolus fx, avulsion of lateral malleolus, strains of peroneal tendon, extensor digitorum brevis, 5^th metatarsal base fx, midtarsal joint sprain, talar osteochondral fx of superomedial portion of talus.
         2. Eversion - most commonly a Deltoid sprain involving its components of tibiocalcaneal ligament (easily torn), tibionavicular ligament (weakest), tibiospring ligament, posterior tibiotalar ligament (often associated with avulsion fx), medial malleolus avulsion fx also occur as do lower 1/3 fibular fx, bimalleolar fxs.
         3. Plantar flexion - uncommon, can cause anterior capsule sprain, anterior talofibular ligament sprain, bifurcate ligament sprain, posterior talar impingement of lateral posterior tubercle of talus between tibia & calcaneus, midtarsal joint sprain.
         4. Dorsiflexion - anterior & posterior inferior tibiofibular ligament sprain, Achilles tendon strain, posterior talofibular ligament sprain, calcaneofibular ligament sprain, posterior capsule sprain, anterior talar impingement, fx fibula, fx of talar neck, talar dome fx.
         5. Dorsiflexion & inversion - calcaneofibular ligament sprain, lateral talar dome fx, osteochondral fx, posterior talofibular sprain.
         6. Dorsiflexion & eversion - dorsiflexed & everted position in combination with strong peroneal contraction can lead to acute anterior dislocation of peroneal tendons, resulting peroneal tendon subluxation.
         7. Hyperextension of 1^st Interphalangeal or Metatarsophalangeal joint - common turf toe, capsuloligamentous sprain, compression injury to articular cartilage metatarsophalangeal dislocation.
         8. Dorsiflexion of the Forefoot - can cause spring ligament & plantar fascia tear, tibialis posterior muscle strain, interphalangeal & metatarsophalangeal sprains.
      2. Direct Blow
         1. Dorsum of the Foot - contusion or fx of mid or forefoot, tarsometatarsal sprains
         2. Malleoli - contusions, periostitis, fx, (lateral malleolus) peroneal subluxation
         3. Plantar Surface of the Foot - subcutaneous tissue contusion, sesamoiditis, sprain of forefoot or midfoot ligaments.
         4. Calcaneus - calcaneal heel pad contusion, calcaneal periostitis, calcaneal compression fx
      3. Forced Muscle Contraction - muscle or tendon strain or rupture, particularly Achilles, gastrocnemius, peroneal tendon subluxation.
      4. Overuse
         1. Running, Jumping, Dancing - contributed to by poor exercise surface, poor exercise technique, inadequate shoe wear, training errors, muscle imbalances, structural abnormalities such as compensated subtalar varus, forefoot varus, talipes equinus, excessive tibial torsion, excessive tibial varum, or tarsal coalition.
         2. Stress Fractures - tibia (more common in pronated feet), tarsal (talus, navicular), metatarsals (usually 2^nd or 3^rd , more common in cavus foot), fibula, sesamoids, calcaneus.
         3. Periosteitis or Stress Reaction - tibia, fibular, calcaneus, sesamoids, talus, calcaneal spur or exostosis
         4. Tendonitis - Achilles, peroneal, anterior & posterior tibial, flexor hallucis longus, flexor digitorum longus
         5. Blisters and Calluses - posterior heel & metatarsal heads
         6. Compartment Syndromes - anterior, posterior (deep or superficial), lateral, tarsal tunnel syndrome
         7. Synovitis - especially 1^st metatarsophalangeal joint
         8. Calcaneal Irritations - repetitive movements can irritate medial & lateral calcaneal nerves, calcaneal fat pad, calcaneal bursa, calcaneal exostosis & spurs, plantar fasciitis.
      5. Sports Related - analyze common activities for sports & positions
      6. Forces in the Sports
      7. Body Position - weight-bearing or not
      8. Demonstrate the Mechanism
      9. Sport or Running Surface - shock absorbing characteristics of surface, level
      10. Footwear
          1. Toe Box - shallow causes toenail injury, too narrow causes 1^st or 5^th metatarsal problems
          2. Longitudinal Arch - inadequate can cause pronation problems, tibialis posterior tendonitis, tibialis anterior tendinitis, plantar fasciitis.
          3. Heel Counter - if inadequate ankle sprains or Achilles tendinitis, if rigid, retrocalcaneal blisters & exostosis.
          4. Sole - too flexible can lead to metatarsalgia or hyperextension of 1^st MTP joint, too stiff at MTP joint places excessive strain on Achilles tendon. Straight last soles are better fro pronating feet and curve-last soles are better for supinating feet.
   2. Pain
      1. Location
         1. Local Pain - usually from more superficial structures such as skin, fascia, superficial muscles (peroneal, tibialis anterior, gastrocnemius), superficial ligaments (anterior talofibular, calcaneofibular, spring, bifurcate), periosteum (malleoli, tibia, calcaneus).
         2. Referred Pain - usually from deep muscle (tibialis posterior, soleus), deep ligament (posterior talofibular), bursa (posterior bursa), capsule (talocrural joint capsule), bone (tibia & fibula), nerve root (L4, L5, S1), superficial nerve (sural, deep or superficial peroneal).
         3. Onset of Pain - quick onset suggest a more severe problem, if after 24 hours suggests gradual tissue response to trauma such as synovial swelling, tendonitis, minor sprain, capsulitis, if insidious suggest a systemic disorder such as rheumatoid arthritis, Reiter disease, psoriatic disease, gout.
      2. Type of Pain
         1. Sharp - from skin, superficial fascia, tendon, superficial muscle, superficial ligament, bursa, periosteum.
         2. Dull - from tendon sheath (peroneal tendons), deep muscle (anterior, posterior, or lateral compartment), stress fx (metatarsal, fibular, tibia).
         3. Aching - from compact fascia (calcaneal fat pad contusion), deep muscle (compartment syndrome), tendon sheath (chronic peroneal tendinitis), deep ligament (anterior tibiofibular), fibrous capsule (talocrural joint capsular sprain), chronic bursa (retrocalcaneal bursa).
         4. Burning - skin (blister), tendon sheath (acute extensor hallucis longus tendonitis), peripheral nerve (calcaneal or sural nerve entrapment).
         5. Pins and Needles(Paresthesia) - peripheral nerve (lateral cutaneous nerve), nerve roots (L4, L5, S1)
         6. Numbness(Anesthesia) - dorsal nerve root (herniated disc with L4, L5, S1 nerve root compression), peripheral nerve (deep or superficial peroneal cutaneous nerve compression)
      3. When Pain Occurs
         1. All the Time - Acute conditions & long term chronic long-term injuries such as acute bursitis, acute ligament sprain, osteoarthritis, neoplasm.
         2. Only After Repeating the Injury Mechanism - suggests a very localized lesion, specific structures
         3. Only After Repeated Movement - suggest that overuse is the cause
      4. Severity of Pain - generally the more severe the pain the more severe the injury, but not always
   3. Swelling
      1. Location
         1. Local - stress fx of the fibula, metatarsals, peroneal strain or tendinitis, Achilles tendon strain or tendinitis, flexor hallucis longus, extensor digitorum tendons with tendonitis or tenosynovitis.
         2. Diffuse - generalized edema from contusion, diffuse ecchymosis after extra-articular injury, intermuscular or intramuscular swelling.
      2. Time of Swelling
         1. Immediately - indicates severe injury with damage to structure with rich blood supply such severe partial to complete ligament tear, acute osteochondral lesion of talar dome, calcaneal fx of anterior process, talar fx.
         2. After 6 to 12 Hours - less severe suggesting synovitis or irritation of joint synovium such as capsular sprain, subtalar subluxation, ligamentous sprain.
         3. After Activity - suggest activity aggravates the condition such as chronic ankle instability, undetected chondral lesion, subacute ankle injury joint irritation from decreased dorsiflexion ROM.
         4. Insidious Onset - osteoarthritic joint condition or collagen disorder such rheumatoid arthritis, Reiter syndrome, ankylosing spondylitis, gout, lupus.
      3. Amount of Swelling - generally the more swelling, the more severe, but not always & there are many exceptions
         1. Immediate Care - proper immediate care may have reduced the total amount of swelling
         2. When Does it Swell - post cast, repeated sprains, limited ROM, bone chip or fracture
   4. Function - inability to bear weight immediately suggests more severe injury such as fx or severe sprain, locking in the joint suggest a bone chip or osteochondritis dissecans of talus or talar dome, weakness suggest neural or significant muscle injury, reflex muscle inhibition, fx.
      1. Instability - chronic ankle sprain, fx, peroneal weakness & loss of proprioception
   5. Sensations
      1. Type of Sensation
         1. Warmth - indicates active inflammation, infection, gout
         2. Numbness - local neural involvement, most commonly peroneal & posterior tibial, possibly compartment syndrome.
         3. Tingling -neural or circulatory problem
         4. Clicking and Catching - usually osteochondral lesion of the talus
         5. Snapping - indicates subluxing peroneal tendons or tendons snapping over bony prominences
         6. Popping or Tearing (At Time of Injury) - significant muscle or ligament tear
         7. Grating - indicates osteoarthritic changes, osteochondral lesion of talus, lateral talar chondromalacia
         8. Crepitus - in tendons caused by inflammation or Achilles, peroneal, extensor tendon, flexor hallucis longus
   6. Particulars
      1. Chronic - common ongoing problems are stress fxs, Achilles or flexor hallucis longus tendinitis, peroneal dislocations, repeated ankle sprains, anterior capsule impingement, arthritis, osteochondral damage, painful tarsal coalition commonly calcaneonavicular, talocalcaneal area, talonavicular area.
      2. Other Limb Problems - leg length difference, knee problems, unrelated previous tibia, foot, or ankle injuries
      3. Previous Care - previous diagnosis, x-rays, treatment, rehab, results
2. Observations
   1. Prolonged Pronation - forefoot abduction, talar adduction & plantarflexion, talar adduction & subtalar eversion.
   2. Fixed Supination - forefoot adduction, dorsiflexion, talar abduction, & subtalar inversion.
   3. Weight-bearing - observe to see how body compensates for structural abnormality.
      1. Anterior View
         1. Lumbar Lordosis - associated with facet dysfunction & intervertebral disc herniation which can radiate pain or numbness to lower leg, foot, or ankle.
         2. Anterior Pelvic Tilt - associated with foot pronation problems, if unilaterally tilted could be leg length difference or rotated ilium.
         3. Leg-length Discrepancy - can be created by one foot be pronated & other being supinated, overuse conditions may develop with excessive pronation.
         4. Femoral Anteversion (Increased Femoral Medial Rotation) - can cause foot pronation, leading to overuse conditions.
         5. Previous Knee Injury - may have caused lower extremity weakness leading to foot, ankle, or leg problem.
         6. Genu Varum - usually associated with cavus foot, causing ankle sprains & peroneal tendinitis.
         7. Genu Valgum - usually associated with over pronation
         8. Tibial Internal Torsion - creates pronation problems with weight-bearing, walking, & running. The forefoot abducts on the rear foot or the foot abducts on the leg causing problems.
         9. Tibial External Torsion - often leads to high-arched cavus foot
         10. Tibial Varum - causes foot pronation problems because foot pronates to compensate for angle of tibia
         11. Tibial Localized Swelling or Enlargement - can be from periostitis from overuse or ecchymosis from direct trauma.
         12. Foot
             1. Longitudinal Arch - depressed (pronated) or elevated (supinated)
             2. Transverse Arch - depressed in weight-bearing can lead to metatarsalgia, Morton neuroma, digital nerve problems. When depressed metatarsal heads bear to much weight.
             3. Subungual Hematomas - occur when shoe toe box is not deep enough
             4. Toe Alignment
                1. Hallux valgus - valgus angulation of proximal phalanx of great toe, leads to pronation problems & bunion development, may be caused by high heels & pointed toe shoes. Second metatarsal can develop callus & stress fxs, often compounded by fallen transverse arch.
                2. Morton’s foot - shorter great toe than second leading to more weight-bearing forces through second toe & hypermobility in first ray. Leads to metatarsalgia.
                3. Swelling (local)
             5. Ankle and Foot
      2. Lateral View
         1. Anterior Pelvic Tilt - usually associated with pronated foot problems
         2. Genu Recurvatum(Hyperextension) - usually results in plantar flexion of ankle even in standing position & possibly lead to Achilles shortening resulting in pronation problems.
         3. Ankle Swelling, Discoloration, Deformity - use to pinpoint location of injury
         4. Forefoot Swelling - injury to tarsals, metatarsals, or phalanges
         5. Longitudinal Arch - if depressed it can result in pronation problems, if elevated it can lead to supination problems.
         6. Claw Toe - hyperextended metatarsophalangeal joint, with PIP & DIP flexed, results in callus formation over PIP dorsally & associated plantar keratoma under involved metatarsal head. Proximal phalanx may sublux dorsally.
         7. Hammer Toe - hyperextended metatarsophalangeal joint, flexed PIP, & extended DIP indicating muscle imbalances, poorly fitting shoes, hereditary component resulting in calluses forming over raised PIP, most commonly in 5^th toe with associated dorsolateral callus.
         8. Mallet Toe - extensor tendon rupture or flexion deformity of DIP results in DIP remaining flexed resulting in distal lesion from pressure on tip of toe at DIP joint.
         9. Enlarged Malleoli - from callus formation of previous fx
         10. Lateral Calcaneal Exostosis(Pump Bump) - common in overpronating foot with a compensated subtalar varus foot & resulting hypermobile foot.
         11. Fifth Metatarsophalangeal Exostosis(Tailor's Bunion) - 5^th metatarsophalangeal exostosis commonly results from fallen metatarsal arch in pronated foot & common in hallux valgus deformities which cause the 5^th toe to rub against shoe.
         12. Talar Exostosis
             1. anterior talar exostosis is a dorsal spur on neck of talus which can cause impingement problems when talar neck impinges on anterior lip of tibia during forced or repeated dorsiflexion—soft tissue or bony damage can result, common in high-arched cavus foot.
             2. posterior impingement can occur between talar tubercle or os trigonum & posterior inferior surface of tibia with excessive or forced plantar flexion resulting in soft-tissue or bony damage.
         13. First Metatarsal-Cuneiform Exostosis - develops from excess force going through 1^st metatarsal head & can restrict forefoot movements & rub in shoe.
         14. Os Navicularis - extra bone can cause the tibialis posterior to attach to medial side of foot preventing it from supporting the longitudinal arch leading to overpronation problems, can also rub on inside of shoe. If attached it can be avulsed with violent contraction of tibialis posterior or from repeated trauma. Overlying callus or bursa can develop.
      3. Posterior View
         1. Pelvis - any differences form side to side can indicate leg-length difference, pelvic rotation, or upward/downward pelvic shift.
         2. Ankle
            1. Subtalar Varus(Inverted Calcaneus) can be associated with fixed cavus foot or a pronating foot.
            2. Subtalar Valgus(Everted Calcaneus) usually causes overpronation problems, if severe, foot may already be fully pronated in pes planus.
            3. Achilles Tendon Alignment - uncompensated subtalar varus position will cause Achilles tendon to bow, resulting in shortened or tight gastrocnemius/soleus complex which, in turn, can pull calcaneus upward & stress the plantar fascia. Can result in strain or tendinitis to Achilles & plantar fasciitis.
            4. Achilles Tendon Enlargement - suggest present or previous Achilles tendonitis, strain, or tear.
            5. Intracapsular Swelling - causes swelling on both sides of ankle under malleolus indicating severe sprain or fx, if developed immediately after injury the swelling is hemarthrosis, if gradual it usually indicates a synovial type swelling with less severe damage.
            6. Extracapsular Swelling - on one side of ankle only is usually caused by soft-tissue damage outside joint capsule.
            7. Achilles Bursa Swelling - superficial retrocalcaneal or posterior calcaneal bursitis can occur between tendon & skin from poorly fitted shoes, deeper swelling between tendon & calcaneus suggest a deep retrocalcaneal bursitis, which is more severe.
            8. Swelling around the Calcaneus - can be caused by a calcaneal fx or apophysitis in the young athlete
            9. Rigid Pes Planus(Flat Foot) - can be caused by tarsal coalition, calcaneus has excessive valgus associated with forefoot abduction & possibly peroneal shortening or spasm.
      4. Non-weight-bearing - observe to appreciate differences between weight & non-weight bearing
         1. Foot and Ankle
            1. Plantar Aspect of the Foot - check for calluses, blisters, corns, plantar warts, tight plantar fascia, nodes in fascia.
            2. Dorsum of the Foot - if extensor tendons are prominent they may be tight suggesting a muscle imbalance, if foot becomes red or blue when lowered, there may be small vessel vascular disease or arterial insufficiency.
            3. Longitudinal Arch of the Foot - check to see if depresses or elevated as compared to weight bearing
            4. Metatarsal Arch - if arch is collapsed in weight bearing & rises on non weight-bearing, arch has not completely collapsed & restorative measures can be taken.
            5. First Ray - may be plantar or dorsiflexed (flexible or rigid), if plantar flexed & flexible the weight-bearing forces are shifted to 2^nd metatarsal during gait while 1^st ray dorsiflexes & inverts. If plantar flexed & rigid, 1^st metatarsal will bear most of the force & may prevent subtalar joint from achieving normal pronation during gait. Dorsiflexed, flexible, & rigid 1^st rays will cause overpronation during gait.
      5. Walking
         1. Normal - watch lumbar spine, pelvis, & entire lower limb during stance & swing phase
         2. Stance Phase
            1. Heel Strike - calcaneus is inverted 2⁰ to 4⁰ of varus, subtalar & midtarsal joints are supinated at heel strike & start to move toward pronation. The tibia, talus, & calcaneus must be aligned to absorb the vertical force of the body. Ankle dorsiflexors contract eccentrically to lower foot to ground & to control amount of pronation. Knee moves in to slight flexion to absorb body weight. Hip extensors & lateral rotators contract to move body forward & to stabilize hip & pelvis.
            2. Foot Flat - tibia rotates medially to allow subtalar joint to pronate, talocrural joint continues to dorsiflex, talus rolls medially to fully articulate with medial facet of calcaneus. Midtarsal joint unlocks when subtalar joint pronates. Longitudinal arch depresses, the cuboid & navicular alignment become more parallel, & forefoot becomes mobile, absorbs shock, and accommodates to the terrain.
            3. Midstance - knee moves into extension, tibia rotates laterally, subtalar joint supinates, & midtarsal joints lock to make the foot a rigid lever to push off.
            4. Heel Rise and Push Off - resupination of foot is initiated by lower limb external rotation. Lateral rotation of tibia causes subtalar supination, talus is pushed into lateral position, cuboid & navicular move more perpendicular, causing the midtarsal joints to lock up.
         3. Swing Phase
            1. Acceleration, Midswing, Deceleration - lower extremity is brought forward by the hip flexors while knee is flexed, ankle is dorsiflexed, & metatarsophalangeal joints extend.
         4. Problems
            1. Stride Length - should be same bilaterally
            2. Step Length - more equal the step length, the more the gait symmetry
            3. Degree of Toe Out - foot placement angle is normally 7⁰ from sagittal plane, greater than 7⁰ can cause excessive pronation problems, longitudinal arch collapse, decreased stride length, rotational torsion through entire limb.
            4. Stride Width - usually 2 to 4 inches, base is widened with heavy thighs, balance or proprioception problems, or decreased sensation in heel or sole of foot.
            5. Rhythm of the Gait - indicates coordination between limbs & weight distribution on each limb, knee should go into full extension & lock in midstance, upper limb movements should be opposite lower limb movements.
            6. Heel Strike - shortened period of time or foot pain in heel strike usually indicates heel pain probably caused by calcaneal spurs, plantar fasciitis, calcaneal periostitis, calcaneal apophysitis, calcaneal medial entrapment problems.
            7. Foot Flat - pain can be caused by anterior compartment syndrome or a dorsiflexion muscle strain
            8. Midstance - shortened time in midstance can be due to any of the foot or ankle joint
               1. Prolonged Pronation during Midstance - pronation should take 33% & supination should take 67% of the time, if more than 50% of time is in pronation it represents abnormal pronation. If resupination is too late, pronation problems can also develops.
               2. No Pronation during Midstance - can cause supination conditions including peroneal tendonitis, 5^th metatarsal & fibular stress fx.
            9. Heel Rise - should occur just as opposite leg swings by the stance leg, occur prematurely if triceps surae is tight, leading to excessive forces through the foot, if delayed there may be triceps weakness or previous rupture.
            10. Push Off - uneven forces on push off (forefoot valgus, forefoot varus, hallux valgus) can cause problems. Pushing off mainly through 1^st toe causes sesamoiditis or calluses, Pushing off at increased toe-out angle-abducted causes calluses, metatarsalgia, forefoot sprains, transverse arch collapse, Inability to push off with plantar flexors may be due to gastrocnemius/soleus strain, S1 nerve root irritation, Achilles tendon rupture or tendinitis, Inability to hyperextend the forefoot or toes during late push off may be due to plantar fasciitis, metatarsophalangeal joint sprain, metatarsal flexor strain, hallux rigidus.
         5. Swing Phase Problems
      6. Running - look for overpronation, no supination, lower leg rotation, foot & toe alignment
         1. Stance Phase Problems in Runners
            1. Prolonged Pronation - pronation problems not present in walking may appear
            2. No Supination - if subtalar joint remains supinated the lack of shock absorption can cause overuse problems.
            3. Rotation - if lower leg kicks outward during swing phase or if foot, pelvis, or upper body rotate, rotational forces can cause overuse problems.
      7. Footwear
         1. Upper - excessive pronation will bend the shoe upper medially, supination will bend it laterally, excessive wear in upper will inhibit its support role & lead to overuse problems.
         2. Sole - lateral edge of sole & just under metatarsal heads should be slightly worn, if too worn shock absorbing properties of foot may be lost, wear bar under metatarsal heads indicates rotation of foot prior to take off.
         3. Heel Counter - if too loose, it no longer supports subtalar joint & may allow overpronation, too tight can cause blisters & skin breakdown.
         4. Toe Box - hallux rigidus may crease toe box on an angle, inflexible toe box can cause midfoot problems, if too narrow problems develop between toes.
         5. Arch Support - needed for good shock absorption, insure that it fit correctly
         6. Heel - excessive wear on lateral heel increases ankle sprain, Achilles tendinitis, peroneal tendinitis. Medial wear is a sign of calcaneal valgus problems & overpronation.
         7. Last(Curved or Straight) - curved last is best for rigid cavus foot, straight last is better for overpronating foot
         8. Flexibility - too much flexibility may permit hyperextension injuries to metatarsophalangeal joints.
3. Palpation
   1. Medial structures
      1. Bony
         1. Head of the 1^st Metatarsal - bunions, blisters, bony exostosis, gout
         2. First Cuneometatarsal - exostosis, especially in high arched cavus foot
         3. Navicular tubercle - tenderness from aseptic necrosis, pressure from shoe if prominent
         4. Medial malleolus - contusion, fracture, avulsion
         5. Tibia -tibial stress reaction
      2. Soft tissue
         1. Cuneonavicular ligaments - tender form over pronation because they help support longitudinal arch
         2. Cuneometatarsal ligaments - sprains, & form overpronation
         3. Spring ligament - tender if foot is losing its arch, prolonged jumping or running
         4. Calcaneonavicular joint - tender especially if coalition is present
         5. Tibialis posterior tendon & muscle - tendinitis, form prolonged pronation
         6. Tibialis anterior tendon - tenderness caused by overpronation
         7. Deltoid ligament
            1. Posterior tibiotalar ligament -eversion & dorsiflexion sprain
            2. Tibiocalcaneal ligament - eversion
            3. Tibionavicular ligament - eversion & plantar flexion
         8. Flexor hallucis longus tendon - not usually palpable, tenderness posterior to medial malleolus
         9. Flexor digitorum longus tendon - tenderness just below medial malleolus
         10. Tarsal tunnel - includes tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial nerve & artery, flexor hallucis longus tendon.
         11. Talocalcaneal joint - tenderness caused by talocalcaneal coalition, limited subtalar movements & very flat foot
   2. Lateral structures
      1. Bony
         1. Lateral malleolus - periosteal contusion or fracture, avulsion
         2. 5^th metatarsal bone - fx or bursa
      2. Soft Tissue
         1. 5^th Metatarsophalangeal joint - tailor’s bunion, blister, sprain or dislocation
         2. Lateral ligaments
            1. Anterior talofibular ligament - highest incidence of sprains
            2. Calcaneofibular ligament - next most common sprain
            3. Posterior talofibular ligament - only sprained in very severe ankle sprains or dislocations
         3. Bifurcate ligaments - tender if sprained, from plantar flexion mechanism
         4. Peroneal tendons - tender if snapping out of groove from subluxation or tenosynovitis
         5. Peroneal muscles - may be tender from overuse or strains
         6. Lateral compartment - acute or chronic compartment syndrome
         7. Superior tibiofibular joint - tender form any dysfunction in superior or inferior tibiofibular joint
   3. Posterior structures
      1. Bony
         1. Calcaneus - tender from contusion, compression fracture or growth plate fracture
      2. Soft Tissues
         1. Achilles tendon - tender form Achilles tendinitis or strain, calcaneal bursitis, retrocalcaneal bursitis
         2. Gastrocnemius - tender from strains or contusions
         3. Soleus - tender from strains or contusions
   4. Plantar structures
      1. Bony
         1. Calcaneus - calcaneal bursa, calcaneal spur, calcaneal periostitis
         2. Sesamoid bones - flexor hallucis brevis tendon, sesamoiditis
         3. Metatarsal head - if ore prominent it may bear more weight, metatarsalgia if transverse arch collapses, between 3^rd & 4^th if Morton’s neuroma, plantar warts
      2. Soft tissue
         1. Plantar fascia - fasciitis down medial side of fascia
         2. Long & Short Plantar Ligaments (Plantar Calcaneocuboid ligaments) - support longitudinal arch, may be acutely point tender if foot sprain, strain, or prolonged pronation occurs
         3. Spring ligament (Plantar calcaneonavicular) - supports arch, strained from overuse
         4. Plantar flexor muscles - may be tender from strain or contusion, will affect gait during midstance & toe-off
   5. Dorsal structures
      1. Bony
         1. Sinus tarsi - may be swollen & tender secondary to ankle sprains or if extensor digitorum brevis is strained
         2. Metatarsals, Phalanges, & Local soft tissue - corns, psoriasis, fractures, contusions
      2. Soft Tissues
         1. Anterior Inferior Tibiofibular Ligament - sprains of this ligament & secondary to lateral ankle sprains
         2. Tibialis Anterior Tendon & Muscle - tendinitis, tenosynovitis - creaking, crepitus
         3. Anterior compartment syndrome - if tight, swollen, tender, & warm - acute compartment syndrome, may be chronic after exertion
         4. Extensor Digitorum Longus - tendinitis or tenosynovitis
         5. Extensor Digitorum Brevis - tendinitis or strain
         6. Extensor Hallucis Longus & Brevis - tendinitis or strain, especially the longus
         7. Extensor Digiti Minimi & Peroneus Tertius - strained with inversion mechanism, especially if foot rolls
4. Functional Testing
   1. Rule Out
      1. Inflammatory Disorders - rheumatoid arthritis, Reiter disease, psoriatic arthritis, gouty arthritis
      2. Lumbar Spine
      3. Knee Joint
      4. Superior Tibiofibular Joint - injury can limit fibular movement which limits talocrural dorsiflexion & cause ankle dysfunction.
      5. Fracture - test to assist in ruling out
      6. Fracture tests
         1. Fibula - percuss at lateral malleolus & fibula head, varus force with one hand & valgus with other hand above & below site of suspected fx site, crepitus & local point tenderness.
         2. Tibia - percuss anywhere along its length, varus & valgus force applied above & below suspected fx site, heel tap test, crepitus & local point tenderness.
         3. Talus - tap calcaneus into talus
         4. Calcaneus - percussing & compressing
   2. Test in Long Sitting
      1. Active talocrural plantar flexion (50⁰) - pain, weakness, or limited ROM can be caused by injury to muscles or their nerve supply
         1. gastrocnemius - tibial N. (S1, S2)
         2. soleus - tibial N. (S1, S2)
      2. Passive talocrural plantar flexion (50⁰) - passive ROM may be limited/painful due to
         1. tight or shortened ankle/foot dorsiflexors
         2. tight or adhesed anterior joint capsule
         3. extra accessory bone (os trigonum or steida process) located behind talus above calcaneus
         4. intracapsular swelling
         5. extracapsular swelling
         6. anterior talofibular ligament sprain
         7. posterior talofibular ligament sprain
         8. tibialis anterior muscle tendinitis, strain, or tear
         9. tibialis posterior muscle tendinitis, strain, or tear
         10. extensor digitorum muscle tendinitis, strain, or tear
         11. anterior deltoid ligament sprain
      3. Active talocrural dorsiflexion (20⁰) - pain, weakness, or limited ROM can be caused by injury to muscles or their nerve supply
         1. tibialis anterior - deep peroneal N. (L4, L5, S1)
         2. extensor hallucis longus - deep peroneal N. (L4, L5, S1)
         3. extensor digitorum longus - deep peroneal N. (L4, L5, S1)
         4. peroneus tertius - superficial peroneal N. (L4, L5, S1)
      4. Passive talocrural dorsiflexion (knee extended and knee flexed 20⁰) - passive ROM may be limited/painful due to
         1. gastrocnemius, soleus, or plantaris muscle strain
         2. posterior joint capsule sprain
         3. posterior talofibular ligament sprain
         4. posterior deltoid ligament sprain
         5. intracapsular joint swelling
         6. posterior joint contracture
         7. thickening of anterior inferior tibiofibular ligament from previous injury
         8. anterior talar exostosis
      5. Resisted talocrural dorsiflexion - weakness, pain, or limited ROM can be caused by:
         1. injury to prime movers or their nerve supply
         2. L4 nerve root injury
         3. tibialis anterior tendinitis
         4. tibialis anterior periostitis
         5. anterior compartment syndrome problems
         6. extensor digitorum longus tendinitis
      6. Active subtalar inversion - assisted by talocalcaneal, talonavicular, & calcaneocuboid movement. Pain, weakness, or limited ROM can be caused by injury to prime movers or their nerve supply
         1. tibialis anterior - deep peroneal N. (L4, L5, S1)
         2. tibialis posterior - tibial N. (L5, S1)
      7. Passive subtalar inversion - passive ROM may be limited/painful due to
         1. anterior talofibular ligament sprain
         2. lateral capsular ligament sprain
         3. subtalar joint effusion
         4. calcaneal fx
         5. calcaneofibular ligament sprain
         6. bifurcate ligament sprain
         7. peroneal tendinitis
         8. 5^th metatarsal fx
      8. Passive plantar flexion and subtalar inversion - passive ROM may be limited/painful due to
         1. anterior capsular sprain
         2. anterior talofibular ligament sprain
         3. calcaneocuboid ligament sprain
         4. extensor digitorum longus or brevis strain
         5. peroneal tendonitis or strain
      9. Passive dorsiflexion and subtalar inversion - passive ROM may be limited/painful due to
         1. calcaneofibular ligament sprain
         2. posterior talofibular ligament sprain
         3. talar dome osteochondral lesion
         4. anterior & posterior tibiofibular ligament sprain
         5. fibular stress fx
         6. lateral malleolus fx
      10. Resisted subtalar inversion - pain or weakness caused by injury to muscles or their nerve supply
          1. tibialis posterior tendinitis
          2. deep posterior compartment syndrome
      11. Active subtalar eversion - pain, weakness, or limited ROM can be caused by injury to muscles or their nerve supply
          1. peroneus longus - superficial peroneal N. (L4, L5, S1)
          2. peroneus longus - superficial peroneal N. (L4, L5, S1)
      12. Passive subtalar eversion - passive ROM may be limited/painful due to
          1. injury to invertors
          2. deltoid ligament sprain
          3. bifurcate ligament sprain
      13. Resisted subtalar eversion - pain or weakness can be caused by
          1. injury to muscles or their nerve supply
          2. peroneal tendinitis
          3. peroneal tendon subluxations
          4. chronic subluxing peroneal tendons "snapping ankle"
          5. weakness of peroneal can be caused by 5^th lumbar level disc protrusion, repeated ankle sprains, peroneal strains or tendinitis, lateral compartment syndrome.
      14. Resisted subtalar plantar flexion - can be done standing unless too weak/painful to stand which will require manual testing, should be done with knee both flexed & extended to check soleus & gastrocnemius respectively.
      15. Active toe flexion - pain, weakness, or limited ROM can be caused by injury to muscles or their nerve supply
          1. flexor hallucis brevis - tibial N. (L4, L5, S1)
          2. flexor hallucis longus - tibial N. (L5, S1, S2)
          3. flexor digitorum brevis - tibial N. (L4, L5, S1)
          4. flexor digitorum longus - tibial N. (L5, S1)
          5. quadratus plantae - tibial N. (S1,S2)
          6. Lumbrical 1 - tibial N. (L4, L5, S1)
          7. Lumbricals 2,3, 4 - tibial N. (S1, S2)
          8. Plantar interossei - tibial N. (S1, S2)
      16. Great toe (Hallux) flexion and extension - may be limited by hallux limitus (caused by direct trauma or inflammatory disease) or chronic hallux limitus which can progress to rigidus can be caused by
          1. structural congenital or acquired abnormalities
          2. long 1^st metatarsal bone
          3. hypermobility of 1^st ray with prolonged pronation problem
          4. metatarsus primus elevatus
          5. prolonged immobilization
          6. degenerative joint disease of hallux metatarsophalangeal joint
          7. degenerative sesamoids on plantar surface of great toe
      17. Passive toe flexion (I to V) - passive ROM may be limited/painful due to
          1. toe extensor tendonitis, strain, or avulsion
          2. metatarsophalangeal, PIP, or DIP synovitis sprain or tear
          3. metatarsal or phalangeal fx
          4. retinaculum that has adhered to extensor tendon
      18. Resisted toe flexion (I to V) - pain or weakness can be caused by injury to muscles or their nerve supply
      19. Active toe extension (I to V) pain, weakness, or limited ROM can be caused by injury to muscles or their nerve supply
          1. extensor digitorum longus - peroneal N. (L4, L5, S1)
          2. extensor digitorum brevis - deep peroneal N. (L4, L5, S1)
          3. extensor hallucis longus - deep peroneal N. (L4, L5, S1)
          4. extensor hallucis brevis - deep peroneal N. (L4, L5, S1)
          5. lumbricales - tibial N. (L4, L5, S1, S2)
          6. dorsal interossei - tibial nerve (S1, S2)
      20. Passive toe extension (I to V) - passive ROM may be limited/painful due to
          1. toe flexor strain or tendinitis
          2. plantar fasciitis
          3. flexor hallucis longus tendinitis
          4. metatarsal or phalangeal fx
          5. metatarsophalangeal, PIP, or DIP sprain
      21. Resisted toe extension (I to V) - pain or weakness can be caused by injury to muscles or their nerve supply
   3. Special Tests
      1. Anterior Drawer sign
         1. knee flexed 90⁰, ankle relaxed & dangling, place one hand over anterior distal shin & cup other hand around posterior calcaneus, pull forward on calcaneus while stabilizing tibia, look anterolaterally to visualize talus sliding forward if anterior talofibular is sprained. Look for dimple or suction sign over anterior talofibular ligament.
         2. knee flexed 90⁰, ankle relaxed & heel resting on table surfaced, place one hand over anterior distal shin use other hand to gently hold forefoot while pushing backward on tibia, look anterolaterally to visualize tibia sliding backward if anterior talofibular ligament is sprained. Look for dimple or suction sign over anterior talofibular ligament.
         3. Prone -
      2. Posterior talofibular ligament test (Lapenskie) - with knee flexed & ankle relaxed passively dorsiflex ankle fully, maintain this position & attempt to externally rotate the rearfoot, if rearfoot can be rotated then posterior talofibular ligament is sprained.
      3. Talar tilt
         1. Lateral ligaments - grasp calcaneus & invert it with foot in plantar flexion & inversion to determine amount of lateral talar tilt to assess lateral ligamentous stability.
         2. Medial ligaments - grasp calcaneus & evert it with foot to determine amount of medial talar tilt to assess deltoid ligamentous stability.
      4. Wedge test (anterior inferior tibiofibular ligament) - press talus up into the mortise by passively dorsiflexing the ankle maximally with the knee flexed.
      5. Inferior tibiofibular joint stability test (Lapenskie) - supine, flex knee & bring heel as close to buttocks as possible, tightly dorsiflex. Fix the forefoot with one hand on the dorsum of the foot, use other hand behind the foot with the heel of the hand against posterior aspect of lateral malleolus & attempt to move fibula anteriorly.
      6. External rotation test (Kleiger test) for anterior inferior tibiofibular ligament - with knee flexed, grasp forefoot and passively externally rotate it while stabilizing posterior lower leg with other hand. Pain over ligament caused by this force indicates positive test.
      7. Squeeze test - knee flexed, use the heel of each hand to squeeze the proximal fibula & tibia toward each other which will, in turn, cause the distal tibia & fibular to spread & be painful if anterior inferior tibiofibular ligament sprain exist.
      8. Side to side (transverse drawer) - knee flexed, hold heel from below while stabilizing lower leg with other hand, move the calcaneus & talus as a unit from side to side without tilting talus. If mortised is widened, talus will be able to move sideways, producing a definite thud as it hits fibula, and when it is moved in opposite direction against the tibia.
      9. Pinch test - knee flexed, use the index finger & thumb of one hand to pinch the anteromedial malleolus toward the posterolateral malleolus to appreciate reduction of syndesmosis diastasis while observing anterolaterally, should not spread more than other side appreciably unless anterior inferior tibiofibular ligament is sprained.
      10. Subtalar joint irritation (Lapenskie) - prone with ankle in full plantar flexion, hold foot in this position & gently tap the plantar aspect of calcaneus upward, positive if pain is elicited & radiates up the Achilles tendon.
      11. Swing Test for Posterior Tibiotalar Subluxation - pt. sits with feet dangling over table edge, examiner holds plantar aspect of foot and uses fingers to keep feet parallel to floor. Examiner uses thumbs to palpate anterior portion of talus. Then passively plantar flex & dorsiflex foot & compare quality & degree of movement between feet, particularly into dorsiflexion. The feeling of resistance to normal dorsiflexion indicates + test for posterior tibiotalar subluxation.
      12. Anterolateral subluxation of the talus (Lapenskie) - have athlete stand & take weight on to the anterolateral aspect of plantar flexed & inverted foot & ankle. Deformity of talus moving anteriorly or into sinus tarsi area can be seen & felt at base of extensor digitorum brevis muscle.
      13. Homan's sign - sit with legs over edge of table, dorsiflex foot & extend knee, positive if pain is experienced in calf with deep palpation for deep-vein thrombophlebitis (serious medical problem).
      14. Thompson Test (Simmonds')(Achilles tendon rupture) - prone with knees extended and feet over edge of table, squeeze the medially & laterally, if foot does not plantar flex, test is positive.
      15. Longitudinal arch mobility tests
          1. Toe raise - standing, raise up on toes & observe calcaneus & foot from behind, calcaneus should go into inversion with longitudinal arch supported, navicular moves up, cuboid moves down.
          2. Squat - squat with feet flat on floor, observe calcaneus & arch, calcaneus should evert & subtalar should pronate when squatting, navicular should move down & cuboid should move upward.
          3. Legs-crossed weight transfer - stand with legs & feet crossed, shift weight over one foot & then the other, as weight is shifted over foot, the arch should lower (pronate) & then rise (supinate) as weight is transferred off that foot. Used to grade arch mobility. If arch does not depress & re-elevate but stays rigid as in rigid cavus foot.
      16. Standing superior tibiofibular mobility (Lapenskie) - stand in full weight-bearing, palpate distance from tibial tubercle to the head of fibula. Have patient rotate at trunk to opposite side, distance between the tubercle & fibular head should increase, rotate to same side & distance should decrease. Hypomobility can lead to supinator problem & hypermobility can lead to pronator problems.
      17. Mobility of the tibia and fibula around the X-axis (Lapenskie) - place index finger & thumb in sinus of the talocrural joint just anterior to tibia & fibular. Have patient rotate body to right & left to determine if motion is equal in both directions.
      18. Longitudinal arch height measurement (Feiss line) - mark apex of medial malleolus & plantar aspect of 1^st MTP joint in non-weightbearing. Palpate & locate the navicular tuberosity, noting its relationship to the medial malleolus apex & MTP plantar aspect. Pt. then stands with feet 3 to 6 inches apart. Recheck the navicular tuberosity. It should be in line or very close to the line joining the other 2 points. Measure in weight-bearing the relation of the medial malleolus, navicular, & head of 1^st MP joint. Problems arise when navicular drops. 1^st degree flatfoot = tuberosity falling 1/3 of way to floor, 2^nd degree flatfoot = tuberosity falling 2/3 way to floor, 3^rd degree flatfoot = resting on floor.
      19. Morton's Test - Pt. is supine while examiner grasps the foot around the metatarsal heads & squeezes them together. Pain indicates + test for neuroma & stress fracture.
      20. Swelling measurements - use bony landmarks to measure above & below joint to measure amount of swelling.
      21. Proprioception testing - stand & balance on each leg for 30 seconds with eyes open, then closed
      22. Neurological scan
          1. Dermatomes
          2. Cutaneous nerve supply - paresthesia of
             1. great toe - L4, L5 nerve root or saphenous nerve
             2. great toe & 2^nd toe - L5 nerve root, tight tibial fascial compartment, or pressure on 2^nd digital nerve
             3. Great toe & two adjacent toes - L5 nerve root
             4. All toes - compression of peroneal nerve at fibula & combined pressure at L5 & S1
             5. 2^nd, 3^rd, & 4^th - L5 nerve root
             6. 4^th & 5^th toes - S1 nerve root & Morton’s metatarsalgia
             7. heel, calf, & posterior thigh - S2 nerve root
          3. Achilles tendon reflex - S1 cord level, nerve root can be compressed by L5, S1 disc herniation
      23. Circulatory scan
          1. Posterior tibial artery - palpate for pulse
          2. Dorsal pedis artery - palpate for pulse
      24. Biomechanical Analysis
          1. Non-weight-bearing
             1. Talocrural joint range - dorsiflexion should be at least 10⁰ beyond 90⁰ with knee in extension & 15⁰ with knee flexed
             2. Subtalar joint range - determination of neutral position in prone with other knee flexed & lying across back of leg, push up on 4^th & 5^th metatarsal heads & gently dorsiflex until resistance is met, use other hand to stabilize tibia, maintain dorsiflexion & move foot into inversion & eversion until reaching point at which joint comes to rest in neutral position.
             3. Midtarsal relation of forefoot to hindfoot - prone, move subtalar into neutral, look down from above & observe relationship of forefoot to rearfoot. Metatarsal heads of forefoot should form a line perpendicular to line through calcaneus. If lateral metatarsals are lower than medial metatarsals, the forefoot is in varus, if opposite the forefoot is in valgus. If only 1^st metatarsal is lower or higher a hypermobile 1^st ray may be present.
             4. Mobility of first ray - prone, move 1^st metatarsal inferiorly & superiorly to see amount of movement, hypermobile 1^st rays are unable to carry their share of weight & shift more weight laterally which can cause stress fx of 2^nd metatarsal, metatarsalgia, collapsed transverse arch, overpronation problems, callus or keratosis under head of 2^nd metatarsal.
          2. Weight-bearing - re-examine alignment problems in weight-bearing
             1. Tibial Varum - standing, observe posterior calcaneus at eye level, place subtalar in neutral by palpating & asking patient to medially & laterally tibia. With tibia varum distal tibia is closer to midline than proximal portion, normal position is approximately 0⁰ to 10⁰ from perpendicular. Tibia varum causes a bowing of lower third of tibia, leading to overpronation.
             2. Talocrural joint range
                1. Uncompensated talipes equinus -cannot get heel down to ground, a toe-walker, severe uncompensated exist.
                2. Compensated talipes equinus - if the necessary dorsiflexion did not exist in non weight-bearing & if foot pronates excessively in midstance, a compensated talipes equinus may exist. Problems associated with talus equinus include medial arch pain, plantar fasciitis, Achilles tendonitis.
             3. Subtalar joint
                1. Compensated subtalar varus - rests in inverted position in non weight-bearing, can develop problems with overuse including shearing forces under the forefoot, hypermobility in the 1^st ray, calluses under 2^nd, 3^rd, 4^th metatarsal heads, Achilles bowing, tibialis posterior tendinitis, hallux valgus.
                2. Uncompensated subtalar varus - if subtalar varus is determined in non weight-bearing & foot stays supinated throughout stance phase it is an uncompensated subtalar varus, calcaneus is already inverted & subtalar joint is supinated causing overuse problems such as calluses under 5^th metatarsal head, tailor’s bunion, medial pinch callus under great toe, stress fx of 5^th metatarsal, lateral compartment syndrome.
                3. Subtalar valgus - if subtalar valgus is determined in non weight-bearing & if calcaneus remains everted & longitudinal arch is totally flat while standing & walking. Few symptoms or problems related to this type.
             4. Forefoot
                1. Compensated forefoot varus - occurs if forefoot varus is determined in non weight-bearing & foot pronates excessively in standing & walking, common problem is stress fx of fibular sesamoid bone.
                2. Uncompensated forefoot varus - occurs if forefoot varus is determined in non-weight-bearing & foot does not pronate when patient is standing & walking, rare, but can result in ankle sprains, peroneal tendonitis, stress fx of metatarsals (especially 5^th).
                3. Uncompensated forefoot valgus - eversion of the forefoot on the rearfoot with the subtalar joint in neutral & can lead to inversion ankle sprains, sesamoiditis (medial sesamoid), calluses (1^st metatarsal), supination related conditions.
                4. Compensated forefoot valgus - everted forefoot is more flexible than uncompensated forefoot yet still high arched, subtalar joint compensates by inverting calcaneus during gait, 1^st ray is hypomobile & metatarsals go into equinus position causing overuse conditions such as calluses, metatarsalgia, plantar fasciitis, lateral ankle sprains, arch strain, spring ligament sprain, Achilles tendinitis.

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