SAN FRANCISCO — When a patient with a running injury arrives in a busy primary-care office, there's usually not enough time for the provider to do a full orthopedic examination, but several high-yield static assessments can help the provider conduct an efficient exam within the standard 15-minute office visit, Dr. Anthony Luke said at a conference on sports medicine sponsored by the University of California, San Francisco.
The first thing to evaluate, according to Dr. Luke, of the department of orthopedic surgery at the university, is the patient's alignment. Dr. Luke asks the patient to stand with ankles together, and if he can fit four fingers between the patient's heels, the gap indicates a significant valgus condition.
Then he asks the patient to stand with feet placed apart a distance equal to the shoulder width, and—while watching the patient from both the front and the back—he instructs the patient to rise up on the toes and then go back down again.
“I want to see how high the arch gets, and, as they come down, how it rolls in. This helps you know [whether it's] a flexible flat foot. If they go up and they don't recreate the arch, then there's a problem there, either a tendon problem or a structural problem, such as tarsal coalition.”
This test also allows for further evaluation of varus and valgus conditions, either of which could be behind pronation or other foot problems.
Next, Dr. Luke has the patient squat while keeping the heels flat on the floor. “If they don't get too far, sometimes they have limited dorsiflexion in their ankles, and that could lead to a problem.”
While the patient is squatting, Dr. Luke instructs the patient to do a duck walk, which will indicate whether there are any problems with the hips or knees.
Then he recommends conducting four tests of flexibility:
▸ The Thomas test is used to assess the hip flexor.
The test is conducted by having the patient lie back on the examination table and then raise both of the knees up to the chest. The patient should then hold one knee up while allowing the other leg to drop down.
Meanwhile, the physician should have a hand on the patient's pelvis. At the moment the pelvis begins to rock, the physician should note the angle between the lowered thigh and the table. An angle of greater than 30 degrees indicates a significant loss of flexibility.
▸ The Ely test assesses the quadriceps and is done while the patient is prone. The physician should flex the ankle toward the buttocks and see how tight the patient is on each side.
▸ Ober's test assesses the iliotibial band.
It is done with the patient lying on one side and holding the lower knee in a flexed position.
The physician should stabilize the patient's pelvis with one hand and, with the other hand, hold the patient's ankle and abduct and extend the hip. The physician should then lift the hand that is holding the ankle while continuing to stabilize the pelvis.
In a patient with normal flexibility, the leg will remain parallel to the table. In an especially flexible patient, the leg will dip down a bit farther. However, if the leg hangs up, this would indicate a tight iliotibial band.
▸ The popliteal angle test assesses hamstring flexibility, and is done with the patient supine.
The patient should first bend the hip to 90 degrees and the knee to 90 degrees. The physician should then passively extend the leg, noting the angle of the knee. Low popliteal angles (as little as 120–130 degrees) are common in long-distance runners and indicate a lack of hamstring flexibility.
One of four tests measuring flexibility, the Thomas test (patient position shown above), assesses the loss of flexiblity in the hip flexor. Courtesy Dr. Anthony Luke