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Robert Klingman PT, Joe Godges PT KP SoCal Ortho PT Residency

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

Medical Screening for theKnee, Leg, Ankle or Foot Region

Condition

Red Flag

Data obtained duringInterview/History

Red Flag

Data obtained duringPhysical Exam

Fractures1-4 History of recent trauma: crush

injury, MVA, falls from heights,

or sports injuries

Osteoporosis in the elderly

Joint effusion and hemarthorsis

Bruising, swelling, throbbing pain, and point

tenderness over involved tissues

Unwillingness to bear weight on involved leg

Peripheral Arterial

Occlusive Disease5-9Age > 55 years old

History of type II diabetes

History of ischemic heart diseaseSmoking history

Sedentary lifestyleCo-occurring intermittent

claudication

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 occlusionProlonged vascular filling time

Ankle Brachial index < 0.90

Deep VeinThrombosis

10,11,17Recent surgery, malignancy,

pregnancy, trauma, or leg

immobilization

Calf pain, edema, tenderness, warmthCalf pain that is intensified with standing or

walking and relieved by rest and elevation

Possible pallor and loss of dorsalis pedis pulse

Compartment

Syndrome12-14

History of blunt trauma, crush

injury - or -

Recent participation in a rigorous,

unaccustomed exercise ortraining activity

Severe, persistent leg pain that is intensified with

stretch applied to involved muscles

Swelling, exquisite tenderness and palpable

tension/hardness of involved compartmentParesthesia, paresis, and pulselessness

Septic Arthritis15 History of recent infection, surgery,

or injectionCoexisting immunosuppressive

disorder

Constant aching and/or throbbing pain, joint

swelling, tenderness, warmthMay have an elevated body temperature

Cellulitis16

History of recent skin ulceration orabrasion, venous insufficiency,CHF, or cirrhosis

History of diabetes mellitus

Pain, skin swelling, warmth and an advancing,irregular margin of erythema/reddish streaks

Fever, chills, malaise and weakness

References:1. Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains.Am Fam Physician. 2002;68:785-794.

2. Hatch RL, Hacking S. Evaluation and management of toe fractures.Am Fam Physician. 2002;68:2413-2418.3. Hasselman CT, et al. Foot and ankle fractures in elderly white woman.J of Bone Joint Surg. 2003;85:820-824.4. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies, and recent developments.Injury. 2004;35:443-461.

5. Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patientswith diabetes mellitus.Journal of Clinical Epidemiology. 1997;50:659-668.

6. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review.Arch Intern Med.1998;158:1357-1364.

7. Halperin, JL. Evaluation of patients with peripheral vascular disease.Thrombosis Research. 2002;106:V303-11.

8. Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheralocclusive vascular disease.Scand J Prim Health Care. 1998;16:177-182.9. Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study.BMJ.

1996;313:1440-79.

10. Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis inoutpatients.Amer J Med. 2003;115:436-440.

11. Bustamante S, Houlton, PG. Swelling of the leg, deep venous thrombosis and the piriformis syndrome.Pain Res Manag.2001;6:200-203.

12. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg.Clin Orthop.1989;240:97-104.13. Swain R. Lower extremity compartment syndrome: when to suspect pressure buildup.Postgraduate Medicine. 1999:105.

14. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder.Orthop Trauma. 2002;16:572-577.

15. Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis.Rheumatology. 2001;40:24-30.16. Stulberg D, Penrod M, Blatny R: Common bacterial skin infections.Am Fam Physician. 2002; 66:119-124.

17. Riddle DL, et al. Diagnosis of lower-extremity deep vein thrombosis in outpatients with musculoskeletal disorders: a

national survey study of physical therapists. Phys Ther. 2004; 84 (8): 717-728.

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Joe Godges DPT KP SoCal Ortho PT Residency

1

KNEE/LEG/ANKLE/FOOT SCREENING QUESTIONNAIRE

NAME: ________________________________________ DATE: _____________

Medical Record #: _________________________

Yes No

1. Have you recently experienced a trauma, such as a vehicle accident, 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?

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Joe Godges DPT 1

Normal Gait Mechanics

Normal Gait Patterns Have Two Major Periods:

1. Double Limb Support: a) weight loading

b) weight unloading2. Single Limb Support: a) stance phase of ipsilateral side

b) swing phase of contralateral side

DOUBLE LIMB SUPPORT

WEIGHT UNLOADING: Trailing foot is rolling off floor

Phases: Terminal Stance: when heel risesPre-Swing: when 1st MTP rolls off floor

Joint Motions: Terminal Stance Pre-Swing

Ankle Heel rise Max. plantarflexion (20o)

Knee Full extension Flexes to approx. 40o

Hip Max. extension (20o) Flexes to approx. 0o (neutral)

Pelvis Relative anterior rotation Less anterior rotation

Posterior depression Begin anterior elevation

Trunk Aligned between legs Aligned towards wt. loading leg

WEIGHT LOADING: Weight is transferred to contralateral leg

Phases: Initial Contact: when heel contacts floor

Loading Response: when sole of foot contacts floor

Joint Motions Initial Contact Loading Response

Ankle Neutral Plantarflexes 10o

Knee Knee extended Knee flexes 15o

Hip Flexed 25o Stable 25o flexion

Relative abduction

Pelvis Level Lateral drop to swing legTrunk Aligned between legs Aligned towards wt. bearing leg