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Physical Therapy Protocols for Ankle and Foot Conditions

Physical Therapy Protocols for Ankle and Foot Conditions

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Published by: Shruti on Nov 23, 2010
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01/08/2014

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Robert Klingman PT, Joe Godges PT KP SoCal Ortho PT Residency
Red Flags for Potential Serious Conditions in Patients with Knee, Leg, Ankle or Foot Problems
Medical Screening for the
Knee, Leg, Ankle or Foot Region
ConditionRed FlagData obtained duringInterview/HistoryRed FlagData obtained duringPhysical Exam
Fractures
1-4
History of recent trauma: crushinjury, MVA, falls from heights,or sports injuriesOsteoporosis in the elderlyJoint effusion and hemarthorsisBruising, swelling, throbbing pain, and pointtenderness over involved tissuesUnwillingness to bear weight on involved legPeripheral ArterialOcclusive Disease
5-9
 Age > 55 years oldHistory of type II diabetesHistory of ischemic heart diseaseSmoking historySedentary lifestyleCo-occurring intermittentclaudicationUnilaterally cool extremity (may be bilateral if aorta is site of occlusion)Prolonged capillary refill time (>2 sec)Decreased pulses in arteries below the level of the occlusionProlonged vascular filling timeAnkle Brachial index
 
< 0.90
 
Deep VeinThrombosis
10,11,17
 Recent surgery, malignancy,pregnancy, trauma, or legimmobilizationCalf pain, edema, tenderness, warmthCalf pain that is intensified with standing orwalking and relieved by rest and elevationPossible pallor and loss of dorsalis pedis pulseCompartmentSyndrome
12-14
 History of blunt trauma, crushinjury - or -Recent participation in a rigorous,unaccustomed exercise ortraining activitySevere, persistent leg pain that is intensified withstretch applied to involved musclesSwelling, exquisite tenderness and palpabletension/hardness of involved compartmentParesthesia, paresis, and pulselessnessSeptic Arthritis
15
History of recent infection, surgery,or injectionCoexisting immunosuppressivedisorder
 
Constant aching and/or throbbing pain, jointswelling, tenderness, warmthMay have an elevated body temperatureCellulitis
16
History of recent skin ulceration orabrasion, venous insufficiency,CHF, or cirrhosisHistory of diabetes mellitusPain, skin swelling, warmth and an advancing,irregular margin of erythema/reddish streaksFever, chills, malaise and weakness
References:1.
 
Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains.
 Am Fam Physician
. 2002;68:785-794.2.
 
Hatch RL, Hacking S. Evaluation and management of toe fractures.
 Am Fam Physician
. 2002;68:2413-2418.3.
 
Hasselman CT, et al. Foot and ankle fractures in elderly white woman.
 J of Bone Joint Surg
. 2003;85:820-824.4.
 
Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies, and recent developments.
 Injury
. 2004;35:443-461.5.
 
Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patientswith diabetes mellitus.
 Journal of Clinical Epidemiology
. 1997;50:659-668.6.
 
McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review.
 Arch Intern Med 
.1998;158:1357-1364.7.
 
Halperin, JL. Evaluation of patients with peripheral vascular disease.
Thrombosis Research
. 2002;106:V303-11.8.
 
Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheralocclusive vascular disease.
Scand J Prim Health Care
. 1998;16:177-182.9.
 
Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study.
 BMJ 
.1996;313:1440-79.10.
 
Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis inoutpatients.
 Amer J Med 
. 2003;115:436-440.11.
 
Bustamante S, Houlton, PG. Swelling of the leg, deep venous thrombosis and the piriformis syndrome.
Pain Res Manag
.2001;6:200-203.12.
 
Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg.
Clin Orthop.
1989;240:97-104.13.
 
Swain R. Lower extremity compartment syndrome: when to suspect pressure buildup.
Postgraduate Medicine
. 1999:105.14.
 
Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder.
Orthop Trauma
. 2002;16:572-577.15.
 
Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis.
 Rheumatology
. 2001;40:24-30.16.
 
Stulberg D, Penrod M, Blatny R: Common bacterial skin infections.
 Am Fam Physician.
2002; 66:119-124.17.
 
Riddle DL, et al. Diagnosis of lower-extremity deep vein thrombosis in outpatients with musculoskeletal disorders: anational survey study of physical therapists. Phys Ther. 2004; 84 (8): 717-728.
 
 
Joe Godges DPT KP SoCal Ortho PT Residency
1 
KNEE/LEG/ANKLE/FOOT SCREENING QUESTIONNAIRE
NAME: ________________________________________ DATE: _____________Medical Record #: _________________________Yes No
1.
 
Have you recently experienced a trauma, such as a vehicle accident, afall from a height, or a sports injury?2.
 
Have you recently had a fever?3.
 
Have you recently taken antibiotics or other medicines for aninfection?4.
 
Have you had a recent surgery?5.
 
Have you had a recent injection to one or more of your joints?6.
 
Have you recently had a cut, scrape, or open wound?7.
 
Do you have diabetes?8.
 
Have you been diagnosed as having an immunosuppressive disorder?9.
 
Do you have a history of heart trouble?10.
 
Do you have a history of cancer?11.
 
Have you recently taken a long car ride, bus trip, or plane flight?12.
 
Have you recently been bedridden for any reason?13.
 
Have you recently begun a vigorous physical training program?14.
 
Do you have groin, hip, thigh or calf aching or pain that increases withphysical activity, such as walking or running?15.
 
Have you recently sustained a blow to your shin or any other traumato either of your legs?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Joe Godges DPT 1
Normal Gait Mechanics
Normal Gait Patterns Have Two Major Periods:1. Double Limb Support: a) weight loadingb)
 
weight unloading2. Single Limb Support: a) stance phase of ipsilateral sideb) swing phase of contralateral side
DOUBLE LIMB SUPPORT
WEIGHT UNLOADING:
Trailing foot is rolling off floorPhases: Terminal Stance: when heel risesPre-Swing: when 1st MTP rolls off floorJoint Motions:
Terminal Stance
 
Pre-SwingAnkle
Heel rise
 Max. plantarflexion (20
o
)
Knee
Full extension
 Flexes to approx. 40
o
 
Hip
Max. extension (20
o
)
 Flexes to approx. 0
o
(neutral)
Pelvis
Relative anterior rotation
 Less anterior rotationPosterior depression
 Begin anterior elevation
Trunk
Aligned between legs
 Aligned towards wt. loading leg
WEIGHT LOADING:
Weight is transferred to contralateral legPhases: Initial Contact: when heel contacts floorLoading Response: when sole of foot contacts floorJoint Motions
Initial Contact
 
Loading ResponseAnkle
Neutral
 Plantarflexes 10
o
 
Knee
Knee extended
 Knee flexes 15
o
 
Hip
Flexed 25
o
 
 Stable 25
o
flexionRelative abduction
Pelvis
Level
 Lateral drop to swing leg
Trunk
Aligned between legs
 Aligned towards wt. bearing leg

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