ESTUDIO ORTOPODOLÓGICO
Nº Hª:____________________ 2 FECHA: __________________ 11/4/2014
ANAMNESIS FECHA 1ª CONSULTA:___________________________ 11/4/14 PEREZ LOPEZ JUAN APELLIDOS:________________________________________NOMBRE:________________________ 68 170 cm F.NAC:_____________________EDAD:___________PESO:_______________TALLA:_____________ 30 1/8/1984 RUNNING PROFESIÓN:_____________________________ACT.DEPORTIVA:____________________________ MONITOR DEPORTIVO PENICILINA ALERGIAS?__________________________________________________________________________ DIABETES?___________________________________________________________________________ MEDICACIÓN HABITUAL?____________________________________________________________ DOLOR METATARSO PLANTA MOTIVO 1ª CONSULTA:_______________________________________________________________ ____________________________________________________________________________________ DOLOR?_____________________________________________________________________________ SIEMPRE PROCEDENCIA: ______________________________________________________________________ COMPETICIÓN HACE 1 MES OBSERVACIONES:____________________________________________________________________ ANTEC.FISIOLÓGICOS: -Parto____________________________________________________________________________ X -Gateo___________________________________________________________________________ -Andador/Taca-Taca________________________________________________________________ X TARDÍA -Inicio Deambulación_______________________________________________________________ - Habitos Posturales ________________________________________________________________ SEDESTACIÓN - MIEMBRO INFERIOR EN POSICIÓN DE MONJE (PIERNAS ENTRECRUZADAS) -Cambios Ponderales_______________________________________________________________ -Zurdo /Diestro /Ambidiestro X /__________________________________________________ -Otros___________________________________________________________________________ ANTEC.PATOLÓGICOS: -Patologías Previas_________________________________________________________________ _______________________________________________________________________________ -Enferm. Infantiles_________________________________________________________________ -Ant. Traumáticos _________________________________________________________________ -Hª anterior de: -Distensión/Esguines ___________________________________________________ -Tendinitis/Contracturas_________________________________________________ CONTRACTURAS USUALES TRICEPS SURAL -Bursitis______________________________________________________________ -Capsulitis_____________________________________________________________ -Luxación/Subluxación___________________________________________________ -Fisura/Fractura_________________________________________________________ X -Enf.Reumáticas(gota, fibromialgia…)_______________________________________ -Ciática: ______________________________________________________________ -Otras_________________________________________________________________ ANTEC.FAMILIARES: -Dismetrías________________________________________________________________________ X -Escoliosis_________________________________________________________________________ -Genu varo/valgo___________________________________________________________________ -Tibias varas_______________________________________________________________________ -Pies Planos_______________________________________________________________________ X -Pies Cavos_______________________________________________________________________ -Pies Valgos______________________________________________________________________ -Pies Zambos_____________________________________________________________________ -Metatarsus Aductus/Varus__________________________________________________________ X -H.V_____________________________________________________________________________ X -Dedos Garra______________________________________________________________________ -Otros____________________________________________________________________________ ____________________________________________________________________________ 1
ANTEC. PODOLÓGICOS Y TTOS PREVIOS:_____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ CALZADO UTILIZA HABITUALMENTE (Nº)____________________________________________ DEPORTIVO 41 ______________________________________________________________________________________ EXPLORACIÓN DECÚBITO SUPINO
DCHO
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IZQDO
X 87/84 -MEDICIÓN DE MM.II (Dismetrías):______________________________________________________
______________________________________________________ ______________________________________________________ -PATRÓN ROTADOR(predominio int/ext):_________________________________________________ EXT 40 -Goniómetro Pendular: (Fem/Tib.): Rot.Int.: _______________________________________ 40 Rot.Ext. _______________________________________ -CADERA: (Movilidad Articular) -Flexión(N:130º-140º): _______________________________________________________ -Extensión(N:0º):___________________________________________________________ -Hiperextensión(N:10º-12º):___________________________________________________ -Abducción(N:30º-50º): ______________________________________________________ -Aducción(N:20º-30º): _______________________________________________________ -Rot.Int.(N:30º-45º): _________________________________________________________ -Rot.Ext.(N:40º-50º): ________________________________________________________ __________________________________________________________________________ -RODILLA: (Movilidad Articular) -Flexión(N:120º-150º): ________________________________________________________ -Extensión(N:0º)____________________________________________________________ -Hiperextensión(N:5º-10º)_____________________________________________________ _________________________________________________________________________ -Genu-valgo(Reductible/Irreductible): __________________________________________________ -Genu-varo(Reductible/Irreductible): ___________________________________________________ -Rótulas convergentes?:______________________________________________________________ -Rótulas divergentes?: ______________________________________________________________ -Rótulas paralelas?: ________________________________________________________________ X 15º -Angulo Q(N:15º):__________________________________________________________________ ________________________________________________________________________________
2
DCHO
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IZQDO
-TPA: (Movilidad Articular) 48º -FP(N:40º-50º): ____________________________________________________________ 26º -FD(N:20º-30º): ____________________________________________________________ DECÚBITO PRONO -CADERA(Movilidad Articular) -R.Int.(N:30º): _____________________________________________________________ -R.Ext.(N:60º): ______________________________________________________________ -TORSIÓN FEMORAL(N:45º) -T.Fem.Int. o Ant: __________________________________________________________ -T.Fem.Ext. o Post: __________________________________________________________ -TORSIÓN TIBIAL(N:15º-20º) -T.T.I: ____________________________________________________________________ -T.T.E: ____________________________________________________________________ SEDESTACIÓN -ANTEVERSIÓN FEMORAL ? (N:8º-10ºadulto/N:12ºniño): ___________________________________ -ÁNG. TORSIÓN BIMALEOLAR(N:15º-20º): ______________________________________________ -MANIOBRA DE ROTES(Hiperlaxitud Articular): ___________________________________________ -EXPLORACIÓN ARTICULAR: *RETROPIE -TPA: -FP(N:40º-50º): __________________________________________________________ -FD(N:20º-30º): __________________________________________________________ -ASA:
-Eversión(N:30º): ________________________________________________________ -Inversión(N:60º): ________________________________________________________
-ART.MEDIOTARSIANA: -Pronación(N:15º): __________________________________________ X -Supinación(N:35º): ________________________________________ *ANTEPIE -POSICIÓN O ÁNGULO DE ANTEPIE: ______________________________________________ -1º RADIO: -AMTF: -FP(N:45º) _____________________________________________________ 41º -FD(N:70º): 70º ___________________________________________________ -Falange Distal: -FP(N:80º):_______________________________________________ -FD(N:0º): ______________________________________________ Longitud 1º meta (Maniobra Doble Pinza): ________________________________________ X Hallux Límitus?: ____________________________________________________________ Hallux Rígidus?:____________________________________________________________ Hallux Flexus?: ____________________________________________________________ Hallux Hiperextensus?: ______________________________________________________ H.V?: ____________________________________________________________________ X Otros: ____________________________________________________________________ 40º -2º-5º RADIO: -AMTF: -FP(N:40º): __________________________________________________ -FD(N:60º-80º): ______________________________________________ 69º -IF Prox.: -FP(N:35º): ________________________________________________ -FD(N:0º): _________________________________________________ -IF Dist.: -FP(N:60º): _________________________________________________ . –FD(N:30º): _________________________________________________ 5º Meta Corto?: ______________________________________________________________ 5ºd Varo?: __________________________________________________________________ X 5º Hipermóvil?: ______________________________________________________________ Juanete de Sastre?: ____________________________________________________________ Metatarsus Laxus?(Test de Kellikian):_____________________________________________ Dedos Garra(reductible/irreductible)?: ____________________________________________ Otros: _____________________________________________________________________ 3
DCHO
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IZQDO
-EXPLORACIÓN MUSCULAR: Aductores Cadera…………………… ________________________________________________ Cuadriceps Femoral…………………._________________________________________________ Isquiotibiales…………………………_________________________________________________ Triceps………………………………._________________________________________________ Soleo…………………………………_________________________________________________ Tibial Posterior………………………_________________________________________________ Flex.Prop.1ºd y Flex. Común dedos…_________________________________________________ PLC Y PLL…………………………._________________________________________________ Tibial Anterior y Ext.Prop.1ºd………_________________________________________________ Ext.Común dedos y Peroneo Ant……_________________________________________________ T.A……………………………… Ext.Prop.1ºd……………………. Ext.Común dedos ……………… P.Ant.…………………………… T.P……………………………… Flex.Prop.1ºd…………………… Flex.Común dedos……………... Triceps Sural…………………… Plantar Delgado………………… PLL…………………………….. PLC……………………………. PLL……………………………... PLC…………………………….. P.Ant……………………………. Ext.Común dedos………………. T.A…………………………….. Ext.Prop.1ºd…………………… T.P…………………………….. Flex.Común dedos……………. Flex.Prop.1ºd…………………. Triceps Sural………………….
F.D.: ___________________________________________
F.P.: ____________________________________________
Pronación: _______________________________________
Supinación: ______________________________________
-Simetrías/Asimetrías de masas musculares? ______________________________________________ -Otros: ____________________________________________________________________________ -PALPACIÓN PTOS DOLOROSOS: _______________________________________________________ _______________________________________________________ -PULSOS : Pedio: ______________________________________________________________________ Tibial Post: __________________________________________________________________ -EXPLORACIÓN MORFOLÓGICA: -Fórm.Metatarsal: _______________________________________________________________ -Fórm.Digital: __________________________________________________________________ -Fórm. Podal: ___________________________________________________________________ -Antepie Triangular?: _____________________________________________________________ -Otros: ________________________________________________________________________ _________________________________________________________________________ 4
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
BIPEDESTACIÓN Visión Ant: ______________________________________ _______________________________________ _______________________________________ ________________________________________ Visión Post: _______________________________________ ________________________________________ ________________________________________ ________________________________________ Visión Lateral: _____________________________________ ________________________________________ ________________________________________ ________________________________________ __________________________________________________ __________________________________________________
-Simetría/Asimetría Postural?:_____________________________________________________________ LEVE ASIMETRÍA -Báscula Escapular?: ____________________________________________________________________ -Báscula Pélvica(dismetría,mm)?: __________________________________________________________ -Posición Escoliótica?: __________________________________________________________________ -Test de Adams(gibosidad)?: _____________________________________________________________ -Simetría/Asimetría Pliegues Subglúteos?: __________________________________________________ -Simetría/Asimetría Huecos Poplíteos?: ____________________________________________________ -Pruebas de Isquiotibiales Cortos?: ________________________________________________________ 5
GENU: -G.Fisiológico?:___________________________ X -G. Valgo?:______________________________ DIM:______________________________ -G.Varo?: ______________________________ DIC:______________________________ TIBIAS: -T.Fisiológicas?: __________________________ X -T. Valgas: _______________________________ -T.Varas: _________________________________ DCHO / IZQDO VALGO 2º/ VALGO 4º PIES: -Retropie: _____________________________________________________________________ -Antepie: ______________________________________________________________________ -Algún Radio Insuficiente? ________________________________________________________ -Sobrecarga de algún Meta? _______________________________________________________ LÍNEA DE HELBING: ________________________________________________________________ LÍNEA DE FEISS: ____________________________________________________________________ LÍNEA DE MEYER: __________________________________________________________________ IMAGEN PODOSCOPIO(Huella): _______________________________________________________ _______________________________________________________ ANÁLISIS EN DINÁMICA BANCO DE MARCHA: Visión Ant.: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Visión Post.: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Ángulo de Fick(N:15º) ________________________________________________________ Desarrollo del Paso: -Choque de Talón: ____________________________________________________________ -Apoyo Total del Pie: _________________________________________________________ -Despegue Dedos: ____________________________________________________________ Otros: _________________________________________________________________________ ESTUDIO DE PRESIONES(PODOBIT): En Estática: _________________________________________________________________ _________________________________________________________________ En Dinámica: _______________________________________________________________ _________________________________________________________________ Otros: ___________________________________________________________________________ ___________________________________________________________________________ DEAMBULACIÓN CON CALZADO: ____________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 6
ESTUDIO DEL CALZADO DESGASTE/DEFORMIDAD (Escarpología):___________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ PRUEBAS COMPLEMENTARIAS PEDIGRAFÍA: ______________________________________________________________ RX: _______________________________________________________________________ _______________________________________________________________________ ANÁLISIS SANGUÍNEO: _____________________________________________________ CULTIVO: _________________________________________________________________ DOPPLER: _________________________________________________________________ OTRAS: ____________________________________________________________________ _____________________________________________________________________ FOTOS (fecha): ______________________________________________________________ _______________________________________________________________ ______________________________________________________________ DIAGNÓSTICO _____________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ TRATAMIENTO FÍSICO: _______________________________________________________________________ EJERCICIOS PROPIOCEPTIVOS: _________________________________________________ ______________________________________________________________________________ FARMACOLÓGICO: ___________________________________________________________ QUIROPODOLÓGICO: _________________________________________________________ ORTOSIS DIGITAL: ___________________________________________________________ _____________________________________________________________________________ SOPORTE PLANTAR: _________________________________________________________ TAD:_______________________________________________________ Termomoldeables:_____________________________________________ Resinas: ____________________________________________________ Blandos/Espumas:_____________________________________________ Polipropileno:________________________________________________ Componentes:_______________________________________________ Otros: _____________________________________________________ VENDAJE FUNCIONAL: _______________________________________________________ _____________________________________________________________________________ PREVENTIVO: _______________________________________________________________ CALZADOTERAPIA: __________________________________________________________ _____________________________________________________________________________ OTROS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 7
ATENDIDO POR (fecha): ______________________________________________________________ _____________________________________________________________________ TARIFA ( precio): _____________________________________________________________________ _____________________________________________________________________ OBSERVACIONES: ___________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________
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