Activity in EEPT

02/11/2022

A 35-year-old woman attended the clinic after she was walking her dogs outdoors when they lunged
suddenly, causing her to slip on some ice. She fell, rolling her right ankle to the side, and was able to get
back up and weight bears through her injured ankle, although limping back home. Her ankle was pretty
sore with some noticeable swelling, so she went to see her family physician the following day. X-rays
were taken of the ankle, and she was advised that she did not have a fracture but rather sprained her
ankle. She was recommended to rest the ankle for the next three days and to limit her weight bearing as
tolerated using an ace-up brace. She has also been prescribed anti-inflammatories and referred to
physiotherapy.

Questions:

1. What is the probable diagnosis?

- Ankle sprain

2. At the time of evaluation, is the diagnosis considered to be acute or chronic?

- Acute

3. What are the possible clinical manifestations seen in the patient during the assessment?

- Pain, especially when you bear weight on the affected foot, tenderness when you touch the ankle,
swelling, bruising, restricted range of motion and instability in the ankle.

How can these manifestations be assessed for accurate findings?

- Tenderness and swelling, limited motion of the ankle, difficulty bearing weight, checking
temperature in the affected area, assessing neurological function, and checking for ankle
instability.

4. Given the list of clinical manifestations, what treatment procedures should be included in the

plan of care (POC)?

- Stabilization
- Proper positioning of the ankle
- Immobilization
- Manage pain and swelling
- R.I.C.E

Special test

Provide the list of special tests under each group. Kindly explain the procedures, positive sign, and
indications. 

Knee

1.) For meniscus lesions

ST: Appley’s test

Procedure: Patient in prone position. Then, fixate the tested leg with your own leg and bring the knee into
90° of flexion. While you give distraction, perform lateral rotation of the tibial and medial rotation. You are
looking for excessive rotation compared to the other side or discomfort.
(+): Pain or restriction with compression and internal or external rotation.
I: The injury may occur with or without an external force being applied to the knee. Usually, pain is located
along the joint line of the knee. Common complaints are pain and mechanical complaints such as clicking,
catching, locking, or inability to fully extend the knee.

2.) For plica lesions

ST: Hughston's plica test

Procedure: The patient lies supine and the examiner flexes the knee with medial rotation of the tibia and
pressing the patella medially with the heel of the hand and palpating the region just medial to the patella.
While flexing and extending the knee a snapping or popping will be felt and/or heard.
(+): Pain or palpable clicking indicative of abnormal plica.
I: —
3.) For swelling

ST: Brush test

Procedure: Patient in supine lying position with a fully extended leg. Then begin by brushing proximally
at the medial side of the knee with a relaxed hand and fingers. Consequently, brush down the lateral side
of the knee.
(+): If you can see a wave of fluid floating down the medial side of the knee.
I: Asses for swelling in the knee joint.

4.) For Patellofemoral pain syndrome

ST: Clarke’s test

Procedure: Patient is positioned in supine or long sitting with the involved knee extended. The examiner
places the web space of his hand just superior to the patella while applying pressure. The patient is
instructed to gently and gradually contract the quadriceps muscle.
(+): pain in the patellofemoral joint
I: The amount of pressure applied must be carefully controlled as more pressure can elicit positive
response even in normal individuals.

5.) Patellar instability

ST: Fairbanks apprehension test

Procedure: Pt places the knee to be examined into full extension. A lateral force is applied to the patella
with the examiner's thumb. The examiner then moves the knee from full extension to 90 degree of flexion
and then returning to full extension while maintaining the laterally applied force on the patella.
(+): It is positive when there is pain and muscle defensive contraction of lateral patellar dislocation with
20°–30° of knee flexion. The positive test indicates that lateral patellar instability is an important part of
the patient’s problem. This may be so positive that the patient pulls the leg back when the therapist
approaches the knee with his hand, preventing any contact, or the patient grabs the therapist’s arm.
I: Indicates that lateral patellar instability is an important part of the patient's problem.

6.) Iliotibial band syndrome

ST: Noble’s test

Procedure: test starts in supine posture and a knee flexion of 90 degrees. As the patient extends the
knee the assessor applies pressure to the lateral femoral epicondyle.
(+): induces pain over the lateral femoral epicondyle near 30-40 degrees of flexion
I: assess for iliotibial band friction syndrome.
Ankle

1.) For determining the position of the talus:

ST: navicular drop test

Procedure: Patient in standing so there is full weight-bearing through the lower extremity and ensure the
foot is in the subtalar joint neutral position. Mark the most prominent part of the navicular tuberosity and
measure its distance from the supporting surface. Ask the patient to relax and then measure the amount
of sagittal plane excursion of the navicular with a ruler.
(+):
I: amount of foot pronation present

2.) For alignment:

ST: forefoot heel alignment test

Procedure: the patient lies in the prone position with foot extending over the end of the examining table.
the examiner then places a mark over the midline of the calcaneus at the insertion of the Achilles tendon,
the examiner makes a second mark ~1 cm distal to the first mark and as close to the midline of the
calcaneus as possible. a calcaneal line is then made to join the two marks. Next, the examiner makes two
marks on the lower third of the leg in the midline forming the tibial line, which represents the longitudinal
axis of the tibia. the examiner then places the subtalar joint in the prone neutral position. While the
subtalar joint is held in neutral, the examiner looks at the two lines.
(+): If the lines are parallel or in slight varus (2° to 8°), the leg-to-heel alignment is considered normal.
And If the heel is inverted and everted, the patient has hindfoot varus
I: To test the Forefoot to Heel Alignment

3.) For ligamentous instability:

ST: Anterior drawer test

Procedure: patient lies supine, the upper leg is supported by the table, the knee joint is flexed, and the
ankle joint is held in 10-15° of plantarflexion. Then grasp the heel, while the patient's foot lies on the
anterior aspect of your forearm.
(+): when there is an excessive anterior movement of the foot and a dimpling of the skin on both sides of
the Achilles tendon when compared to the uninjured foot. A positive test also implies a rupture of the
anterior talofibular joint. No psychometric properties have been reported for this ankle test.
I: —

4.) For joint instability (syndesmosis)

ST: Cotton test

Procedure: stabilizes the proximal ankle while shifting the talus laterally
(+): marked by increased motion relative to the uninvolved side and is indicative of a sprain of the distal
tibiofibular syndesmosis or the subtalar joint.
I: A manual stress test used to identify the amount of lateral translation of the talus within the ankle
mortise.

5.) For third-degree strain (rupture):

ST: Matles test

Procedure: The patient lies in prone, active or passively flexing the knee to 90° with both feet and ankles
in a neutral position according to the patient. When an absence of plantar flexion is observed, the test
proves positive. The rupture will tend the foot more into dorsiflexion.
(+): the foot in front shows absence of plantar flexion (ie, the foot falls completely flat (to the neutral
position with 0° plantar flexion).
I: The Matles test assesses the Achilles tendon for suspected rupture
6.) For swelling

ST: Figure of Eight Method of Measuring

Procedure: Patients were positioned in long-sitting on a bed with the testing foot resting over the end.
The knee may be slightly flexed over a bolster to allow for ease of measurement if needed. The ankle
should ultimately be maintained in a position of neutral dorsiflexion.

The therapist placed the zero-point over the mark on the anterior aspect of the ankle and pulled the tape
medially over the navicular tuberosity, and then infero-laterally across the medial arch to the proximal
aspect of the base of the fifth metatarsal. The tape was then pulled superiorly and medially over the tarsal
bones across the inferior aspect of the medial malleolus, and posterolaterally around the Achilles tendon
over the distal lateral malleolus to finish at the zero point. At last, the measurement is recorded.
(+): ankle size and ankle joint swelling (edema)
I: measure swelling across the several common sites of ankle sprains: the anterior talofibular ligament,
calcaneofibular lig- ament, and anterior tibiofibular ligament. The procedure is easily reproduced by using
boney landmarks about the ankle.