Figure 20-46 Top, Technique for testing the collateral ligaments. Bottom, Rupture of the medial collateral ligament.

Ask the patient to stand. Inspect the ankles and feet for swelling and deformities. The number and position of toes should be noted. The toes should be straight, flat, and proportional to one another in comparison with the other foot. Compare one foot with the other with regard to symmetry. Are any toes overlapping? Describe abnormalities of the longitudinal arch. A cavus foot has an abnormally high arch. In flatfoot, the longitudinal arch is flatter than normal. Common foot abnormalities are illustrated in Figure 20-49.

Ask the patient to walk without shoes and socks, and observe the gait. The patient should be able to walk normally, on heels, on toes, and one foot in front of the other (tandem walking). Note any deformities such as the width or length of the feet, heel varus or valgus, calf atrophy, varicose veins, and in-toeing or out-toeing. Take note of the patient's posture and any shuffling or other abnormality.

Ask the patient to sit with the feet dangling off the side of the bed. Normally, there is mild plantar flexion and inversion of the feet. Palpate the medial and lateral malleoli. The distal portion of the fibula constitutes the lateral malleolus. It extends more distally than the medial malleolus. Palpate the Achilles tendon. Are any nodules present? Is tenderness present?

Test the range of motion at the ankle, which includes dorsiflexion and plantar flexion. The range of motion necessary for normal gait is 10° dorsiflexion and 20° plantar flexion. Ankle joint dorsiflexion with the knee flexed should approach 15°.

If dorsiflexion at the ankle joint is less than 10°, measurement should be taken again with the knee flexed. If dorsiflexion is less than 10° in both positions, limitation of motion is usually caused by an osseous block at the ankle. If dorsiflexion increases with knee flexion, a tight gastrosoleus complex is probably responsible.

Figure 20-47 Another technique for testing the collateral ligaments.

Figure 20-48 Technique for testing the cruciate ligaments: the drawer test.

Normal arch

Cavus foot

Flat foot

Figure 20-49 Common foot abnormalities.

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