PHYSICAL EXAMINATION
OF THE
FOOT AND ANKLE
Presenter
Dr. Richard Coughlin
AOFAS Lecture Series
OBJECTIVES
1. ASSESS
2. DIAGNOSE
3. TREAT
HISTORY TAKING
• Take a HISTORY
– 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?
HISTORY TAKING: Background
Information
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Any Previous Injuries
Past Surgical History
Past Medical History
Medications
Allergies
Social History
– Work situation (laboring type job?)
– Home situation
STEPS in the PHYSICAL EXAM
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Inspection
Palpation
Range of motion
Neurovascular assessment
Special tests
INSPECTION
What do you see?
• Alignment (neutral? valgus? varus?)
– Knees, hindfoot, forefoot
• Foot shape: Flatfoot? High arched? Normal?
• Toe shape: Clawed, Hammer, Mallet toes?
• 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
– Ex. 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
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?
NEUROVASCULAR ASSESSMENT
• Nerve Function
– Sensation
– Reflexes
– Motor Strength
• Vascular Status
– Distal pulses
– Capillary refill
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
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
NEUROVASCULAR ASSESSMENT
EVERSION
• Peroneus Longus
• Peroneus Brevis
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
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.
• Apply an anteriorly directed force to the
calcaneus
• Does anterior translation of the foot
occurs?
• Compare to the contralateral side
Foot Types
Flatfoot
Subtle Cavus
GAIT ANALYSIS
OBJECTIVES
• Identify the phases of gait and
perform a functional gait analysis.
GAIT ANALYSIS
PHASES OF GAIT
Toe Off
SWING PHASE
Heel Rise
Flatfoot
STANCE PHASE
Heel Strike
GAIT ANALYSIS
STRIDE LENGTH
• Symmetrical side-to-side?
• Shortened?
GAIT ANALYSIS
FOOT PROGRESSION
• Symmetrical?
• Neutral?
• Internal?
• External?
GAIT ANALYSIS
ASYMETRY?
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Does one side have:
Decreased stride length?
Decreased stance time?
Increased trunk shift?
Increase or decreased foot progression angle?
Abnormal heel to toe progression?
Ankle Joint Biomechanics
• Ankle Dorsiflexion
– Anterior Talar Dome
Wider
– More Stability
– More Tibiotalar Contact
– Fibula Moves Laterally
Ankle Joint Biomechanics
• Ankle Joint Axis
– 82o Medial Cephalad to Lateral
Caudad
– 20-30o Anteromedial to
Posterolateral
Ankle Joint Biomechanics
• Effects of Oblique Ankle Axis
– Ankle Dorsiflexion
• Foot External Rotation
• Tibia Internal Rotation
– Ankle Plantarflexion
• Foot Internal Rotation
• Tibial External Rotation
Effect of Foot Position on
Muscle Function
• Foot Inverter or Everter
– Relation to Subtalar Axis
• Foot Plantarflexor or Dorsiflexor
– Relation to Ankle Axis
Calcaneocuboid and
Talonavicular Joints
• Joint Axes Parallel with Subtalar Eversion
– Chopart’s Joints Unlocked
– Increased Dorsiflexion and Plantarflexion
• Joint Axes Not Parallel with Subtalar Inversion
– Chopart’s Joints More Rigid
– Decreased Dorsiflexion and Plantarflexion
Hindfoot Biomechanics
Summary
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Ankle Joint
Dorsiflexion Plantarflexion
Subtalar Joint
Eversion
Inversion
Tibial Rotation
Internal
External
Talonavicular &
Calcaneocuboid
Joint
Axes
Parallel
Non-Parallel
• Foot
Supple
Rigid
Arch Support
• Beam and Truss
• No Muscle Activity with
Relaxed Standing
• Plantar Fascia
– Windlass Mechanism
Arch Support
• Ligamentous Support Bone Architecture
QUESTIONS?