PHYSICAL EXAMINATION OF THE FOOT AND ANKLE
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1 PHYSICAL EXAMINATION OF THE FOOT AND ANKLE Presenter Dr. Richard Coughlin AOFAS Lecture Series
2 OBJECTIVES 1. ASSESS 2. DIAGNOSE 3. TREAT
3 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?
4 HISTORY TAKING: Background Information Any Previous Injuries Past Surgical History Past Medical History Medications Allergies Social History Work situation (laboring type job?) Home situation
5 STEPS in the PHYSICAL EXAM Inspection Palpation Range of motion Neurovascular assessment Special tests
6 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?
7 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!
8 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 1 st MTP joint motion interphalangeal motion Abduction/Adduction of Transverse Tarsal Joints
9 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
10 RANGE OF MOTION HINDFOOT INVERSION & EVERSION Compare to contralateral side Assess midpoint Inversion Eversion
11 RANGE OF MOTION MEDIAL COLUMN MOBILITY Stabilize 2 nd MT head Assess dorsal & plantar movement of 1 st MT Translation >1cm suggests hypermobility Increased Movement? 1st TMT joint N-C joint T-N joint
12 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?
13 RANGE OF MOTION INTERPHALANGEAL JOINT MOTION Test individual joints Fixed contracture? Painful?
14 NEUROVASCULAR ASSESSMENT Nerve Function Sensation Reflexes Motor Strength Vascular Status Distal pulses Capillary refill
15 NEUROVASCULAR ASSESSMENT SENSATION Light touch 2 point discrimination Vibration sense Neuropathy Loss of 5.07 monofilament sensation Loss of protective sensation
16 NEUROVASCULAR ASSESSMENT REFLEXES Ankle Reflex S-1-2 Dermatome
17 NEUROVASCULAR ASSESSMENT MOTOR STRENGTH Graded = Full strength 4 = 3 = Antigravity strength 2 = 1 = Flicker 0 = No contraction
18 NEUROVASCULAR ASSESSMENT ANKLE DORSIFLEXION Tibialis Anterior EHL EDL
19 NEUROVASCULAR ASSESSMENT INVERSION Posterior Tibialis Flexor Digitorum Longus Flexor Hallucis Longus
20 NEUROVASCULAR ASSESSMENT EVERSION Peroneus Longus Peroneus Brevis
21 NEUROVASCULAR ASSESSMENT PLANTAR FLEXION Gastrocnemius Soleus Heel Rise 1 = 4/5 strength 30+ = 5/5 strength
22 NEUROVASCULAR ASSESSMENT DISTAL ARTERIAL SUPPLY Posterior Tibial Pulse Dorsalis Pedis Pulse
23 SPECIAL TESTS Special Test = Physical examination maneuvers designed to answer a specific question
24 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
25 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
26 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
27 Flatfoot Foot Types Subtle Cavus
28 GAIT ANALYSIS OBJECTIVES Identify the phases of gait and perform a functional gait analysis.
29 GAIT ANALYSIS PHASES OF GAIT Toe Off Heel Rise Flatfoot Heel Strike SWING PHASE STANCE PHASE
30 GAIT ANALYSIS STRIDE LENGTH Symmetrical side-to-side? Shortened?
31 GAIT ANALYSIS FOOT PROGRESSION Symmetrical? Neutral? Internal? External?
32 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?
33 Ankle Joint Biomechanics Ankle Dorsiflexion Anterior Talar Dome Wider More Stability More Tibiotalar Contact Fibula Moves Laterally
34 Ankle Joint Biomechanics Ankle Joint Axis 82 o Medial Cephalad to Lateral Caudad o Anteromedial to Posterolateral
35 Ankle Joint Biomechanics Effects of Oblique Ankle Axis Ankle Dorsiflexion Foot External Rotation Tibia Internal Rotation Ankle Plantarflexion Foot Internal Rotation Tibial External Rotation
36 Effect of Foot Position on Muscle Function Foot Inverter or Everter Relation to Subtalar Axis Foot Plantarflexor or Dorsiflexor Relation to Ankle Axis
37 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
38 Hindfoot Biomechanics Summary Ankle Joint Dorsiflexion Plantarflexion Subtalar Joint Eversion Inversion Tibial Rotation Internal External Talonavicular & Calcaneocuboid Axes Parallel Non-Parallel Foot Supple Rigid Joint
39 Arch Support Beam and Truss No Muscle Activity with Relaxed Standing Plantar Fascia Windlass Mechanism
40 Arch Support Ligamentous Support Bone Architecture
41 QUESTIONS?
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