Physical Examination and Imaging





KEY FACTS





  • A thorough physical examination includes the following components:




    • Inspection



    • Palpation



    • Assessment of motion



    • Strength testing



    • Examination of vascular status



    • Stability assessment



    • Evaluation of alignment



    • Assessment for gastrocnemius contracture



    • Assessment of 1st-ray mobility




  • Inspect for swelling, scars, skin condition, pigmented lesions, calluses, and shoe condition.



  • Describe all tenderness anatomically.



  • 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.



  • Radiographic stress testing can allow the clinician to precisely quantify any instability.




    • Comparison to the contralateral side can be more easily performed in the office.




  • Weight matters; heavy patients who lose weight can eliminate foot pain.



  • Are there any other joints involved? The patient’s problem could be an inflammatory arthropathy.



  • Does the patient smell of smoke? Nicotine inhibits bone and wound healing, leading to higher surgical complication rates.







Heavy callusing under the 1st metatarsal head suggests a cavus foot.








Equinus measured with hindfoot in neutral and knee extended is shown. The examiner’s thumb is over the medial navicular to maintain neutrality of the hindfoot.








Improved dorsiflexion with knee bent implies gastrocnemius equinus.








Anterior drawer test of the ankle is shown. Stabilize the tibia and translate slightly plantar flexed foot anteriorly.






Inspection, Palpation, and Motion


Inspection





  • Examination may begin with the patient sitting on an elevated table with the leg at eye level for the physician.



  • The location and amount of swelling is noted.




    • Swelling may be diffuse from peripheral edema.



    • Swelling may be focal as with inflammation of tendonitis or single-joint arthritis.




  • Previous wounds are noted in order to understand the role of previous injury or surgery in current pathology.



  • Pigmented lesions should be noted.




    • Subungual hematomas are common.



    • A pigmented subungual lesion that does not grow out with time raises the possibility of melanoma.




  • Is the skin shiny, “wooden,” &/or with loss of hair?




    • This could indicate an underlying vasculopathy.




  • Is the skin tight with poor flexibility?




    • This is seen with chronic hyperglycemia.




  • Does the patient have calluses?




    • Calluses are the clue to where the patient is bearing the most weight.




  • It is normal to have mild callusing under the 1st metatarsal head or the heel.



  • Callusing under the 2nd metatarsal head is an indirect sign of 1st-ray hypermobility/instability.



  • Heavy calluses under the 1st metatarsal head may be present in the cavus foot.



  • Thick calluses under the heel will be seen with calcaneus deformity from a weak Achilles.



  • Calluses under the navicular may be seen with a collapsed arch (pathologic flatfoot).



  • Look at the shoes.




    • Many patients with forefoot deformities will be wearing shoes that are too small for the deformity.




      • A switch to proper-fitting shoes may relieve symptoms.




    • Wear under the lateral shoe suggests cavus or varus alignment, while medial wear is visible with valgus or flatfoot deformity.




      • Some wear on the heel lateral to midline is normal for many people, though.





Palpation





  • Most structures in the foot are superficial and directly palpable.



  • Describe the tenderness anatomically.




    • For example, instead of saying “lateral foot or ankle tenderness,” say where it is exactly.



    • 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?




Motion





  • Begin with knee motion.




    • Misalignment in the knee can overload the foot with secondary pain.



    • Stiffness in the knee may be present and may make mild foot deformities or mild ankle stiffness more symptomatic.




  • 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.



  • Subtalar motion is a complex motion with contributions from the 3 hindfoot joints (talocalcaneal, talonavicular, and calcaneocuboid).




    • The motion is described as inversion and eversion.



    • Hindfoot motion is not purely in the coronal plane.




      • It is a complex motion that is best measured by comparing with the contralateral side.




    • The motion is normal if it is fluid and equal to that of the unaffected side.




  • Limitations of hindfoot motion are important to note.




    • 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.




      • This finding may determine whether a joint-sparing or fusion surgery is indicated for flatfoot reconstruction.




    • 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.




  • All the metatarsophalangeal (MTP) joints normally have good motion, especially in extension.





Gastrocnemius Contracture





  • When checking ankle dorsiflexion, gastrocnemius contracture may limit passive ankle dorsiflexion.




    • 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.




  • Normally, passive ankle dorsiflexion should be at least 5° or 10° past neutral.




    • When examining the patient’s right foot, the examiner’s right hand cups the heel with the thumb on the navicular tuberosity.



    • The left hand is wrapped around the metatarsal heads to keep them level.




  • It is essential to keep the hindfoot neutral or just slightly inverted.




    • Because of the oblique axis of the subtalar joint, hindfoot eversion will also dorsiflex the forefoot, masking any gastrocnemius equinus.




  • Passive ankle dorsiflexion is checked 1st with the knee extended.




    • The normal ankle dorsiflexes 5° or 10° past neutral.



    • Then the knee is flexed, and dorsiflexion is checked again.




  • Limitation of ankle dorsiflexion with the knee extended that corrects with knee flexion indicates gastrocnemius contracture.



  • Limitation of dorsiflexion in all knee positions means that both the soleus and the gastrocnemius are contracted.


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Oct 29, 2019 | Posted by in ORTHOPEDIC | Comments Off on Physical Examination and Imaging
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