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Foot and Ankle. Rance L. McClain, D.O., FACOFP Associate Professor – FM Dept. KCUMB-COM. Learning Objectives. Review the diagnosis of the foot and ankle Apply specific osteopathic testing to the diagnosis of the foot and ankle

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Foot and ankle l.jpg

Foot and Ankle

Rance L. McClain, D.O., FACOFP

Associate Professor – FM Dept.


Learning objectives l.jpg
Learning Objectives

  • Review the diagnosis of the foot and ankle

  • Apply specific osteopathic testing to the diagnosis of the foot and ankle

  • Understand the application of osteopathic treatment to the foot and ankle

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  • The foot and ankle is the focal point of total body weight, performing this function both when stationary and with gait

  • Adaptation to the terrain upon which a person stands and walks

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  • Problems with the foot and ankle can arise from mechanical, pathological, vascular, or inflammatory origins

  • The foot is affected not only by local stresses, but also by systemic diseases

    • Approximately 40% of people have foot and ankle problems

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Inspection - Ankle

  • Range of Motion

    • Plantar flexion: 50 degrees

    • Dorsiflexion 20 degrees

      • Excess motion can cause fibular dysfunction

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Inspection - Ankle

  • Accessory motions of side-to-side glide, rotation, abduction, and adduction are also present depending on the position of the foot

  • Because the talus is wider anteriorly than posteriorly, the ankle is more mobile in plantarflexion than dorsiflexion

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Inspection - Ankle

  • Ankle Mortis

    • Relationship of the medial and lateral malleoli causes the ankle articulation to be held in a position of 15 degrees of toeing out

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Inspection - Ankle

  • Tibiofibular syndesmosis

    • Responsible for maintaining the width of the ankle mortise

    • If torn, the mortise can widen, and the talus becomes unstable

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Inspection - Ankle

  • Soft Tissue & Edema

    • Medially located deltoid ligament

    • Laterally located anterior & posterior talofibular ligaments, as well as the calcaneofibular ligament

      • Anterior talofibular ligament is highly susceptible to injury

      • Lateral ankle edema inferior and anterior to the lateral malleolus

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Inspection - Ankle

  • Unilateral swelling is usually trauma, while bilateral swelling is usually indicative of cardiovascular problems (CHF, venous insufficiency, etc.)

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Inspection - Ankle

  • Vascular

    • Posterior tibial pulse

    • When you progress down to the inspection of the foot, you will also inspect the dorsal pedal pulse

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Inspection - Foot

  • How many toes are present and are they deformed

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Inspection - Foot

  • How does the foot contact the floor

    • Pressure points can develop calluses

    • Skin is usually thicker at the weight bearing areas at the heel, the lateral border, and the 1st and 5th metatarsal heads

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Inspection - Foot

  • Can you slide your fingers under the medial arch of the foot

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Inspection - Foot

  • Arches

    • Lateral longitudinal arch

      • Calcaneus, Cuboid, 4th & 5th Metatarsal bones

      • Low arch with limited mobility

      • Transmits weight and thrust to the ground

    • Medial longitudinal arch

      • Calcaneus, Talus, Navicular, Cuneiforms, and 1st-3rd Metatarsals

      • Higher arch, much more mobile. Sustained by the skeletal structures as well as the Plantar Fascia

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Inspection - Foot

  • Inspect the arches with the patient sitting

    • Spastic flat foot will cause the foot to dorsiflex and evert, whereas a normal foot will plantar flex and invert

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Inspection - Foot

  • Range of Motion

    • Calcaneal abduction and adduction at the subtalar articulation

    • Inversion and eversion are combination motions

      • Inversion is calcaneal adduction, navicular rotation, and glide on the talus

      • Eversion is produced by the opposite motions above

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Inspection - Foot

  • Forefoot abduction and adduction

  • Pronation is the motion of the foot and ankle combining calcaneal abduction, forefoot abduction, subtalar- cuboid-navicular eversion, and ankle dorsiflexion

  • Supination consists of calcaneal adduction, subtalar-cuboid-navicular inversion, forefoot adduction, and ankle plantar flexion

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Shoe Inspection

  • Alterations in structure and function will show in the wear and tear on shoes

  • Normal wear from heal strike to toe off gives a transverse crease

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Shoe Inspection

  • Abnormal wear examples

    • Foot Drop (neurological damage)

      • Dorsiflexors are paralyzed

      • Toe scrapes in ambulation causes scuff marks on the toe box and the front part of the soles

    • Hallux Rigidus (no motion of the 1st MTP joint)

      • Does not allow normal toe off with gait, leading to an oblique crease in the shoes

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Shoe Inspection

  • Flat Feet (Pes planus)

    • Tend to over pronate and increase wear on the soles of the shoe medially

  • High Arches (Pes cavus)

    • Tend to supinate and increase wear on the lateral aspects of the soles of the shoes

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Lab/Treatment Section

  • Evaluation

    • Dorsiflexion/Plantarflexion

    • Subtalar Abduction/Adduction

    • Calcaneal Inversion/Eversion

    • Navicular (medial) & Cuboid (lateral)

    • Metatarsal motion

    • Phalanges motion

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Lab/Treatment Section

  • Muscle Energy

    • Dorsiflexion/plantarflexion

    • Subtalar abduction/adduction

    • Calcaneal inversion/eversion

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Lab/Treatment Section

  • Counterstrain

    • Calcaneal TP (plantar fasciitis)

  • Soft tissue treatment

    • Plantar fascia

  • Lymphatics

    • Effleurage & Pétrissage

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Lab/Treatment Section

  • HVLA

    • Inversion/eversion calcaneus (ankle traction)

    • Subtalar thrust

    • Dorsal metatarsals treatment

    • Transtarsal thrust

    • Cuboid-Navicular treatment (Hiss whip)