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Foot & Ankle Examination for Orthopaedic Exams
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Foot & Ankle Examination for Orthopaedic Exams
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Language: EN.
Segment:0 .
Hugh Evans, and tonight we're privileged to have Mr. Krishna Vemulapinni who's a consultant, orthopedic surgeon in foot and ankle surgery.
He works at Kings College Hospital in good Mason Queen's Hospital in romford, where he specializes in foot and ankle surgery and orthopedic surgery for children. He did his foot and ankle surgery training in Norfolk and Norwich hospital and in children's orthopedic surgery at the Royal London Hospital. He also teaches surgeons in various orthopedic and parks examination courses.
This evening we have Ruth and Hannah from our UK and the mentors this evening or Kashif swan and Imran as well as myself. Following the presentation, we're going to go for the cq tests and we'd like you to answer those as quickly as possible and then we'll take questions from the participants. If you have any questions during the presentation, if you put them in the chat box, we will monitor that and we'll ask at the end of the presentation.
After all the questions are finished, we will stop the recording and we'll move on to the vyver practice. If you would like a vyver, we ask that you raise your hand or let myself or Ruth know. And also when you're sitting the fastest part to do so. Without any further ado, I will pass you over to Mr. to for the presentation. Thank you.
Thank you, Nick. Thank you. Ruth, and oh, are you ok? I've been a consultant for the last 13 years. I work in queensland, King George hospital, Northeast part of the London there. Thank you for inviting me to talk about foot and ankle. Before we go into the foot and ankle examination, I just want to say that I've been doing this for the law for the last two years.
However, I do this face to face and I usually bring patients and I demonstrate my examination skills and fine tuned my registers and everyone. I am very, very particular about my examination findings and all my registrars who has gone through the training know about the importance of this examination. So we have 26 bones just to touch base on the anatomy.
We have in each foot. That's 26 bones, 33 joints, more than 100 ligaments and tendons for an ankle examination is largely similar to any other joint examination, which is look, feel and move, and then followed by special test. Every person has their own way of examining the foot and ankle. And this is my way and what I have.
What I say is it is for an ankle examination made easy. Like any foreign like any joint examination, foot and ankle examination is an art. It can be painful and scary or to do the examination. And the only way to get over it is you need to know the anatomy. If the anatomy. And if you are King of anatomy, then it is going to be a simple art and it will be powerful and effective.
The aim of the foot and ankle examination is to find out the pathology. It's like a bit of detective work then, unlike a hip or a knee. I have a disadvantage that I have 26 bones, 33 joints and more than 100 ligaments and tendons there, so I have to be meticulous. And even though, it is looking like a duck, quacks like a duck, I don't believe that it is a duck because it might come and bite me.
So I have to poke it and see whether it is a duck or not. It's a detective work. What exactly is happening there? Because I don't want to bark at the wrong tree, and if I am barking up the wrong tree as a surgeon, I have lost the game there. So the aim of this talk is to find out the pathology from the history and examination. So this is the most important thing.
Each and every time my registrar changes every six months, they will be given the instructions each and every new patients. They have to take history. And with the history, they should be coming with a differential diagnosis of about three or four, and then they have to do the examination and knock off two of the differential diagnosis, then only refer the patient to the investigation.
So that we will know exactly what is happening over there. And so to take the history, we have to go back to the basics like what we did in our medical school, the nine characters of the pain, what exactly has caused the pain? Was there any history of trauma, anatomical location, type of pain, whether it is radiating into the toes or whether it is radiating into the leg? Is it associated with Schubert or is it also there with bare feet?
Is it more on uneven floor or even floor? Is it there with clothing, shoes or even open top shoes? Was there any kind of pain while you are walking, standing or whatever it is running is what how? How long do you need to walk to get the pain? So quantifying the pain what are the alleviating factors? Is it like taking off the footwear? Does it help you or taking painkillers or taking rest?
Then the special characters like start up pain and early morning pain. Once all these things it it will make your life easy. Before you touch any patient. You have to expose the patient until the knee, and if possible, you can go about it. But definitely it is mandatory to expose that limb and it is not one limb. It is both the legs.
And then you have to look for any kind of walking aids around it at all. But the patient has walked with the crutch or a frame, whether there is any kind of surgical shoes, insoles or any kind of auto system. And then you have to start looking at the gait. You comment on the gait from the front, standing at the front of the patient, how they are walking and whether they are using any kind of auto space or they need any kind of help and then comment on their pelvic tilt. They comment on their gait.
And then you, you comment the gait from the side. What? what are the rockers? How is the first rocker, second rocker, third rocker, the movement of the knee movement of the hip? And then if they are able to walk without any aids, then I always ask them whether they can walk with their tiptoes. The reason why I ask them to walk with their tiptoes is because within two seconds, I will know about their ankle flexibility.
I know about their midfoot functions if there is any stress fracture, if there is any joint sinusitis, and also very quickly as one as to function as well, then I will ask them to walk with heels. So again, ankle mobility tibial is a function, egil and ideal functions. If they have plantar fasciitis or heel problems, they will not be able to walk on their heels.
And also, we are checking L4 and L5 nerve route to their. Walking on the outer, inner aspect of the feet, so we will ask, we can ask, I can assess the subthalamic joint, I can see whether there was any there is any medial or lateral that are impingement, if there is any first rate problems or three problems over there. So once we have looked at the gait and everything then comes to looking.
So you have to always look from the whole of the lower limb. How is the alignment of the lower limb to the hind foot? How is the midfoot to the hind foot and forefoot and toes? Because you can easily miss something which is above the knee. If you are just concentrating on the foot and ankle, once you rule out that there is nothing, no problem with the alignment, then you look from that front, you look from the side that is in aspect.
You look from behind its, you need to go around the patient and then you look from the outer aspect of the foot. Please do not forget to look underneath because that might be the pathology, what the patient is having. Once you have taken the history and an inspection, then what exactly is the problem or where is the problem? So then you tailor your examination, rest of the examination, depending on your history and inspection findings.
There is no point of doing Coleman block test for a flat foot and vice versa, doing too many toes, commenting on too many toes or single foot tip toeing in a best case. So you need to tailor your examination from here onwards, depending on what do you think is the pathology? So the best position of examination is patient sitting in on an examination table and you are sitting in a chair and the foot is to your elbow level.
How's everybody doing this patient is comfortable and you are also comfortable there. First and foremost, before you touch the patient, you ask where exactly is the tender point? Once you know that they read, the tender point is try to examine that tender point at the last point in your examination, you check your feeling with your temperature. Then, as I have clearly said, that you need to know that anatomy, if the anatomy that the life is really easy, you need to keep looking at the patient's face, but your fingers has to do the work.
You need to know where your thumb, where you were index finger is, whether it is on the middle, whether it is on the table is 70-year or whatever it is. You need to have a systematic palpation if you want to come from the top to the medial side. It is entirely up to you whether you want to go from inside to outside, whether it is entirely up to you, but you have to dial up a type of systematic palpation inside you.
What exactly you are looking for outside, what are you looking for? And then posterior and on the plantar aspect of the heel on the top of the metatarsals and also underneath on the metatarsal part. So these are the points where you have to look and feel for the patient there. Depending on the location of the pain, depending on the tenderness, you have different pathologies which are illustrated on this tabular form.
Then you start your movement. I always start you the movement with silver skills test. By doing this thing, I will know whether at least whether the Achilles tendon is tight because of the spot on the soldiers part of the Achilles tendon. Then I will start moving the ankles up Taylor tassel chopper joints and metatarsal filling gel joint. Remember, circulation is a complex moment of inversion addiction and plantar flexion, and pronation is inversion, a reduction and dose reflection.
So this tabular form will tell you what are the possible causes of restriction if you have those inflection, plantar flexion inversion or reversion restrictions? So that this is a picture where I am demonstrating the silver scale test on this picture. I have flex the knee so that the gastronomy is relaxed and I could get this much of those inflection and with the dose effect.
With my right hand in the same position, I have straighten the knee as soon as I have straighten the knee. You can see that the patient can't have that much of those inflection, so this patient has a anemia tightness over that. Once I do the movement over there, then I'm going to go now. Special test each and every muscle has to be tested that the first common first muscle, which I usually do, is to be a You don't need to follow this regime, but this is what I do.
And for doing that, the ankle should be indoorsy, flexion and inversion so that it I am isolating only the tibialis anterior and I don't get any kind of power or movement from the tibialis posterior. So once I get the ankle in that movement, then I will ask the patient to hold the foot in that position and with my right finger, I'm trying to pull it down. And with my left finger, I'm feeling the power and the contractions in the tibial is anterior.
Tibial is posterior. The foot ankle should be in plantar flexion inversion. So my left finger is on the posterior aspect of the medial malice and on the right finger, I'm trying to push it laterally. So a bit of close up of picture. So this is my finger on the table is posterior and you can see that over there and I'm trying to push. Bush, that foot away from my finger, my hand there, baronial tendons.
Again, the plant is plantar flexion. You need to have the foot in a full plantar flexion and inversion. And with my left hand, I'm asking the patient to push my left finger and then I'm feeling the perennial tendon. So you can see not only you can feel it, but you can also see that strength of the coronal tendon over that.
Excellent idea. Again, the same thing asking ankle in a neutral position and then trying to pull it up, and it is again trying to pull it up that the FHL and FDL slightly in plantar flexion and then asking the patient to push the big toe or the lesser toes over my fingers there. So once I do the power of these tendons, then I will go.
I, depending on the patient's history, if the patient is complaining of any kind of giving way, then I will do a anterior sign. If the patient has pressed cavers, then I will be doing Coleman test and thecable sign. If there is a flat feet, I will be looking at pick up that too many toes sign up single leg tip toe test if I'm seeing a diabetic patient, so I will do a semi swing state and monofilament test.
So, a Drosten, let's assume that there is a patient who is complaining of giving way. Patient sitting high up on the examination table, foot in slight plantar flexion. And I'm a right handed, so I am holding the right the heel with my index finger and with the my long, long finger in the back, and then I have the thumb in the front. Slight plantar flexion and the my left hand is holding the tibia.
So then what I'm doing is I am pulling in the direction from slight plantar flexion and anterior. It is a similar test like what we do for the ACL in the knee. So this is again one more picture demonstrating that is holding the tibia plantar flexing. And then that is the direction, anteriorly and slightly plantar flexion there. Then what you will see is a bit of sulcus sign that is the skin getting sucked inside on the lateral aspect.
And also you will see a bit of movement over there and always compared with the opposite side. And sometimes you can hear if it is significantly unstable, you can hear and feel a clunk. That is the anti lateral sign that if there is a possibility of syndesmosis injury because history of trauma and everything. What I do is mostly stress test, which is a holding the leg with my right hand don't flexing the foot and externally rotating arm stretching the syndesmosis over there.
You can do this test by standing. I will also do this test in a standing position that is weight bearing. I will ask the patient to stand up on one leg and twist the body so that we know what exactly whether we are having any stress, pain in the syndesmosis, that this is the zygomatic again representation of what I do. And then comes to that too many toes sign.
This is mainly for the tibialis posterior dysfunction when there is a hind foot and right foot involved. Normally, if you are looking at the foot from the posterior aspect, you should see the little toe or half of the fourth toe. If you see more than 1 and 1/2 toes from the posterior. That means too many toes sine positive, so you can see here little toe, fourth, third, second and a bit of big toe.
That means this foot is collapsed medially and there is a hand a hind foot Bulger's there. So here also, you can see a lot of toes here and you can see that it's a big toe and the rest of the toes. So this is all hind foot, mid foot and four foot while the. Then comes the single leg tip toe test. So you have to take a patient to the wall and ask them to take the support of the wall standing one foot away from the wall, standing on a good side and take by taking the support of the wall.
He can you ask him to go on tiptoes? He has to stay on tiptoe for 30 second and then swap it with the scatological side or the painful side. Some people does this holding the chair. That is completely wrong because if you are holding a chair and going on the tiptoes, that means you are using your upper limb to push your body in the air. So I always recommend to get this done holding the wall.
This is a peekaboo sign, so it is like if you have a child or a nephew, whatever whoever is a child, you play with your child like a peekaboo. So on the right side here, you can't see any heel, so you should not be able to see any heel. If you are looking at anybody's feet, if you are seeing a bit of heel there, that means Culkin is playing a game with you like a peekaboo game.
So it is like, like that game, which we play with our children. So this is where you have significant hind foot bearers and you can see the arches, which are high that. Now comes the Coleman block test, this is mainly meant for to find out if the hind foot is flexible, whether the hind foot wears deformity is driven by the forefoot. So how do we do it?
The Polonius longest is very, very strong. So what it does is turn as long as it is attached onto the base of the first metatarsal, so it pulls the first metatarsal down. And because of that, the whole four foot is in slight pronation. To compensate that you, you completely turn your hind foot into whera. So the hind foot is driven by the forefoot plantar flex flexed first train by doing the Coleman block test, where you are taking off the first ray and the secondary off the block.
Then you will correct the hind foot deformity. This is the hind foot, which is in, whereas the patient is standing on a block. So we have neutralized the Polonius longest and the plantar flexed first rate, and you can see that the hind foot is completely corrected. This is the textbook pictures, and you can see you can see that there is a peekaboo sign over here. The foot is in wearer's bilaterally and you put the Coleman block test first and second rate or maybe the third race of the Coleman.
And you can get the feel, which is very straight compared to the opposite side, which is in reference to the last special test is Sammy's Weinstein monofilament test. So this is a 10 grams monofilament very sensitive and you need to push it. You need to push it so that there is a bend in the monofilament. And if the patient is able to feel the sensation, that means that there is a pressure sensation intact.
If the patient cannot feel the sensation, there is a high chance that this patient is going to develop ulcers that are so complete the examination by prone in the patient and prone or nailed down there, where you can examine the lower end of the spine. And also you can see the plantar aspect of the foot and the neurovascular examination. So that is, in short, a synopsis of how I examine my foot and ankle, so I will wait for any questions now.
Then we will go for some case discussions. Oh, sorry. Actually, hang on. We have some, some more slides. Hang on there. So these are the slides which I want to show you. Common cases for the farc? Yes so this is obviously Alex Vargas or Alex rejoinders people who usually miss.
I'm just making a box because I usually bring the patients and ask one of the Registrar to present because there is no patient to be presented. I'm just giving a box of information that people keep forgetting to or forgetting to mention these things, or some of the important salient features which examiners expect you to comment on. So don't forget about walking shoes and any kind of orthotics gait.
Then you comment not only on the big toe, you have to comment on the lesser toes. Don't forget about plantar Kessler cities. Think about system tenderness in the Vargas or hallux rigid foot and ankle examination. Talk about the flexibility and the movement of the joints because if there is no movement, that means it is hallux visitors. If there is movement, then that means it is Vargas and also whether you can correct it or not.
Then at the same time, you have to think about whether the forefoot deformity is a compensatory deformity because of the midfoot or hind foot, for example, tibial its posterior dysfunction where there is a pronation deformity and the collapse of the medial arch. There will be compensatory Alex Vargas. So if you are doing a surgery in your table is posterior dysfunction, it is going to fail.
It's the same thing that one of the common reasons of Alex Vargas is Achilles tightness, so you need to do the Achilles tendon examination in four complete for complete sake of this pathology. Don't forget that 60% to 70% of these patients who has this much of this deformity will have loss of sensation their. And what's the face always when you are doing the.
This is the second commonest case in the FARC rebels bas status dysfunction. So these are the things which you should not forget about talking about in the is bas status dysfunction, walking shoes, autos, gait, too many toes side one foot tip toe test, which we talked about Achilles tightness. This is one of the commonest cause of tibialis posterior dysfunction.
Also when you are because this is basically because the midfoot is collapsed, when you are trying to examine Achilles tendon tightness or doing a silver skills test. Don't do it without locking the midfoot in the slap. Otherwise, what you are getting is a dorsiflexion movement from the midfoot and the rest of the things are. Don't forget about examining the alignment of the knee because there might be a gene of algum and the foot pronation deformity and the tibialis posterior dysfunction is secondary to the Vargas deformity of the knee.
Again, please keep watching the face of the patient. Then the next commonest thing is cavers. And in this one again, walking shoes, autopsies, please don't forget it and shock at foot. Sorry pest cave us in this country. And most of the Western countries are short, committed tooth syndrome, so they will have some kind of hand in ferocious muscle wasting.
And so please examine before you go to the foot and ankle so that you have completed that and that is a passing tick box exercise. Look at the comment about the part about the peekaboo sign. And these patients have weakness of tibial a So they will have a foot drop type of gait where there is no ill contact as an initial contact there and you will have a compensatory closing of the toes, basically because of the tibial is weak.
You will be the patient will be recruiting that he channel and Edl to do the dose reflection that there is an inverted champagne bottle calf muscle because the patients walk on the outer aspect. You will have calluses on the fifth metatarsal. And they might have fifth metatarsal stress fractures. And don't forget about common block test, and these patients might have lateral ligament insufficiency, so try to do a drawer sign some patients will be coming to you with the fifth metatarsal stress fracture.
Sometimes they will have giving way symptoms, instability signs. So look at the lateral ligament insufficiency. Tibial is anterior and corona's brevis is very weak compared to the tibial is posterior and felonious longer. So you need to examine all the four muscles there. Don't forget to examine the lower end of the spine, because this is a neurological pathology, unless proven otherwise.
So finally, my foot and ankle examination is history, history, history and examination, and then we will confirm the diagnosis, what we have done by investigation the first term. First question is ideal position of the foot and ankle while testing the tibialis anterior power. So we know that the tibial is anterior and the dorsal tendons, which are each Edl and Sturgis, which is not anterior and the tibial is posterior, which is on the medial side, can cause some kind of inversion there and the dose reflection.
So to neutralize the tibial posterior, then you need to put the foot in full dose of flexion and inversion. How's everybody doing that, you are neutralizing and isolating only tibial is a So the answer for the first question is dorsiflexion and inversion, where 95% of the people who has vote has got correct. Some people have voted neutral and inversion and the other one.
Some people have noted that plantar flexion and inversion. So these things you do not get the tibial is anterior into the isolation thing. So in the same context, ideal position second cushion is ideal position of foot and ankle while testing the tibialis posterior. So you need to again now neutralize the tibial is anterior. How are we going to neutralize the tibial s.a.? If you put it on the maximum stretch, the maximum stretch is in the plantar flexion and inversion.
How's everybody doing that, you are isolating. You are getting only the power of tibialis posterior. So the answer is plantar flexion and inversion. So again, 90% of the part the candidates got it right that Coleman block test. As I have mentioned, that Coleman block test will check, first of all, whether the hind foot is driven by the forefoot and whether the hind foot is flexible or not. So first and foremost, if it is because of the.
Erroneous, longer hyperactivity and the COVID block test will confirm that the hind foot will hind foot will be correcting. We will correct the hind foot, whereas deformity, for example, if the hind foot has burst so patient is old or had been there for a long time, and there is arthritis in the slap Taylor joint, even if it is forefoot driven. You will not be able to correct the hind foot virus, so that's why the answer is forefoot driven, flexible hind foot, whereas it is not fixed hind for two errors.
Thank you. Thank you very much, Krishna, and thank you for your talk. I think that was a really useful talk for the candidates because you will. It's quite likely that you'll be asked to examine somebody's foot and ankle in the exam, and that was lots of good tips for your clinical examination, which you know, we've not had the benefit of all the courses that we normally would to practice.
So I would watch that again and just make sure that you can familiarize yourself with those techniques. So what we're going to do next is move on to the questions from the audience. I think ani and Imran were looking at the questions. Yeah is Omar Ahmed said if the patient has more than 10% of those affliction, but it increases on knee flexion. Is this to be considered as positive silver cold test?
So if there is 10% of those reflection and it is, it is increased by flexing the knee. Correct? well, the thing is the normal dose reflection varies from 10 to 20 degrees. So if it is same as the opposite side, then it is positive. If it is same on both sides, then the patient has that much of the reflection, so it is always competition with the opposite side.
OK so he asked, do we need to test the longus muscle power in plantar flexion of the first trade? So what I have said that is baronial muscles. I did not isolate coronal longest and perennial brevis over that because it is a bit difficult. And I have to demonstrate face to face, but I can't do it on this one.
That's why I put it as Petrone muscles. So if we are doing the perennial muscles, that is usually the inversion. A combination of Polonius longest and bravest will cause evolution, and you need to neutralize the erroneous tertius. So the parallel stoushes is attached on the dorsal aspect of the three. The way to isolate the Polonius neutralize the perennial stoushes is putting the patient ankle in a plantar flexion, so it is maximum stretched.
And what you are testing is mainly the Polonius brevis. That is what it is. OK, so, Melinda. So how we can examine sprained ligament, please spring a ligament. Right, so this is the spring ligament. There are different tests which are being mentioned, but there is no clear cut, a clear cut, complete specific test for that.
One of the things is that you hold the foot in neutral and then try to do the valve with one finger. You push the forefoot into valgus. If it stays there and it is not springing it back into the position, there is a complete tear and there is a insufficiency of spring ligament. It is, again, we have done that research on the cadavers in some cadavers.
It was positive and in some cadavers it is not positive, but it is 50% and it is difficult to isolate the spring ligament on its own. OK, so another one, so if we have a rigid hind foot virus and blunt flex, it's very strange how to differentiate the origin of the hind foot virus. Well, it is. I think if you have a rigidity in the hind foot, it is now more of a bony procedure.
We can't do any kind of soft tissue procedure. The reason why we need to do that is whether it is a flexible deformity or a fixed deformity. So that is again, the orthopedic principles. If there is a flexible deformity, you try to do the soft tissue reconstruction. If the patient has a bony rigidity or a fixed rigidity, then you have to do the bony procedures. So that means that differentiating is going to be difficult. And we don't do anything because the patient needs a bony procedure like slap La fusion with or without cranial osteotomy.
OK, so without question, if the patient has fixed flatfoot, how can I look the transverse tassal joint to test the ankle range of movement? So the effort is actually it is going into the fixed Vargas usually trying to do a supination lock the midfoot and the TMT joints, so that is how the gait is. So you try to separate the midfoot and four-foot and see whether you can dorsiflex the ankle.
If there is any flexion, that means you are getting the movement only from the ankle joint. If there is no dorsiflexion. That means it is. There is arthritis in the ankle and you don't get any movement in the ankle joint that. OK slap question how we can confirm flexibility of the here in stage two three four tiberias bas status insufficiency.
For is arthritis and subtalar arthritis. 3 is up after this thing, so it is only the two, so that is the tibial is posterior dysfunction classification is when you have a 1 and 2 is the flexible thing you said. What are the different investigations that we can request in food problems? This is from Mohammad Javad. Well, it all.
It is a big, big open question. So we can start from X rays, ultrasound scan, MRI scan and the bone scan and some of the cases, which are very, very complex pathology where we do not know which is the culprit. And if we have two or three differential diagnosis even after the MRI scan, I go for CTE. That is the highest scan.
And I also do a diagnostic injections. These are really very good because it will. It will tell me which joint is the pathology. So if I think that there are two joints, which are pathology, for example, navic look uniform joint and Taylor La joint, so I will try to isolate one of the joint by giving a steroid injection or a local anesthetic into the joint, asking the patient to keep the pain diary.
I use this regularly for before I take the patient to the theater for ankle replacement or ankle fusion. I try to find out whether the subtalar joint is involved or not by doing a short program and injection into the cocktail hour joint, asking the patient to keep the pain diary. And if the patient has no pain improvement, that means all his pain is coming from the ankle joint. So those are the diagnostic investigations we do.
OK, just one last question, I think, to clarify. I know you mentioned about soupy nation food screening and food pronation. Somebody is asking whether nation is a separate movement. But I know that you mentioned is a composite movement. Coronation is a composite movement to a place. Well, superannuation is a combination of inversion, adoption and plantar flexion. Pronation is a combination of immersion, abduction and dose reflection.
The best thing you can do is where you are sitting, whoever has asked this question where you are sitting. Look at your foot and try to put the foot in inversion plantar flexion. And it ought to as soon as you put your foot in inversion and a reduction in plantar flexion that is the slap. That's what it is.
If you are flexing and trying to move you a little towards the proximal part of your proximal part of your body. So that is abduction evolution and dorsiflexion. That is what supine and pronation is. Try to feel yourself, look at your foot, put your foot in inversion and action and plantar flexion. That is, to put your foot in inversion, abduction and flexion that is pronation.
Thank you. OK, that's great, thank you. Thank you. So we're going to move on to some case based discussions now. And I think Ruth has got a couple of volunteers that it's not quite a vyver, but we're going to discuss it and you've got the opportunity to talk through it.
Yeah, Joe. Joe is going to do the first case discussion with Krishna. OK Yes. Hello Hello. All right. Joe is there. Yes, I'm here. OK you see me and hear me. Don't know.
Yeah hi, Joe. So hi, is the 30-year-old female complaining of foot pain history of stepped into a pothole while playing with nephew in the garden. Pain and swelling in the foot, unable to wait back. What is happening in your mind? If you if you hear this story? What do you think? Are the possible pathology here?
OK, so the traumatic so fracture stress fracture. Joe sorry. Sorry not stress for traumatic fracture of the foot for these 26 bones, Joe. OK well, I count the pain and swelling in the foot. It's not in a specific part, so I need to take more history about where is the pain?
I just want to stop you. There is something very important in the history, which is a pothole. Does it ring a bell? Does it make you worry about it? Yes I'm worried about that. It might cause a ligament injury from an inversion, from an inversion injury to the ankle. Next stop.
Sorry this is not. OK and you want to see from the planter aspect, this is the case. So what do you think is happening? So it can also on the sole of the foot. And my worries here is that there might be a ligament injury to the left flank ligament. And this might be a less Lisfranc injury due to this. Moses, I want to say sorry, this is not a bible, so I will stop your debt.
OK, sorry, this is unable to White Bear midfoot grossly swollen with Moses tender on palpation of the midfoot. OK, I'm going to just run through. That is correct. The list Frank's fracture. This is the X-ray which we have over there. OK, now the list. Frank's fracture is not just the ligament injury, the list.
Frank's joint is any bony or ligament injury in the first, second, third, fourth and fifth empty joints. This is the list Frank's thing. So if there is a disruption between the uniform over here, all of them is less Frank's joint and everything. So you do the X-ray and then you need to look at the medial border of the medial cuneiform into the first metatarsal. And this is what you are looking on the April letter TMT joint and the medial border of the second TMT joint.
Then you will have to look at the space between the medial and intermediate cuneiform, and the first web space should match on the oblique reel. Then you have to think about. As I look for the first TMT line and the third medial border of the metatarsal shaft should match the lateral cuneiform and again, lateral border should match the lateral border of the lateral cuneiform. And the fourth metatarsal medial border should match the border.
Then the spacers should match all with that. Then on the dorsal side, there should not be any step if there is a direct list franks, you don't look for these things there. The treatment for the list Franks fracture. If you suspect the list Franks fracture, there is no non-operated treatment unless the patient is taken to the theater and make sure that there is it.
You do the EU and the ankle and the foot is stable, then only you do the non-operated trade. Otherwise, it is obturator treatment and the principles are stability of the middle column, even at the cost of the restriction of movement. Every attempt must be made to reconstruct and preserve the essential joints. So what is non-essential joints? The non-essential joint is very little movement that is first, second and third to empty joint intra cuneiform joints over there and navicular cuneiform joints.
All of that, and the essential joints are fourth and fifth to empty joint Calcasieu cowboy joint and navicular joint, all with their principal number two is proximal to distal. So if there is a cuneiform metatarsal cuneiform navicular cuneiform joint destruction, you need to fix that before you go to the cuneiform metatarsal. And then medial collateral. So that is the second principle over that.
So open reduce and fix the medial border of the medial cuneiform to the middle of the first TMT, then open. Reduce the second TMT open, reduce the third TMT and then concurrency of fourth and fifth should be checked and fixed with key allies. So in principle, the say in summary, first, second to 3 to 3 TMT joints should be fixed with a rigid fixation, like with screws or plate.
Fourth and fifth should be fixed with care wires. So this is what is the main problem. If you see any kind of this X-ray like this, you definitely you don't want to see this at all in your life. So this is the last time you are going to see and you are never, ever going to see that never, ever fixed the list. Frank's fractures with care. Thank you.
Who is going to take the second case? The case? 23-year-old complaining of pain in the ankle history of injury to the ankle while snowboarding is having difficulties in full weight bearing that is the ankle. What is going through your mind with this thing? No x-rays, rays, nothing. This is the history and that is the clinical examination.
Tell me, what do you think is happening? Since that is a snowboarding injury, I suspect fractured spray in the form of fracture until the process of calcaneus or fracture of the lateral bruises of Taylor's fracture. Brilliant OK, so that is fantastic. So continuing the examination, he's unable to weight bear grossly tender all over the lateral aspect of the ankle, ankle movements and slap tell our moments are very, very painful.
TMT joints and Achilles tendon is normal. That that is the X-ray. What can you see? Yes maybe I should displace the fracture of the lateral Bruce of the Taylors. It was stated in the subscapularis space that is the latter process of the fracture, Taylor's fracture, unique structure in the four in the tolerance because it articulates with the ankle, and it also articulates with the subtalar joint.
So if you have this fracture, you have two joints screwed up. One is the ankle joint and the other one is a large joint and it is called a snowboard fracture. The unfortunate thing is that 33% of these fractures are missed by us and also by the A&E. What you have to look for is you need to think about high index of suspicion as soon as you think that the patient is having unable to walk and wait.
Don't think that it is a sprain. If the patient is unable to wait there, that means that there is some kind of bony problem. Look and think about it. If you think about it, you were brain. If your AIIS will look for it. If you think in your brain, that could this be a lateral process of the talus, then your AIIS will look for it.
And what are you going to look for? It is called as we sign on the lateral view, I will show you in that this is the classification type 1 is a small chip fracture. Type 2 is large fragment, whether it is displaced or not, and type III is committed and involve the entire electoral process. So here you can see that this is a skewed v here, and you should have a broad v like that.
This is normal. If you have a skewed and we. It is it is bad. So what I say to my register saves my people. Call me Mr Ray in my hospital. So I am fat, so I always say fat is normal and this is cured or bent, which is very bad. That is the best way to remember for all of you that what we do.
Type I and type Ii 2a, which is displaced. You fix them. And type two, B and three. You do the fixation. Or if it is mushed up, you just exercise those, those things. So the diagnosis, if you diagnose early and treat properly, the patients will have better hind foot score.
Right that is the second case who can take the third case, then five-year-old fit and healthy training for a marathon complaining of pain, sudden onset with Wake aching pain and swelling on the foot. No history of trauma able to walk and carry on his normal day to day activities. Pain increase with activity and progress was to post activity. What do you think is happening there? This structure study stress structure.
Very good. So that is what it is. Normal range of movement. Normal strength, diffuse swelling. No Moses local pain or the forefoot tenderness over the second and third metatarsal unable to hop. That is what is important. Unable to hop or go on tiptoes there. So that is the diffuse swelling.
And when you do this, X ray, this is not the same patients, but you can say that there is already healing, that you need to think about why the patient had the stress fracture. Could it be sudden change in the activity? Could it be osteoporosis? Could it be because of poor conditioning that is suddenly lost during the lockdown? People have started going for long walks and running and everything.
So this is without conditioning, without training. That is what happens in proper technique. Change of surfaces people who were doing indoor running has started going out door into the woods. That might have caused a change of surface. Improper equipment and excessive loading because of. Whereas while the hind foot or the knee problems. Treatment is activity modification. Avoid high impact activities, and if they are still very painful, then you can put them in place to start.
Operative treatment is very rare, but if it goes into nonunion, you can do that one. And if it is because of the biomechanics, then you try to do the gait analysis here. The foot is there, and by doing the insoles, you can correct that one and you can address the biomechanics there. Thank you. Mohammad year fit and healthy commutes to work on motorbike complaining of limp and difficulties complaining of limp and difficulties to change the motorbike gear denies any trauma.
No history of pain or swelling. Notice is more limp and frequent. Dripping with bare feet or flip-flops. Feels comfortable with less limp with boots. What is happening? What do you think is happening, muhammad? I think there is some posterior, probably the tibialis posterior inflammation, which is causing the problem.
So what is the tibia is supposed to do? The function of tibia is posterior. It's bound to flex and invert. Yeah so this is he is unable to. He can do it plantar flexion, but he can't do the other way around. You going to do the dossey flexion? Yeah so.
Or at least tendinitis. So what we have done is I have looked at this thing. This is the foot and inspection. There is a small scar where you can see the dots as shown and there is no other abnormality. So I asked him to walk and he can walk on tiptoes, but he is unable to walk on his heels. Allen one position, I guess. No so this is a typical anti rural rupture, the economic sign of tiberias a dysfunction is inability to walk on his heels alone.
Now, when I questioned him, this guy is a very big, Macho Man. So he was saying that he was helping his wife and he dropped the knife and it went through that and there was a small scar he put some pressure on and he carried on. So when he dropped his knife, helping his wife, he has cut his tables. And it was lying somewhere over there. So this is an inability of the patient cannot walk on their heels.
One of the commonest economic thing is you have to think if the patient is able to do everything and suddenly he's unable to walk on his heels. It has to be a unless it is proven otherwise. Thank you. Thank you very much for your excellent presentation. As always, if our guest mentors is really, really pleased to work with our UK in providing these webinar sessions, our UK is a charity that's recognized in the orthopedic research, but also orthopedic education.
The website has further future webinars and also a number of courses and books as far as mentor group as you all are aware of us. We are a large group of mentors that are passionate about teaching and preparing people for their parks. There's a telegram group, Facebook and YouTube channels, and we also have concise Orthopedics textbook over my shoulder if you guys can see my video.
Thank you so much to our presenter today who was an excellent talk. Thank you.
Segment:0 .
Hugh Evans, and tonight we're privileged to have Mr. Krishna Vemulapinni who's a consultant, orthopedic surgeon in foot and ankle surgery.
He works at Kings College Hospital in good Mason Queen's Hospital in romford, where he specializes in foot and ankle surgery and orthopedic surgery for children. He did his foot and ankle surgery training in Norfolk and Norwich hospital and in children's orthopedic surgery at the Royal London Hospital. He also teaches surgeons in various orthopedic and parks examination courses.
This evening we have Ruth and Hannah from our UK and the mentors this evening or Kashif swan and Imran as well as myself. Following the presentation, we're going to go for the cq tests and we'd like you to answer those as quickly as possible and then we'll take questions from the participants. If you have any questions during the presentation, if you put them in the chat box, we will monitor that and we'll ask at the end of the presentation.
After all the questions are finished, we will stop the recording and we'll move on to the vyver practice. If you would like a vyver, we ask that you raise your hand or let myself or Ruth know. And also when you're sitting the fastest part to do so. Without any further ado, I will pass you over to Mr. to for the presentation. Thank you.
Thank you, Nick. Thank you. Ruth, and oh, are you ok? I've been a consultant for the last 13 years. I work in queensland, King George hospital, Northeast part of the London there. Thank you for inviting me to talk about foot and ankle. Before we go into the foot and ankle examination, I just want to say that I've been doing this for the law for the last two years.
However, I do this face to face and I usually bring patients and I demonstrate my examination skills and fine tuned my registers and everyone. I am very, very particular about my examination findings and all my registrars who has gone through the training know about the importance of this examination. So we have 26 bones just to touch base on the anatomy.
We have in each foot. That's 26 bones, 33 joints, more than 100 ligaments and tendons for an ankle examination is largely similar to any other joint examination, which is look, feel and move, and then followed by special test. Every person has their own way of examining the foot and ankle. And this is my way and what I have.
What I say is it is for an ankle examination made easy. Like any foreign like any joint examination, foot and ankle examination is an art. It can be painful and scary or to do the examination. And the only way to get over it is you need to know the anatomy. If the anatomy. And if you are King of anatomy, then it is going to be a simple art and it will be powerful and effective.
The aim of the foot and ankle examination is to find out the pathology. It's like a bit of detective work then, unlike a hip or a knee. I have a disadvantage that I have 26 bones, 33 joints and more than 100 ligaments and tendons there, so I have to be meticulous. And even though, it is looking like a duck, quacks like a duck, I don't believe that it is a duck because it might come and bite me.
So I have to poke it and see whether it is a duck or not. It's a detective work. What exactly is happening there? Because I don't want to bark at the wrong tree, and if I am barking up the wrong tree as a surgeon, I have lost the game there. So the aim of this talk is to find out the pathology from the history and examination. So this is the most important thing.
Each and every time my registrar changes every six months, they will be given the instructions each and every new patients. They have to take history. And with the history, they should be coming with a differential diagnosis of about three or four, and then they have to do the examination and knock off two of the differential diagnosis, then only refer the patient to the investigation.
So that we will know exactly what is happening over there. And so to take the history, we have to go back to the basics like what we did in our medical school, the nine characters of the pain, what exactly has caused the pain? Was there any history of trauma, anatomical location, type of pain, whether it is radiating into the toes or whether it is radiating into the leg? Is it associated with Schubert or is it also there with bare feet?
Is it more on uneven floor or even floor? Is it there with clothing, shoes or even open top shoes? Was there any kind of pain while you are walking, standing or whatever it is running is what how? How long do you need to walk to get the pain? So quantifying the pain what are the alleviating factors? Is it like taking off the footwear? Does it help you or taking painkillers or taking rest?
Then the special characters like start up pain and early morning pain. Once all these things it it will make your life easy. Before you touch any patient. You have to expose the patient until the knee, and if possible, you can go about it. But definitely it is mandatory to expose that limb and it is not one limb. It is both the legs.
And then you have to look for any kind of walking aids around it at all. But the patient has walked with the crutch or a frame, whether there is any kind of surgical shoes, insoles or any kind of auto system. And then you have to start looking at the gait. You comment on the gait from the front, standing at the front of the patient, how they are walking and whether they are using any kind of auto space or they need any kind of help and then comment on their pelvic tilt. They comment on their gait.
And then you, you comment the gait from the side. What? what are the rockers? How is the first rocker, second rocker, third rocker, the movement of the knee movement of the hip? And then if they are able to walk without any aids, then I always ask them whether they can walk with their tiptoes. The reason why I ask them to walk with their tiptoes is because within two seconds, I will know about their ankle flexibility.
I know about their midfoot functions if there is any stress fracture, if there is any joint sinusitis, and also very quickly as one as to function as well, then I will ask them to walk with heels. So again, ankle mobility tibial is a function, egil and ideal functions. If they have plantar fasciitis or heel problems, they will not be able to walk on their heels.
And also, we are checking L4 and L5 nerve route to their. Walking on the outer, inner aspect of the feet, so we will ask, we can ask, I can assess the subthalamic joint, I can see whether there was any there is any medial or lateral that are impingement, if there is any first rate problems or three problems over there. So once we have looked at the gait and everything then comes to looking.
So you have to always look from the whole of the lower limb. How is the alignment of the lower limb to the hind foot? How is the midfoot to the hind foot and forefoot and toes? Because you can easily miss something which is above the knee. If you are just concentrating on the foot and ankle, once you rule out that there is nothing, no problem with the alignment, then you look from that front, you look from the side that is in aspect.
You look from behind its, you need to go around the patient and then you look from the outer aspect of the foot. Please do not forget to look underneath because that might be the pathology, what the patient is having. Once you have taken the history and an inspection, then what exactly is the problem or where is the problem? So then you tailor your examination, rest of the examination, depending on your history and inspection findings.
There is no point of doing Coleman block test for a flat foot and vice versa, doing too many toes, commenting on too many toes or single foot tip toeing in a best case. So you need to tailor your examination from here onwards, depending on what do you think is the pathology? So the best position of examination is patient sitting in on an examination table and you are sitting in a chair and the foot is to your elbow level.
How's everybody doing this patient is comfortable and you are also comfortable there. First and foremost, before you touch the patient, you ask where exactly is the tender point? Once you know that they read, the tender point is try to examine that tender point at the last point in your examination, you check your feeling with your temperature. Then, as I have clearly said, that you need to know that anatomy, if the anatomy that the life is really easy, you need to keep looking at the patient's face, but your fingers has to do the work.
You need to know where your thumb, where you were index finger is, whether it is on the middle, whether it is on the table is 70-year or whatever it is. You need to have a systematic palpation if you want to come from the top to the medial side. It is entirely up to you whether you want to go from inside to outside, whether it is entirely up to you, but you have to dial up a type of systematic palpation inside you.
What exactly you are looking for outside, what are you looking for? And then posterior and on the plantar aspect of the heel on the top of the metatarsals and also underneath on the metatarsal part. So these are the points where you have to look and feel for the patient there. Depending on the location of the pain, depending on the tenderness, you have different pathologies which are illustrated on this tabular form.
Then you start your movement. I always start you the movement with silver skills test. By doing this thing, I will know whether at least whether the Achilles tendon is tight because of the spot on the soldiers part of the Achilles tendon. Then I will start moving the ankles up Taylor tassel chopper joints and metatarsal filling gel joint. Remember, circulation is a complex moment of inversion addiction and plantar flexion, and pronation is inversion, a reduction and dose reflection.
So this tabular form will tell you what are the possible causes of restriction if you have those inflection, plantar flexion inversion or reversion restrictions? So that this is a picture where I am demonstrating the silver scale test on this picture. I have flex the knee so that the gastronomy is relaxed and I could get this much of those inflection and with the dose effect.
With my right hand in the same position, I have straighten the knee as soon as I have straighten the knee. You can see that the patient can't have that much of those inflection, so this patient has a anemia tightness over that. Once I do the movement over there, then I'm going to go now. Special test each and every muscle has to be tested that the first common first muscle, which I usually do, is to be a You don't need to follow this regime, but this is what I do.
And for doing that, the ankle should be indoorsy, flexion and inversion so that it I am isolating only the tibialis anterior and I don't get any kind of power or movement from the tibialis posterior. So once I get the ankle in that movement, then I will ask the patient to hold the foot in that position and with my right finger, I'm trying to pull it down. And with my left finger, I'm feeling the power and the contractions in the tibial is anterior.
Tibial is posterior. The foot ankle should be in plantar flexion inversion. So my left finger is on the posterior aspect of the medial malice and on the right finger, I'm trying to push it laterally. So a bit of close up of picture. So this is my finger on the table is posterior and you can see that over there and I'm trying to push. Bush, that foot away from my finger, my hand there, baronial tendons.
Again, the plant is plantar flexion. You need to have the foot in a full plantar flexion and inversion. And with my left hand, I'm asking the patient to push my left finger and then I'm feeling the perennial tendon. So you can see not only you can feel it, but you can also see that strength of the coronal tendon over that.
Excellent idea. Again, the same thing asking ankle in a neutral position and then trying to pull it up, and it is again trying to pull it up that the FHL and FDL slightly in plantar flexion and then asking the patient to push the big toe or the lesser toes over my fingers there. So once I do the power of these tendons, then I will go.
I, depending on the patient's history, if the patient is complaining of any kind of giving way, then I will do a anterior sign. If the patient has pressed cavers, then I will be doing Coleman test and thecable sign. If there is a flat feet, I will be looking at pick up that too many toes sign up single leg tip toe test if I'm seeing a diabetic patient, so I will do a semi swing state and monofilament test.
So, a Drosten, let's assume that there is a patient who is complaining of giving way. Patient sitting high up on the examination table, foot in slight plantar flexion. And I'm a right handed, so I am holding the right the heel with my index finger and with the my long, long finger in the back, and then I have the thumb in the front. Slight plantar flexion and the my left hand is holding the tibia.
So then what I'm doing is I am pulling in the direction from slight plantar flexion and anterior. It is a similar test like what we do for the ACL in the knee. So this is again one more picture demonstrating that is holding the tibia plantar flexing. And then that is the direction, anteriorly and slightly plantar flexion there. Then what you will see is a bit of sulcus sign that is the skin getting sucked inside on the lateral aspect.
And also you will see a bit of movement over there and always compared with the opposite side. And sometimes you can hear if it is significantly unstable, you can hear and feel a clunk. That is the anti lateral sign that if there is a possibility of syndesmosis injury because history of trauma and everything. What I do is mostly stress test, which is a holding the leg with my right hand don't flexing the foot and externally rotating arm stretching the syndesmosis over there.
You can do this test by standing. I will also do this test in a standing position that is weight bearing. I will ask the patient to stand up on one leg and twist the body so that we know what exactly whether we are having any stress, pain in the syndesmosis, that this is the zygomatic again representation of what I do. And then comes to that too many toes sign.
This is mainly for the tibialis posterior dysfunction when there is a hind foot and right foot involved. Normally, if you are looking at the foot from the posterior aspect, you should see the little toe or half of the fourth toe. If you see more than 1 and 1/2 toes from the posterior. That means too many toes sine positive, so you can see here little toe, fourth, third, second and a bit of big toe.
That means this foot is collapsed medially and there is a hand a hind foot Bulger's there. So here also, you can see a lot of toes here and you can see that it's a big toe and the rest of the toes. So this is all hind foot, mid foot and four foot while the. Then comes the single leg tip toe test. So you have to take a patient to the wall and ask them to take the support of the wall standing one foot away from the wall, standing on a good side and take by taking the support of the wall.
He can you ask him to go on tiptoes? He has to stay on tiptoe for 30 second and then swap it with the scatological side or the painful side. Some people does this holding the chair. That is completely wrong because if you are holding a chair and going on the tiptoes, that means you are using your upper limb to push your body in the air. So I always recommend to get this done holding the wall.
This is a peekaboo sign, so it is like if you have a child or a nephew, whatever whoever is a child, you play with your child like a peekaboo. So on the right side here, you can't see any heel, so you should not be able to see any heel. If you are looking at anybody's feet, if you are seeing a bit of heel there, that means Culkin is playing a game with you like a peekaboo game.
So it is like, like that game, which we play with our children. So this is where you have significant hind foot bearers and you can see the arches, which are high that. Now comes the Coleman block test, this is mainly meant for to find out if the hind foot is flexible, whether the hind foot wears deformity is driven by the forefoot. So how do we do it?
The Polonius longest is very, very strong. So what it does is turn as long as it is attached onto the base of the first metatarsal, so it pulls the first metatarsal down. And because of that, the whole four foot is in slight pronation. To compensate that you, you completely turn your hind foot into whera. So the hind foot is driven by the forefoot plantar flex flexed first train by doing the Coleman block test, where you are taking off the first ray and the secondary off the block.
Then you will correct the hind foot deformity. This is the hind foot, which is in, whereas the patient is standing on a block. So we have neutralized the Polonius longest and the plantar flexed first rate, and you can see that the hind foot is completely corrected. This is the textbook pictures, and you can see you can see that there is a peekaboo sign over here. The foot is in wearer's bilaterally and you put the Coleman block test first and second rate or maybe the third race of the Coleman.
And you can get the feel, which is very straight compared to the opposite side, which is in reference to the last special test is Sammy's Weinstein monofilament test. So this is a 10 grams monofilament very sensitive and you need to push it. You need to push it so that there is a bend in the monofilament. And if the patient is able to feel the sensation, that means that there is a pressure sensation intact.
If the patient cannot feel the sensation, there is a high chance that this patient is going to develop ulcers that are so complete the examination by prone in the patient and prone or nailed down there, where you can examine the lower end of the spine. And also you can see the plantar aspect of the foot and the neurovascular examination. So that is, in short, a synopsis of how I examine my foot and ankle, so I will wait for any questions now.
Then we will go for some case discussions. Oh, sorry. Actually, hang on. We have some, some more slides. Hang on there. So these are the slides which I want to show you. Common cases for the farc? Yes so this is obviously Alex Vargas or Alex rejoinders people who usually miss.
I'm just making a box because I usually bring the patients and ask one of the Registrar to present because there is no patient to be presented. I'm just giving a box of information that people keep forgetting to or forgetting to mention these things, or some of the important salient features which examiners expect you to comment on. So don't forget about walking shoes and any kind of orthotics gait.
Then you comment not only on the big toe, you have to comment on the lesser toes. Don't forget about plantar Kessler cities. Think about system tenderness in the Vargas or hallux rigid foot and ankle examination. Talk about the flexibility and the movement of the joints because if there is no movement, that means it is hallux visitors. If there is movement, then that means it is Vargas and also whether you can correct it or not.
Then at the same time, you have to think about whether the forefoot deformity is a compensatory deformity because of the midfoot or hind foot, for example, tibial its posterior dysfunction where there is a pronation deformity and the collapse of the medial arch. There will be compensatory Alex Vargas. So if you are doing a surgery in your table is posterior dysfunction, it is going to fail.
It's the same thing that one of the common reasons of Alex Vargas is Achilles tightness, so you need to do the Achilles tendon examination in four complete for complete sake of this pathology. Don't forget that 60% to 70% of these patients who has this much of this deformity will have loss of sensation their. And what's the face always when you are doing the.
This is the second commonest case in the FARC rebels bas status dysfunction. So these are the things which you should not forget about talking about in the is bas status dysfunction, walking shoes, autos, gait, too many toes side one foot tip toe test, which we talked about Achilles tightness. This is one of the commonest cause of tibialis posterior dysfunction.
Also when you are because this is basically because the midfoot is collapsed, when you are trying to examine Achilles tendon tightness or doing a silver skills test. Don't do it without locking the midfoot in the slap. Otherwise, what you are getting is a dorsiflexion movement from the midfoot and the rest of the things are. Don't forget about examining the alignment of the knee because there might be a gene of algum and the foot pronation deformity and the tibialis posterior dysfunction is secondary to the Vargas deformity of the knee.
Again, please keep watching the face of the patient. Then the next commonest thing is cavers. And in this one again, walking shoes, autopsies, please don't forget it and shock at foot. Sorry pest cave us in this country. And most of the Western countries are short, committed tooth syndrome, so they will have some kind of hand in ferocious muscle wasting.
And so please examine before you go to the foot and ankle so that you have completed that and that is a passing tick box exercise. Look at the comment about the part about the peekaboo sign. And these patients have weakness of tibial a So they will have a foot drop type of gait where there is no ill contact as an initial contact there and you will have a compensatory closing of the toes, basically because of the tibial is weak.
You will be the patient will be recruiting that he channel and Edl to do the dose reflection that there is an inverted champagne bottle calf muscle because the patients walk on the outer aspect. You will have calluses on the fifth metatarsal. And they might have fifth metatarsal stress fractures. And don't forget about common block test, and these patients might have lateral ligament insufficiency, so try to do a drawer sign some patients will be coming to you with the fifth metatarsal stress fracture.
Sometimes they will have giving way symptoms, instability signs. So look at the lateral ligament insufficiency. Tibial is anterior and corona's brevis is very weak compared to the tibial is posterior and felonious longer. So you need to examine all the four muscles there. Don't forget to examine the lower end of the spine, because this is a neurological pathology, unless proven otherwise.
So finally, my foot and ankle examination is history, history, history and examination, and then we will confirm the diagnosis, what we have done by investigation the first term. First question is ideal position of the foot and ankle while testing the tibialis anterior power. So we know that the tibial is anterior and the dorsal tendons, which are each Edl and Sturgis, which is not anterior and the tibial is posterior, which is on the medial side, can cause some kind of inversion there and the dose reflection.
So to neutralize the tibial posterior, then you need to put the foot in full dose of flexion and inversion. How's everybody doing that, you are neutralizing and isolating only tibial is a So the answer for the first question is dorsiflexion and inversion, where 95% of the people who has vote has got correct. Some people have voted neutral and inversion and the other one.
Some people have noted that plantar flexion and inversion. So these things you do not get the tibial is anterior into the isolation thing. So in the same context, ideal position second cushion is ideal position of foot and ankle while testing the tibialis posterior. So you need to again now neutralize the tibial is anterior. How are we going to neutralize the tibial s.a.? If you put it on the maximum stretch, the maximum stretch is in the plantar flexion and inversion.
How's everybody doing that, you are isolating. You are getting only the power of tibialis posterior. So the answer is plantar flexion and inversion. So again, 90% of the part the candidates got it right that Coleman block test. As I have mentioned, that Coleman block test will check, first of all, whether the hind foot is driven by the forefoot and whether the hind foot is flexible or not. So first and foremost, if it is because of the.
Erroneous, longer hyperactivity and the COVID block test will confirm that the hind foot will hind foot will be correcting. We will correct the hind foot, whereas deformity, for example, if the hind foot has burst so patient is old or had been there for a long time, and there is arthritis in the slap Taylor joint, even if it is forefoot driven. You will not be able to correct the hind foot virus, so that's why the answer is forefoot driven, flexible hind foot, whereas it is not fixed hind for two errors.
Thank you. Thank you very much, Krishna, and thank you for your talk. I think that was a really useful talk for the candidates because you will. It's quite likely that you'll be asked to examine somebody's foot and ankle in the exam, and that was lots of good tips for your clinical examination, which you know, we've not had the benefit of all the courses that we normally would to practice.
So I would watch that again and just make sure that you can familiarize yourself with those techniques. So what we're going to do next is move on to the questions from the audience. I think ani and Imran were looking at the questions. Yeah is Omar Ahmed said if the patient has more than 10% of those affliction, but it increases on knee flexion. Is this to be considered as positive silver cold test?
So if there is 10% of those reflection and it is, it is increased by flexing the knee. Correct? well, the thing is the normal dose reflection varies from 10 to 20 degrees. So if it is same as the opposite side, then it is positive. If it is same on both sides, then the patient has that much of the reflection, so it is always competition with the opposite side.
OK so he asked, do we need to test the longus muscle power in plantar flexion of the first trade? So what I have said that is baronial muscles. I did not isolate coronal longest and perennial brevis over that because it is a bit difficult. And I have to demonstrate face to face, but I can't do it on this one.
That's why I put it as Petrone muscles. So if we are doing the perennial muscles, that is usually the inversion. A combination of Polonius longest and bravest will cause evolution, and you need to neutralize the erroneous tertius. So the parallel stoushes is attached on the dorsal aspect of the three. The way to isolate the Polonius neutralize the perennial stoushes is putting the patient ankle in a plantar flexion, so it is maximum stretched.
And what you are testing is mainly the Polonius brevis. That is what it is. OK, so, Melinda. So how we can examine sprained ligament, please spring a ligament. Right, so this is the spring ligament. There are different tests which are being mentioned, but there is no clear cut, a clear cut, complete specific test for that.
One of the things is that you hold the foot in neutral and then try to do the valve with one finger. You push the forefoot into valgus. If it stays there and it is not springing it back into the position, there is a complete tear and there is a insufficiency of spring ligament. It is, again, we have done that research on the cadavers in some cadavers.
It was positive and in some cadavers it is not positive, but it is 50% and it is difficult to isolate the spring ligament on its own. OK, so another one, so if we have a rigid hind foot virus and blunt flex, it's very strange how to differentiate the origin of the hind foot virus. Well, it is. I think if you have a rigidity in the hind foot, it is now more of a bony procedure.
We can't do any kind of soft tissue procedure. The reason why we need to do that is whether it is a flexible deformity or a fixed deformity. So that is again, the orthopedic principles. If there is a flexible deformity, you try to do the soft tissue reconstruction. If the patient has a bony rigidity or a fixed rigidity, then you have to do the bony procedures. So that means that differentiating is going to be difficult. And we don't do anything because the patient needs a bony procedure like slap La fusion with or without cranial osteotomy.
OK, so without question, if the patient has fixed flatfoot, how can I look the transverse tassal joint to test the ankle range of movement? So the effort is actually it is going into the fixed Vargas usually trying to do a supination lock the midfoot and the TMT joints, so that is how the gait is. So you try to separate the midfoot and four-foot and see whether you can dorsiflex the ankle.
If there is any flexion, that means you are getting the movement only from the ankle joint. If there is no dorsiflexion. That means it is. There is arthritis in the ankle and you don't get any movement in the ankle joint that. OK slap question how we can confirm flexibility of the here in stage two three four tiberias bas status insufficiency.
For is arthritis and subtalar arthritis. 3 is up after this thing, so it is only the two, so that is the tibial is posterior dysfunction classification is when you have a 1 and 2 is the flexible thing you said. What are the different investigations that we can request in food problems? This is from Mohammad Javad. Well, it all.
It is a big, big open question. So we can start from X rays, ultrasound scan, MRI scan and the bone scan and some of the cases, which are very, very complex pathology where we do not know which is the culprit. And if we have two or three differential diagnosis even after the MRI scan, I go for CTE. That is the highest scan.
And I also do a diagnostic injections. These are really very good because it will. It will tell me which joint is the pathology. So if I think that there are two joints, which are pathology, for example, navic look uniform joint and Taylor La joint, so I will try to isolate one of the joint by giving a steroid injection or a local anesthetic into the joint, asking the patient to keep the pain diary.
I use this regularly for before I take the patient to the theater for ankle replacement or ankle fusion. I try to find out whether the subtalar joint is involved or not by doing a short program and injection into the cocktail hour joint, asking the patient to keep the pain diary. And if the patient has no pain improvement, that means all his pain is coming from the ankle joint. So those are the diagnostic investigations we do.
OK, just one last question, I think, to clarify. I know you mentioned about soupy nation food screening and food pronation. Somebody is asking whether nation is a separate movement. But I know that you mentioned is a composite movement. Coronation is a composite movement to a place. Well, superannuation is a combination of inversion, adoption and plantar flexion. Pronation is a combination of immersion, abduction and dose reflection.
The best thing you can do is where you are sitting, whoever has asked this question where you are sitting. Look at your foot and try to put the foot in inversion plantar flexion. And it ought to as soon as you put your foot in inversion and a reduction in plantar flexion that is the slap. That's what it is.
If you are flexing and trying to move you a little towards the proximal part of your proximal part of your body. So that is abduction evolution and dorsiflexion. That is what supine and pronation is. Try to feel yourself, look at your foot, put your foot in inversion and action and plantar flexion. That is, to put your foot in inversion, abduction and flexion that is pronation.
Thank you. OK, that's great, thank you. Thank you. So we're going to move on to some case based discussions now. And I think Ruth has got a couple of volunteers that it's not quite a vyver, but we're going to discuss it and you've got the opportunity to talk through it.
Yeah, Joe. Joe is going to do the first case discussion with Krishna. OK Yes. Hello Hello. All right. Joe is there. Yes, I'm here. OK you see me and hear me. Don't know.
Yeah hi, Joe. So hi, is the 30-year-old female complaining of foot pain history of stepped into a pothole while playing with nephew in the garden. Pain and swelling in the foot, unable to wait back. What is happening in your mind? If you if you hear this story? What do you think? Are the possible pathology here?
OK, so the traumatic so fracture stress fracture. Joe sorry. Sorry not stress for traumatic fracture of the foot for these 26 bones, Joe. OK well, I count the pain and swelling in the foot. It's not in a specific part, so I need to take more history about where is the pain?
I just want to stop you. There is something very important in the history, which is a pothole. Does it ring a bell? Does it make you worry about it? Yes I'm worried about that. It might cause a ligament injury from an inversion, from an inversion injury to the ankle. Next stop.
Sorry this is not. OK and you want to see from the planter aspect, this is the case. So what do you think is happening? So it can also on the sole of the foot. And my worries here is that there might be a ligament injury to the left flank ligament. And this might be a less Lisfranc injury due to this. Moses, I want to say sorry, this is not a bible, so I will stop your debt.
OK, sorry, this is unable to White Bear midfoot grossly swollen with Moses tender on palpation of the midfoot. OK, I'm going to just run through. That is correct. The list Frank's fracture. This is the X-ray which we have over there. OK, now the list. Frank's fracture is not just the ligament injury, the list.
Frank's joint is any bony or ligament injury in the first, second, third, fourth and fifth empty joints. This is the list Frank's thing. So if there is a disruption between the uniform over here, all of them is less Frank's joint and everything. So you do the X-ray and then you need to look at the medial border of the medial cuneiform into the first metatarsal. And this is what you are looking on the April letter TMT joint and the medial border of the second TMT joint.
Then you will have to look at the space between the medial and intermediate cuneiform, and the first web space should match on the oblique reel. Then you have to think about. As I look for the first TMT line and the third medial border of the metatarsal shaft should match the lateral cuneiform and again, lateral border should match the lateral border of the lateral cuneiform. And the fourth metatarsal medial border should match the border.
Then the spacers should match all with that. Then on the dorsal side, there should not be any step if there is a direct list franks, you don't look for these things there. The treatment for the list Franks fracture. If you suspect the list Franks fracture, there is no non-operated treatment unless the patient is taken to the theater and make sure that there is it.
You do the EU and the ankle and the foot is stable, then only you do the non-operated trade. Otherwise, it is obturator treatment and the principles are stability of the middle column, even at the cost of the restriction of movement. Every attempt must be made to reconstruct and preserve the essential joints. So what is non-essential joints? The non-essential joint is very little movement that is first, second and third to empty joint intra cuneiform joints over there and navicular cuneiform joints.
All of that, and the essential joints are fourth and fifth to empty joint Calcasieu cowboy joint and navicular joint, all with their principal number two is proximal to distal. So if there is a cuneiform metatarsal cuneiform navicular cuneiform joint destruction, you need to fix that before you go to the cuneiform metatarsal. And then medial collateral. So that is the second principle over that.
So open reduce and fix the medial border of the medial cuneiform to the middle of the first TMT, then open. Reduce the second TMT open, reduce the third TMT and then concurrency of fourth and fifth should be checked and fixed with key allies. So in principle, the say in summary, first, second to 3 to 3 TMT joints should be fixed with a rigid fixation, like with screws or plate.
Fourth and fifth should be fixed with care wires. So this is what is the main problem. If you see any kind of this X-ray like this, you definitely you don't want to see this at all in your life. So this is the last time you are going to see and you are never, ever going to see that never, ever fixed the list. Frank's fractures with care. Thank you.
Who is going to take the second case? The case? 23-year-old complaining of pain in the ankle history of injury to the ankle while snowboarding is having difficulties in full weight bearing that is the ankle. What is going through your mind with this thing? No x-rays, rays, nothing. This is the history and that is the clinical examination.
Tell me, what do you think is happening? Since that is a snowboarding injury, I suspect fractured spray in the form of fracture until the process of calcaneus or fracture of the lateral bruises of Taylor's fracture. Brilliant OK, so that is fantastic. So continuing the examination, he's unable to weight bear grossly tender all over the lateral aspect of the ankle, ankle movements and slap tell our moments are very, very painful.
TMT joints and Achilles tendon is normal. That that is the X-ray. What can you see? Yes maybe I should displace the fracture of the lateral Bruce of the Taylors. It was stated in the subscapularis space that is the latter process of the fracture, Taylor's fracture, unique structure in the four in the tolerance because it articulates with the ankle, and it also articulates with the subtalar joint.
So if you have this fracture, you have two joints screwed up. One is the ankle joint and the other one is a large joint and it is called a snowboard fracture. The unfortunate thing is that 33% of these fractures are missed by us and also by the A&E. What you have to look for is you need to think about high index of suspicion as soon as you think that the patient is having unable to walk and wait.
Don't think that it is a sprain. If the patient is unable to wait there, that means that there is some kind of bony problem. Look and think about it. If you think about it, you were brain. If your AIIS will look for it. If you think in your brain, that could this be a lateral process of the talus, then your AIIS will look for it.
And what are you going to look for? It is called as we sign on the lateral view, I will show you in that this is the classification type 1 is a small chip fracture. Type 2 is large fragment, whether it is displaced or not, and type III is committed and involve the entire electoral process. So here you can see that this is a skewed v here, and you should have a broad v like that.
This is normal. If you have a skewed and we. It is it is bad. So what I say to my register saves my people. Call me Mr Ray in my hospital. So I am fat, so I always say fat is normal and this is cured or bent, which is very bad. That is the best way to remember for all of you that what we do.
Type I and type Ii 2a, which is displaced. You fix them. And type two, B and three. You do the fixation. Or if it is mushed up, you just exercise those, those things. So the diagnosis, if you diagnose early and treat properly, the patients will have better hind foot score.
Right that is the second case who can take the third case, then five-year-old fit and healthy training for a marathon complaining of pain, sudden onset with Wake aching pain and swelling on the foot. No history of trauma able to walk and carry on his normal day to day activities. Pain increase with activity and progress was to post activity. What do you think is happening there? This structure study stress structure.
Very good. So that is what it is. Normal range of movement. Normal strength, diffuse swelling. No Moses local pain or the forefoot tenderness over the second and third metatarsal unable to hop. That is what is important. Unable to hop or go on tiptoes there. So that is the diffuse swelling.
And when you do this, X ray, this is not the same patients, but you can say that there is already healing, that you need to think about why the patient had the stress fracture. Could it be sudden change in the activity? Could it be osteoporosis? Could it be because of poor conditioning that is suddenly lost during the lockdown? People have started going for long walks and running and everything.
So this is without conditioning, without training. That is what happens in proper technique. Change of surfaces people who were doing indoor running has started going out door into the woods. That might have caused a change of surface. Improper equipment and excessive loading because of. Whereas while the hind foot or the knee problems. Treatment is activity modification. Avoid high impact activities, and if they are still very painful, then you can put them in place to start.
Operative treatment is very rare, but if it goes into nonunion, you can do that one. And if it is because of the biomechanics, then you try to do the gait analysis here. The foot is there, and by doing the insoles, you can correct that one and you can address the biomechanics there. Thank you. Mohammad year fit and healthy commutes to work on motorbike complaining of limp and difficulties complaining of limp and difficulties to change the motorbike gear denies any trauma.
No history of pain or swelling. Notice is more limp and frequent. Dripping with bare feet or flip-flops. Feels comfortable with less limp with boots. What is happening? What do you think is happening, muhammad? I think there is some posterior, probably the tibialis posterior inflammation, which is causing the problem.
So what is the tibia is supposed to do? The function of tibia is posterior. It's bound to flex and invert. Yeah so this is he is unable to. He can do it plantar flexion, but he can't do the other way around. You going to do the dossey flexion? Yeah so.
Or at least tendinitis. So what we have done is I have looked at this thing. This is the foot and inspection. There is a small scar where you can see the dots as shown and there is no other abnormality. So I asked him to walk and he can walk on tiptoes, but he is unable to walk on his heels. Allen one position, I guess. No so this is a typical anti rural rupture, the economic sign of tiberias a dysfunction is inability to walk on his heels alone.
Now, when I questioned him, this guy is a very big, Macho Man. So he was saying that he was helping his wife and he dropped the knife and it went through that and there was a small scar he put some pressure on and he carried on. So when he dropped his knife, helping his wife, he has cut his tables. And it was lying somewhere over there. So this is an inability of the patient cannot walk on their heels.
One of the commonest economic thing is you have to think if the patient is able to do everything and suddenly he's unable to walk on his heels. It has to be a unless it is proven otherwise. Thank you. Thank you very much for your excellent presentation. As always, if our guest mentors is really, really pleased to work with our UK in providing these webinar sessions, our UK is a charity that's recognized in the orthopedic research, but also orthopedic education.
The website has further future webinars and also a number of courses and books as far as mentor group as you all are aware of us. We are a large group of mentors that are passionate about teaching and preparing people for their parks. There's a telegram group, Facebook and YouTube channels, and we also have concise Orthopedics textbook over my shoulder if you guys can see my video.
Thank you so much to our presenter today who was an excellent talk. Thank you.
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