Red Flags for Potential Serious Conditions in Patients with Knee, Leg, Ankle or Foot Problems Medical Screening

for the Knee, Leg, Ankle or Foot Region

Condition Fractures1-4 Red Flag Data obtained during Interview/History History of recent trauma: crush injury, MVA, falls from heights, or sports injuries Osteoporosis in the elderly Age > 55 years old History of type II diabetes History of ischemic heart disease Smoking history Sedentary lifestyle Co-occurring intermittent claudication Recent surgery, malignancy, pregnancy, trauma, or leg immobilization Red Flag Data obtained during Physical Exam Joint effusion and hemarthorsis Bruising, swelling, throbbing pain, and point tenderness over involved tissues Unwillingness to bear weight on involved leg Unilaterally cool extremity (may be bilateral if aorta is site of occlusion) Prolonged capillary refill time (>2 sec) Decreased pulses in arteries below the level of the occlusion Prolonged vascular filling time Ankle Brachial index < 0.90 Calf pain, edema, tenderness, warmth Calf pain that is intensified with standing or walking and relieved by rest and elevation Possible pallor and loss of dorsalis pedis pulse History of blunt trauma, crush Severe, persistent leg pain that is intensified with injury - or stretch applied to involved muscles Recent participation in a rigorous, Swelling, exquisite tenderness and palpable unaccustomed exercise or tension/hardness of involved compartment training activity Paresthesia, paresis, and pulselessness History of recent infection, surgery, Constant aching and/or throbbing pain, joint or injection swelling, tenderness, warmth Coexisting immunosuppressive May have an elevated body temperature disorder History of recent skin ulceration or Pain, skin swelling, warmth and an advancing, abrasion, venous insufficiency, irregular margin of erythema/reddish streaks CHF, or cirrhosis Fever, chills, malaise and weakness History of diabetes mellitus

Peripheral Arterial Occlusive Disease5-9

Deep Vein Thrombosis10,11,17

Compartment Syndrome12-14

Septic Arthritis15

Cellulitis16

References: 1. Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains. Am Fam Physician. 2002;68:785-794. 2. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2002;68:2413-2418. 3. Hasselman CT, et al. Foot and ankle fractures in elderly white woman. J of Bone Joint Surg. 2003;85:820-824. 4. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies, and recent developments. Injury. 2004;35:443-461. 5. Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. Journal of Clinical Epidemiology. 1997;50:659-668. 6. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. 1998;158:1357-1364. 7. Halperin, JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002;106:V303-11. 8. Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral occlusive vascular disease. Scand J Prim Health Care. 1998;16:177-182. 9. Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ. 1996;313:1440-79. 10. Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis in outpatients. Amer J Med. 2003;115:436-440. 11. Bustamante S, Houlton, PG. Swelling of the leg, deep venous thrombosis and the piriformis syndrome. Pain Res Manag. 2001;6:200-203. 12. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989;240:97-104. 13. Swain R. Lower extremity compartment syndrome: when to suspect pressure buildup. Postgraduate Medicine. 1999:105. 14. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder. Orthop Trauma. 2002;16:572-577. 15. Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology. 2001;40:24-30. 16. Stulberg D, Penrod M, Blatny R: Common bacterial skin infections. Am Fam Physician. 2002; 66:119-124. 17. Riddle DL, et al. Diagnosis of lower-extremity deep vein thrombosis in outpatients with musculoskeletal disorders: a national survey study of physical therapists. Phys Ther. 2004; 84 (8): 717-728.
Robert Klingman PT, Joe Godges PT KP SoCal Ortho PT Residency

KNEE/LEG/ANKLE/FOOT SCREENING QUESTIONNAIRE

NAME: ________________________________________ Medical Record #: _________________________ DATE: _____________

Yes 1. Have you recently experienced a trauma, such as a vehicle accident, a fall from a height, or a sports injury? 2. Have you recently had a fever? 3. Have you recently taken antibiotics or other medicines for an infection? 4. Have you had a recent surgery? 5. Have you had a recent injection to one or more of your joints? 6. Have you recently had a cut, scrape, or open wound? 7. Do you have diabetes? 8. Have you been diagnosed as having an immunosuppressive disorder? 9. Do you have a history of heart trouble? 10. Do you have a history of cancer? 11. Have you recently taken a long car ride, bus trip, or plane flight? 12. Have you recently been bedridden for any reason? 13. Have you recently begun a vigorous physical training program? 14. Do you have groin, hip, thigh or calf aching or pain that increases with physical activity, such as walking or running? 15. Have you recently sustained a blow to your shin or any other trauma to either of your legs?

No

Joe Godges DPT

KP SoCal Ortho PT Residency

Normal Gait Mechanics

Normal Gait Patterns Have Two Major Periods: 1. Double Limb Support: a) weight loading b) weight unloading 2. Single Limb Support: a) stance phase of ipsilateral side b) swing phase of contralateral side

DOUBLE LIMB SUPPORT WEIGHT UNLOADING: Phases: Trailing foot is rolling off floor when heel rises when 1st MTP rolls off floor Pre-Swing Max. plantarflexion (20 o) Flexes to approx. 40o Flexes to approx. 0o (neutral) Less anterior rotation Begin anterior elevation Aligned towards wt. loading leg

Terminal Stance: Pre-Swing:

Joint Motions: Ankle Knee Hip Pelvis Trunk

Terminal Stance Heel rise Full extension Max. extension (20o) Relative anterior rotation Posterior depression Aligned between legs

WEIGHT LOADING: Phases:

Weight is transferred to contralateral leg Initial Contact: Loading Response: when heel contacts floor when sole of foot contacts floor

Joint Motions Ankle Knee Hip Pelvis Trunk

Initial Contact Neutral Knee extended Flexed 25o Level Aligned between legs

Loading Response Plantarflexes 10o Knee flexes 15o Stable 25o flexion Relative abduction Lateral drop to swing leg Aligned towards wt. bearing leg

Joe Godges DPT