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Examination of the Foot & Ankle

Examination of the Foot & Ankle

Summary

Look

  • General
    • RA, diabetes, No evidence of systemic disease
  • mobility aids, external appliances
  • Shoes
    • Wear pattern
    • Off the self commercial shoes with no modifications & orthotic

Undress from waist down

From Front

stand patient facing you, describe proximal to distal

Deformity

  • knee alignment: physiological valgus, patella alignment, valgus with pes planus
  • foot rotation: symmetrical ER
  • forefoot: splaying
  • hallux: valgus / varus, pronation, lPJ
  • lesser toes: overriding, hammer, claw, callosities over IPJ

Skin

  • scars, trophic changes, venous stasis, circulatory disturbance, hair loss, hyperpigmentation, varicosities, ulcers, disuse / denervation, dry skin, dekeratinisation, nails

Contour

  • Swelling
  • anterolateral ankle
  • navicular
  • bunion
  • bunionette
  • Muscle Wasting
    • Calf
    • EDB

From Medial Side

  • turn affected side away

Deformity

  • medial arch is preserved
  • pes planus
  • pes cavus

Skin

  • scars

Contour

  • Swelling
  • tibialis posterior

From Lateral Side

Deformity

  • knee
  • flexion attitude
  • ankle
  • equinus

Skin

  • scars

Contour

  • Swelling
  • peroneal tendons

From Behind

Deformity

  • Back
    • Sagitall spinal deformity
    • Cutaneous manifestastions of spinal dysraphism
  • hindfoot
    • physiological valgus
    • varus
      • then ask for Coleman Block
    • Valgus
      • Single heel raise
  • forefoot
    • too many toes
  • Skin
    • scars

Contour

  • Swelling
  • calf
  • Duchenne
  • Tendo Achilles
  • heel
    • Haglund’s
  • Wasting
    • calf

Gait

ask patient to walk

  • walk away
  • walk towards
  • Features
    • Stiff ankle
    • Foot drop
    • Fixed equines
    • Antalgic
    • Rocker

Walk to wall & face it

Wall

face wall

Double heel raise

  • Ability
  • neurological
    • likely central cause
    • cerebral palsy, spina bifida, cord injury
  • muscular
    • muscular dystrophy
    • disuse
  • Heel movement
    • symmetrical heel swing into varus
    • heel remains in valgus
  • Medial arch
    • restoration
  • Single heel raise
    • on normal foot
    • on abnormal foot
  • neurological
    • central – stroke, polio, radiculopathy
    • peripheral - nerve injury
  • tendinous
    • tibialis posterior dysfunction

Sole

sit patient on side of bed with you seated

look at sole

Skin

  • scars
  • footprint
    • normal
      • well-distributed weight-bearing
      • heel, lateral border, metatarsal heads
    • abnormal
      • altered weight distribution
      • callosities
      • MT heads (II, III), midfoot
  • lesions
    • warts
    • ulcers
    • soft corns
    • pedal sepsis

Contour

  • Swelling
    • plantar fibromatosis

Feel

Ask patient “where is it painful?"

Sole

  • metatarsal heads
    • I - sesamoids
    • II-V - metatarsalgia
  • interdigital neuroma
  • interdigital tenderness
  • lateral compression - pain & click
  • heel
    • origin of plantar fascia

Medial

  • 1st Metatarsal head
  • 1st metatarsal-Cuneiform joint (flare of base of 1st MT)
  • Navicular Tubercle
  • Head of Talus (evert forefoot)
  • Medial Malleolus
  • Sustentaculum Tali (1.5 cm below medial malleolus)

Lateral

  • 5th Metatarsal head
  • Cuboid
  • Calcaneum
  • Peroneal Tubercle (separates peroneus longus & brevis)
  • Lateral malleolus

Tendons

  • Tendo Achilles
    • insertion
      • tenderness
    • along tendon
      • tenderness (diffuse or focal)
    • lump
    • retrocalcaneal bursa (pinch tissue anterior to AT)
    • calcaneal bursa (posterior to AT)
  • Tibialis Posterior
    • prominent with plantarflexion & inversion
    • thickening
    • tenderness
    • crepitus
    • check power if abnormal
    • navicular insertion
  • Peroneals - Brevis & Longus
    • thickening
    • tenderness
    • dislocation (resisted eversion)
    • base of 5th MT insertion
  • Tibialis Anterior
    • Prominent with dorsiflexion & inversion
    • Insertion
  • EHL & EDL
    • Dorsiflex toes

Ankle Joint

  • lateral ligaments
    • 1. Anterior Talo-Fibular Ligament (ATFL)
    • 2. Calcaneo-Fibular Ligament (CFL)
    • 3. Posterior Talo-Fibular Ligament (PTFL)
    • 4. Anterior Inferior Tibiofibular Ligament (AITFL)
    • 5. Posterior Inferior Tibiofibular Ligament (PITFL)
  • joint line
  • Deltoid Ligament
  • Deep
  • Superficial
  • Fluctuance
  • effusion or synovial thickening

Forefoot

  • bunion
  • bunionette
  • pulses
  • dorsalis pedis
  • posterior tibial
  • capillary refill
  • <2 seconds

Move

  • Active, Passive, Power
  • compare both feet at same time
  • Dorsiflexion
    • ‘pull feet up”
    • equal / ¯
    • you push foot up
    • passive range equal / further x° achieved passively
    • breaking at midfoot
    • “hold foot up” & resist
    • power
  • Plantarfiexion
  • Inversion
  • Eversion
  • Ankle / Tibiotalar (Dorsiflexion/Plantarflexion)
    • thumb on talar neck
    • grasp heel with other hand
    • plantarflex & dorsiflex ankle
    • movement occurring at ankle joint
    • relate to foot at neutral (90°)
    • dorsiflexion 20°
    • plantarflexion 50°
  • Subtalar (Inversion/Eversion)
    • forefoot held in neutral at 90° to tibia (locks wider, anterior part of talar dome into ankle mortise)
    • foot relaxed with thumb on talar neck
    • grasp heel with other hand
    • invert & evert heel
    • inversion 10-15°
    • eversion 0-5°
  • Tarsal Coalition
    • Restricted subtalar motion
  • Midtarsal
    • (Adduction/Abduction; Dorsiflexion/Plantarflexion)
    • Foot held at 90° (to lock talus into ankle mortise)
    • Calcaneus grasped
    • Adduct foot (20°)
    • Abduct foot (10°)
    • Dorsiflexion
    • Plantarflexion
  • 1st MTPJ (Flexion/Extension)
    • Stabilise forefoot & IPJ
    • extension 70-90°
    • flexion 45°
  • 1st IPJ (Flexion/Extension)
    • stabilise proximal phalanx
    • flexion 90°
    • extension 0°
  • Toes (Flexion/Extension)
    • extension only occurs at MTPJ

Special tests

Instability

  • Anterior Drawer
  • Due to complete tear of ATFL
  • grasp lower tibia & cup calcaneum
  • "clunk" or draw
  • cf. other side
  • Lateral instability
  • Inversion stress
  • gaping of soft tissues
  • talar tilt (may occur in normal & must cf. with other side)
  • needs to be confirmed on stress views
  • Medial Instability
  • Eversion stress
  • gaping/ widening
  • needs to be confirmed on stress views

Gastrocnemius / Soleus Contracture

  • test if limited dorsiflexion
  • extend knee - dorsiflexion limited by both soleus & gastrocnemius contracture
  • flex knee - gastrocnemius relaxed (crosses knee joint)
  • if dorsiflexion still limited it is due to soleus contracture
  • if limited in extension & not in flexion then due to gastrocnemius contraction

Pes Cavus

  • Modify
  • claw toes
  • individual power cf. other side
  • tibialis anterior (inversion in DF)
  • tibialis posterior (inversion in PF)
  • peronei
  • Add
  • Coleman block test
  • dynamic visualisation of hindfoot correction
  • stand on 2cm block
  • Sensation
  • Spine
  • Hands

Hallux Valgus / Rigidus

  • Add
  • MTPJ
  • dorsal osteophytes
  • passive ROM
  • attempt to correct deformity
  • grind test
  • hallux interphalangeus
  • lesser toes

Lesser Toes

  • Add
  • describe deformity
  • claw, hammer, mallet, overriding, curly
  • callosities
  • palpate joints
  • MTP, PIP, DIP
  • fixed or mobile
  • subluxed or dislocated

Adult Flatfoot

  • Modify
  • tibialis posterior function
  • Lisfranc joint

Tarsal Coalition

  • Modify
  • palpate
  • medially (sustentacullum tali)
  • dorsolaterally (through EDB)

Lateral Ligament Instability

Add

  • Anterior drawer
  • Talar tilt