KEY FACTS
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A thorough physical examination includes the following components:
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Inspection
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Palpation
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Assessment of motion
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Strength testing
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Examination of vascular status
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Stability assessment
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Evaluation of alignment
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Assessment for gastrocnemius contracture
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Assessment of 1st-ray mobility
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Inspect for swelling, scars, skin condition, pigmented lesions, calluses, and shoe condition.
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Describe all tenderness anatomically.
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Proper positioning of the foot and limb is essential for an accurate and reproducible physical exam, particularly during assessment of motion, stability testing, and when evaluating the gastrocnemius and 1st-ray mobility.
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Radiographic stress testing can allow the clinician to precisely quantify any instability.
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Comparison to the contralateral side can be more easily performed in the office.
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Weight matters; heavy patients who lose weight can eliminate foot pain.
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Are there any other joints involved? The patient’s problem could be an inflammatory arthropathy.
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Does the patient smell of smoke? Nicotine inhibits bone and wound healing, leading to higher surgical complication rates.
Inspection, Palpation, and Motion
Inspection
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Examination may begin with the patient sitting on an elevated table with the leg at eye level for the physician.
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The location and amount of swelling is noted.
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Swelling may be diffuse from peripheral edema.
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Swelling may be focal as with inflammation of tendonitis or single-joint arthritis.
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Previous wounds are noted in order to understand the role of previous injury or surgery in current pathology.
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Pigmented lesions should be noted.
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Subungual hematomas are common.
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A pigmented subungual lesion that does not grow out with time raises the possibility of melanoma.
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Is the skin shiny, “wooden,” &/or with loss of hair?
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This could indicate an underlying vasculopathy.
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Is the skin tight with poor flexibility?
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This is seen with chronic hyperglycemia.
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Does the patient have calluses?
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Calluses are the clue to where the patient is bearing the most weight.
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It is normal to have mild callusing under the 1st metatarsal head or the heel.
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Callusing under the 2nd metatarsal head is an indirect sign of 1st-ray hypermobility/instability.
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Heavy calluses under the 1st metatarsal head may be present in the cavus foot.
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Thick calluses under the heel will be seen with calcaneus deformity from a weak Achilles.
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Calluses under the navicular may be seen with a collapsed arch (pathologic flatfoot).
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Look at the shoes.
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Many patients with forefoot deformities will be wearing shoes that are too small for the deformity.
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A switch to proper-fitting shoes may relieve symptoms.
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Wear under the lateral shoe suggests cavus or varus alignment, while medial wear is visible with valgus or flatfoot deformity.
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Some wear on the heel lateral to midline is normal for many people, though.
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Palpation
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Most structures in the foot are superficial and directly palpable.
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Describe the tenderness anatomically.
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For example, instead of saying “lateral foot or ankle tenderness,” say where it is exactly.
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Is it the base of the 5th metatarsal, the anterior process of the calcaneus, the peroneal tendons, the distal fibular tip, or the anterior talofibular ligament?
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Motion
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Begin with knee motion.
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Misalignment in the knee can overload the foot with secondary pain.
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Stiffness in the knee may be present and may make mild foot deformities or mild ankle stiffness more symptomatic.
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Plantar flexion and dorsiflexion of the foot is mainly through the ankle, although in many cases, up to 1/3 of perceived ankle motion is actually through the subtalar and (especially) transverse tarsal (talonavicular and calcaneocuboid) joints.
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Subtalar motion is a complex motion with contributions from the 3 hindfoot joints (talocalcaneal, talonavicular, and calcaneocuboid).
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The motion is described as inversion and eversion.
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Hindfoot motion is not purely in the coronal plane.
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It is a complex motion that is best measured by comparing with the contralateral side.
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The motion is normal if it is fluid and equal to that of the unaffected side.
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Limitations of hindfoot motion are important to note.
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A patient with a flatfoot deformity and a “fixed” hindfoot has moderate to severe restriction of subtalar motion, which implies arthrosis or perhaps peroneal spasticity.
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This finding may determine whether a joint-sparing or fusion surgery is indicated for flatfoot reconstruction.
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An arthritic ankle with decreased subtalar motion may not be a great candidate for an isolated ankle fusion, as this may place more stress on an arthritic joint.
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All the metatarsophalangeal (MTP) joints normally have good motion, especially in extension.
Gastrocnemius Contracture
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When checking ankle dorsiflexion, gastrocnemius contracture may limit passive ankle dorsiflexion.
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Because the gastrocnemius origin is above the knee on the femoral condyles, a contracted gastrocnemius will limit ankle dorsiflexion with the knee extended but not flexed.
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Normally, passive ankle dorsiflexion should be at least 5° or 10° past neutral.
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When examining the patient’s right foot, the examiner’s right hand cups the heel with the thumb on the navicular tuberosity.
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The left hand is wrapped around the metatarsal heads to keep them level.
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It is essential to keep the hindfoot neutral or just slightly inverted.
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Because of the oblique axis of the subtalar joint, hindfoot eversion will also dorsiflex the forefoot, masking any gastrocnemius equinus.
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Passive ankle dorsiflexion is checked 1st with the knee extended.
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The normal ankle dorsiflexes 5° or 10° past neutral.
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Then the knee is flexed, and dorsiflexion is checked again.
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Limitation of ankle dorsiflexion with the knee extended that corrects with knee flexion indicates gastrocnemius contracture.
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Limitation of dorsiflexion in all knee positions means that both the soleus and the gastrocnemius are contracted.