History - These include, but are not limited to: Total ___/8 (1 pt each) 1 1 1 1 1 1 1 1 (quick mark offs)
_____ MOI/How did it happen? |
_____ When did it happen? |
_____ What happened? |
_____ Direction of forces |
_____ Sport/position |
_____ Any sounds |
_____ Location of pain |
_____ Type of pain |
_____ Rate pain level |
_____ Radiating pain |
_____ Medications |
_____ Overuse/acute |
_____ Movement ↑ or ↓ pain |
_____ Tingling/numbing |
_____ Previous injury |
_____ Previous treatment |
_____ Length of symptoms |
_____ Changes in training |
_____ Sounds and sensations |
_____ Age of shoes |
_____ Type of track |
_____ Other intrinsic/extrinsic factors |
|
|
Inspection/Observation - These include, but are not limited to: Total ___/ 8 (1 pt each) 1 1 1 1 1 1 1 1 (quick)
_____ Deformities |
_____ Symmetry of gait |
_____ Symmetry/alignment |
_____ Scars/lacerations |
_____ Skin color |
_____ Swelling |
_____ Shoe/sock removal |
_____ Shoe wear |
_____ Pain/guarding |
_____ Blisters |
_____ Callus patterns |
_____ Pes cavus |
_____ Pes planus |
_____ Atrophy/hypertrophy |
_____ Plantar warts |
_____ Flexibility of foot |
_____ WB vs. NWB |
_____ Hammer/claw toe |
_____ Hallux valgus |
_____ Hallux varus |
_____ Hallux rigidus |
_____ Bunions |
_____ Corns |
_____ Morton toe |
_____ Ingrown toenail |
_____ Hematoma |
_____ Shoe creases |
_____ Shoe pattern (e.g., pronation vs. supination) |
_____ Valgus/Varus orientation of forefoot/rearfoot |
|
Palpations ***Total___/12 (Palpations)***
Bony Palpation - Reasons for bony palpation: AT palpates for: Total 2 points (.5 each) ______
_____ Point tenderness |
_____ Deformity |
_____ Crepitus |
_____ Symmetry |
Bony Palpations:
_____ Medial malleolus |
_____ Lateral malleolus |
____ Calcaneus |
_____ Base of the 5th Metatarsal |
Soft Tissue Palpation - Reasons for soft tissue palpation: AT palpates for: 2 points (.5 each)_______
_____ Point tenderness |
_____Symmetry |
_____ Spasm/tone |
_____ Swelling/warmth |
Soft Tissue Palpations:
_____ Tibialis Anterior Tendon |
_____ Dorsal pedal artery/pulse |
_____ Plantar fascia |
_____ Anterior TibioFibular |
_____ Anterior TaloFibular |
_____ CalcaneoFibular |
_____ Posterior TaloFibular |
_____ Achilles/Calcaneal Tendon |
|
Range of Motion ***Total____/3 (ROM)***
___ Active ROM (DF, PF, IV, EV) |
|
___ Passive ROM (DF, PF, IV, EV) |
Bi-Lateral_________1 pt |
___ Manual muscle (DF, PF, IV, EV) |
|
Special tests ***Total_____/12 (Special tests) (1 each)
Name: |
___ Bump Test |
___ Anterior Drawer Test |
___ Talar Tilt Test |
Mechanics: |
___ |
___ |
___ |
Testing For: |
___ Fractures |
___ ATFL Sprain |
___ CFL Sprain |
Positive Test: |
___ Pain |
___ Anterior Translation |
___ Hypermobility/Pain |