Foot examination:
Look:
- Standing and walking. Gait pattern (limp, foot drop, heel or forefoot sparing), the integrity of the
arches and the hind-foot position.
- Ask the patient to stand on their toes and then on their heels – motor function and stability
- Examine shoes for wear patterns
- Ankles and feet:
o Look for skin and nail changes (rashes, pallor, ulcers, vascular changes, nail pits and
onycholysis)
o Muscle wasting, tendon and tendon sheath swelling (tibialis posterior, peroneal and
achilles), major deformity
o Joint swelling (note: this appearance may be due to other causes such as oedema,
cellulitis, tendonitis, xanthomata and tophi), pattern of involvement (symmetry, sausage
toes).
Feel:
- Ankles / feet. Proximally and move distally. Temperature, swelling (differentiate soft tissue from
bony, nodule from tophus, joint or tendon), tenderness
- Deformity (subluxed or dislocated), crepitus, triggering and stability.
Move:
- Ankle: flexion / extension, internal / external rotation.
- Subtalar inversion and eversion (with the ankle dorsiflexed, grip the calcaneum and move it
medially and laterally whilst the ankle joint is held by your other hand).
- Midtarsal inversion/eversion and pronation/supination are tested as a combined movement (grip
the calcaneum with your left hand and twist the midtarsal joints with your right hand).
- MTP / PIP / DIP joints: flexion & extension
Special tests:
- MTPJ pressure for Morton’s metatarsalgia
- Sensation, vascular examination
- Ankle jerk reflex: in figure 4 position for ease
- Assess knee and hip
Questions:
- Location of ulcers: neuropathic (plantar surface), arterial (lateral and dorsal), venous (medial)
- Presentation of ulcers:
o Neuropathic: deep, painless, sharp margins
o Arterial: deep, minimal discharge and sharp margins unless infected. Pain worse if
decreased perfusion (eg raising the leg)
o Venous: shallow, exudative, variable colour, poorly defined margins
- Treatment:
o Neuropathic: treat underlying causes, protection of wound
o Arterial: vascular surgery, stenting / bypasses
o Venous: bandaging, compression stockings, diuretics
-