Anatomy
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Total bones in the foot: 26
Tarsal bones: 7
Hindfoot: Talus & Calcaneum
Midfoot: Navicular, cuboid, medial, middle, and lateral cuneiform
Forefoot: Metatarsals and phalanges
Important joints:
o Lisfrance and Chopart joint
o Tibiotalar joint
o Subtalar joint
Medial and lateral malleolus: medial malleolus is 1cm shorter than lateral malleolus.
Anterior joint line is crease when plantar/dorsiflex
Common presenting complaints
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Pain
Swelling (localized or edema)
Deformity
Instability (lateral ankle instability due to lateral ligament tear//syndesmotic injury)
Numbness (Nerve compression//peripheral neuropathy)
Foot and ankle examination
1. Wash hands, introduce, exposure: above knees
2. Inspect shoes
a. Types of shoes (diabetic shoes/well-worn shoes)
b. Wear of outsoles (more worn out at? Pes planus valgus – Worn out laterally)
c. Special insoles
Inspection (most important, describe deformities, be systematic: Forefoot → Midfoot → Hindfoot)
In standing (weight-bearing position)
1. Anterior
a. Big toe
i. Bunion (Swelling over medial side of first metatarsal bone)
o Sign of poor fitting shoes or arthritis
ii. Hallux valgus
o Diagnosis, don’t mention if unsure, say bunion
o Normal angle of metatarsal and proximal phalanx: 0-15°
o Severe hallux valgus: toes pronate, nail faces medially
iii. Hallux valgus interphalangeus: Lateral deviation of IPJ
iv. Podagra
b. Lesser toes
i. Hammer toe (PIPJ flexed, DIPJ extended, MTPJ slightly extended)
ii. Mallet toe (hyperflexion of DIPJ)
iii. Claw toe (MTPJ hyperextension → DIPJ & PIPJ flexion)
o Neurological in origin
o Nerves in the foot not functional but nerves in lower leg functioning
iv. Corn (callosity on dorsum of foot)
c. Nails
i. Onychomycosis
ii. Dystrophic
iii. Ingrown
iv. Pincer nail deformity
d. Midfoot cannot really be observed
e. Hindfoot
i. Peekaboo sign
o Seen in calcaneal varus
o Normal unable to see the heel as it is slight valgus (~5° when we stand)
2. Lateral
a. Midfoot: Medial longitudinal arch
o Showmanship place index finger below the arch
o Normal: can insert up till DIPJ
o High arch: can insert up till PIPJ
o Very crude way of testing, proper way is to use a podogram
3. Posterior
a. Calcaneal valgus or varus
b. Too many toes sign (Indicates forefoot abduction)
State how many digits you see, normal: 2 ½ toes seen from the back
4. Ask patient to tiptoe, observe 2 things
a. Heel from slight valgus to varus
Due to attachment of tibialis posterior tendon at the navicular hence line of pull is
medial
b. Arch reconstitution or becomes more obvious
o If no arch reconstitution = rigid pes planus
o Plantar fascia extends from calcaneum to base of all proximal phalanx,
contracted when tiptoe hence arch reconstitutes
5. Ask patient to walk, inspect gait
a. Observe heel strike, foot flat, midstance, toe off, initial swing, mid swing, terminal
swing (don’t always try to categorize the gait, just describe the abnormality)
b. Antalgic gait
c. Foot drop gait (Unable to achieve that 5° of dorsiflexion to clear the ground)
i. Abnormalities in swing phase:
1. Circumduction of leg OR
2. Increased flexion of knee or hip to prevent foot slap
ii. Abnormalities in stance phase:
1. Foot slap
o Eccentric contraction of tibialis anterior (muscle contraction but
tendon lengthening) allows normal people to put foot down in
controlled manner
o Concentric contraction: muscle contract, tendon shorten
o Isometric contraction: Muscle contract without tendon or joint
movement
6. Ask patient to sit down with foot hanging (ideal), otherwise lie down
a. Forefoot pronation or supination (compare the planes of ball of toes and the heel)
i. Big toe higher compared to heel (supination)
ii. Big toe lower compared to heel (pronation)
b. Fungal infection between toes
c. Callosity in soles
Feel: Palpation
Palpate distal to proximal, press one at a time
Palpate only on the side of complaint
1. Warmth (PVD/infection)
2. Tenderness
3. Bony landmarks
a. Navicular bone (2cm inferior to medial malleolus, then 2cm distal from that point)
b. Base of fifth metatarsal
c. First metatarsal head
4. Palpate joints
Move: ROM
Place feet next to each other and compare directly
o Active movement. If unable to, then try to achieve movement passively. Always report in
active and passive, i.e., patient has reduced active dorsiflexion at __ degrees, but I am able
to passively dorsiflex to __ degrees.
o If there is deformity, try to correct it.
1.
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5.
Note:
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Dorsiflexion (Normal 15°)
Plantarflexion (Normal 45°)
Inversion (Tibiotalar plantarflexion, subtalar inversion, supination, adduction)
Eversion (Tibiotalar dorsiflexion, subtalar eversion, pronation, abduction)
Flex and extend toes
Movements in the foot are usually compound movements as the tendon cross multiple joint
Neurovascular screen
1. 3 types of sensation
a. Dermatomal/Nerve root (Spine/neuro PE)
b. Peripheral nerve (Foot and ankle PE)
c. Glove and stocking (Foot and ankle PE)
i. Educate, close eyes
ii. Poke at most distal place, sharp. (Examination ends)
iii. If not, “the moment that you feel it, tell me”/“Masa pakcik rasa tu baigtau”
iv. Poke in 5mm to 1cm interval from distal to proximal (Poke twice)
v. Do slowly so patient can register
vi. “Blunt” record where it is felt then continue until patient says “sharp”
vii. Poke around that level a few more times to confirm
2. Quick motor screen (Power of plantarflexion and dorsiflexion)
3. Pulses (DPA and PTA)
Additional test in diabetic foot ulcer
1. Proprioception
a. IPJ of big toe, if not then second toe, third toe etc if no toes, then ankle
2. Vibration
a. 128Hz tuning fork
b. Put on bony prominences. Dorsum of first IPJ or whichever toe → bunion → medial
malleolus → medial aspect of fibula
3. Semmes-Weinstein monofilament test
a. Test for loss of protective sensation
b. 10 points in total. Push filament until buckle and release, ask whether patient can
feel it
Special tests
1. Jack’s test
a. Assess flexible/rigid pes planus (functionality of windlass mechanism)
b. Patient in weightbearing (standing position).
c. Clinician passively flex all toes (supposedly only big toe)
i. If arch reconstitutes → Flexible pes planus
ii. If arch does not reconstitute → Rigid pes planus
d. Not necessary if arch reconstitutes when patient tiptoes
e. Plantar fascia inserts at the base of proximal phalanx of all toes → Dorsiflex tightens
plantar fascia
2. Simmonds test/Thompson’s test
a. Test for Archilles tendon rupture
b. Patient is prone on couch or kneels on chair
c. Observe
i. Archilles tendon should have nice substance. If ruptured, can feel a palpable
gap.
ii. Foot at rest is normally at plantarflex positions as plantar flexors more
powerful than dorsiflexors
iii. If TA ruptured → Foot in more neutral or dorsiflex position
d. Squeeze gastrocnemius → observe for plantarflexion (if not, ruptured TA)
3. Anterior drawer test of the ankle
a. Assessing for integrity of lateral ligaments (if patient complaints of instability)
b. Patient sitting with foot hanging or lying supine
c. Clinician places one hand on tibia, one hand cup patient’s heel, patient’s forefoot
rests on forearm
d. Pull talus forward feel whether ankle comes forward (must compare both sides)
4. Silfverskiöld test
a. Assess for isolated gastrocnemius contracture/tightening
b. Patient sitting down with legs hanging or supine
c. Fully passive test.
i. Clinician extend patient’s knee, use hand to achieve passive dorsiflexion
(note degree of dorsiflexion)
ii. Flex patient’s knee, use hand to achieve passive dorsiflexion (note degree of
dorsiflexion)
d. Test is positive if there is >15° change (gastrocnemius contracture)
e. If negative but reduced dorsiflexion (can be TA contracture, soleus contracture,
bone block, any other stuff)
f. Must be fully passive, is tibialis anterior is activated, it’ll cancel out the resting tone
of gastrocnemius
g. Knee flexion relaxes gastrocnemius as it originates from proximal femoral condyle
5. Assess Beighton’s score