PHYSICAL EXAMINATION OF THE FOOT AND ANKLE Disclosures Robert B. - - PowerPoint PPT Presentation

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PHYSICAL EXAMINATION OF THE FOOT AND ANKLE

Robert B. Anderson, MD OrthoCarolina

Charlotte, North Carolina

Disclosures

No conflicts with this talk or subject

A Good Exam requires …

• Appropriate history taking skills for patients with

foot and ankle problems

• A complete physical examination of the foot and

ankle including: – Inspection – Palpation – Range of motion – Neurovascular assessment – Special tests

• Identifying the phases of gait and performing a

“brief” functional gait analysis

HISTORY TAKING

• Take a HISTORY (really…)

– What is the patient’s chief complaint? – Pain?

• Where? When? How bad? What is it like?
• What makes it better?
• What makes it worse?

– Acute injury vs. Chronic – Progression of Symptoms? – Treatment to date?

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HISTORY TAKING:

Background Information

• Any Previous Injuries
• Past Surgical History
• Past Medical History
• Medications
• Allergies
• Social History

– Work situation (laboring type job?) – Home situation

The PHYSICAL EXAM

• Must have knowledge of the

anatomy!!!

STEPS in the PHYSICAL EXAM

• Inspection

– Watch them walk/stand

• Palpation
• Range of motion
• Neurovascular

assessment

• Special tests

INSPECTION

Must see from the knee down!!!

What do you see?

• Alignment (neutral? valgus? varus?)

– Knees, hindfoot, forefoot

• Foot shape: Flatfoot? High arched?

Normal?

• Toe shape: Clawed, Hammer, Mallet

toes, Hallux valgus or varus?

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INSPECTION

What do you see? Sitting exam =

• Swelling? Masses?
• Discoloration?
• Scars? / Cuts? / Abrasions?

Plantar callosities? / Ulcers?

PALPATION

• Where does it hurt? What do you feel?
• Surface Anatomy is key!!

– Pathology can be accurately localized

• Anterior talofibular ligament vs talar dome

– Ligaments, Bones, Tendons hurt where they are injured

• Neuropathy is the exception!

RANGE OF MOTION

Accurately assess range of motion including:

• ankle dorsiflexion (knee straight)
• ankle dorsiflexion (knee bent)
• ankle plantar flexion
• hindfoot inversion and eversion
• medial column mobility
• 1st MTP joint motion
• interphalangeal motion
• Abduction/Adduction of Transverse Tarsal Joints

RANGE OF MOTION

ANKLE MOTION (knee straight & bent)

• Ankle dorsiflexion

– Reduce the talonavicular joint – Knee straight (gastrocnemius under tension) – Knee bent (Soleus only)

• Ankle plantarflexion

Thumb on talar neck Navicular reduced

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RANGE OF MOTION

HINDFOOT INVERSION & EVERSION

• Compare to contralateral side
• Assess midpoint

Inversion Eversion

RANGE OF MOTION

MEDIAL COLUMN MOBILITY

• Stabilize 2nd MT head
• Assess dorsal & plantar

movement of 1st MT

• Translation >1cm suggests

hypermobility

• Increased Movement?

1st TMT joint N-C joint T-N joint

RANGE OF MOTION

FIRST MTP JOINT MOTION

• Standing to assess

dorsiflexion

• Limited in hallux rigidus
• Pain at extremes of

motion?

• Does hallux valgus

deformity reduce?

RANGE OF MOTION

INTERPHALANGEAL JOINT MOTION

• Test individual joints
• Fixed contracture? Painful?

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NEUROVASCULAR ASSESSMENT

• Nerve Function

– Sensation – Reflexes – Motor Strength

• Vascular Status

– Distal pulses – Capillary refill

NEUROVASCULAR ASSESSMENT

PERIPHERAL NERVES INERVATING THE FOOT

• Superficial Peroneal Nerve
• Deep Peroneal Nerve
• Saphenous Nerve
• Sural Nerve
• Tibial nerve

NEUROVASCULAR ASSESSMENT

SENSATION

– Light touch – 2 point discrimination – Vibration sense

• Neuropathy

– Loss of 5.07 monofilament sensation – Loss of “protective” sensation

NEUROVASCULAR ASSESSMENT

REFLEXES

• Ankle Reflex

– S-1-2 Dermatome

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NEUROVASCULAR ASSESSMENT

MOTOR STRENGTH

• Graded 0-5

5 = Full strength 4 = 3 = Antigravity strength 2 = 1 = Flicker 0 = No contraction

NEUROVASCULAR ASSESSMENT

ANKLE DORSIFLEXION

• Tibialis Anterior
• EHL
• EDL

NEUROVASCULAR ASSESSMENT

INVERSION

• Posterior Tibialis
• Flexor Digitorum Longus
• Flexor Hallucis Longus
• Don’t get fooled by the ATT

NEUROVASCULAR ASSESSMENT

EVERSION

• Peroneus Longus
• Peroneus Brevis

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NEUROVASCULAR ASSESSMENT

PLANTAR FLEXION

• Gastrocnemius
• Soleus
• Heel Rise

– 1 = 4/5 strength – 30+ = 5/5 strength

NEUROVASCULAR ASSESSMENT

DISTAL ARTERIAL SUPPLY

• Posterior Tibial Pulse
• Dorsalis Pedis Pulse

SPECIAL TESTS

• Special Test = Physical examination

maneuvers designed to answer a specific question

SPECIAL TESTS

SINGLE LEG HEEL RISE QUESTION: Does this patient have a functional posterior tibial tendon?

• Yes, if patient can perform a toe rise with

inversion of the heel

• Normal gastrocsoleus strength = 30 calf raises

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SPECIAL TESTS

THOMPSON TEST QUESTION: Does this patient have an intact Achilles tendon?

• Patient positioned prone with

knee bent 90 degrees

• Squeeze calf and look for ankle

plantar flexion

• Plantar flexion = intact Achilles

SPECIAL TESTS

ANTERIOR ANKLE DRAWER TEST QUESTION: Does this patient have an attenuated or incompetent anterior talofibular ligament?

• Stabilize distal tibia and internally rotate

the foot slightly. Then apply a steady anteriorly directed force to the calcaneus

• How much anterior translation of the foot
• ccurs?
• Compare to the contralateral side

GAIT ANALYSIS

OBJECTIVES

• Identify the phases of gait and

perform a “brief” functional gait analysis

– Ask the patient to walk up and down the hallway

GAIT ANALYSIS

PHASES OF GAIT

Heel Strike Flatfoot Heel Rise Toe Off

STANCE PHASE SWING PHASE

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GAIT ANALYSIS

STRIDE LENGTH

• Symmetrical side-to-side?
• Shortened?

GAIT ANALYSIS

FOOT PROGRESSION

• Symmetrical?
• Neutral?
• Internal?
• External?

GAIT ANALYSIS

ASYMETRY? Does one side have:

• Decreased stride length?
• Decreased stance time?
• Increased trunk shift?
• Increase or decreased foot progression angle?
• Abnormal heel to toe progression?
• Foot drop?

Summary

Thank You

Understand the Anatomy Ask the Right Questions Watch the Walk Assess Alignment Touch the Patient