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College of the Sequoias - Sports Medicine Foot Evaluation Form Name of Athlete:_________________________________ Date:________________ Mechanism of Injury:___________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Flexion, Extension, Hyper-Flexion, Inversion, Eversion, Compression, Abduction, Adduction History:______________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Injured Before, Pain, Swelling, Sound, Sensation, Treatment, Exact Site, Able to Function Visual:_______________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Ecchymosis, Swelling, Deformity, Normal/Abnormal Gait, Weight Displacement Anatomy: Bones ___ Phalanges 1 2 3 4 5 ___ Metatarsals 1 2 3 4 5 ___ Cuneiform 1 2 3 ___ Calcaneus ___ Talus ___ Cuboid ___ Navicular Right_____ Left_____ Joints Arches ___ Interphalangeal 1 2 3 4 5 ___ ___ PIP ___ ___ DIP ___ ___ Tarsometatarsal ___ ___ Subtalar ___ ___ Midtarsal ___ Metatarsophlangeal 1 2 3 4 5 Ligaments Medial Longitudinal Lateral Longitudinal Anterior Metatarsal Transverse Plantar Fascia Muscles ___ Plantar Calcaneonavicular-- “Spring” ___ Medial Talocalcaneal ___ Lateral Talocalcaneal ___ Anterior Talocalcaneal ___ Posterior Talocalcaneal Nerves and Blood Supply ___ Tibial Nerve – Plantar Aspect ___ Common Peroneal Nerve – Anterior Aspect ___ Anterior Tibial Artery ___ Posterior Tibial Artery ___ Tibialis Anterior ___ Tibialis Posterior ___ Extensor Digitorum Longus ___ Peronues Longus ___ Peronues Brevis ___ Flexor Digitorum Longus ___ Flexor Hallicus Longus Please continue on the other side Range of Motion / Strength: 1- Normal 2 - Limited 3- No Movement Flexion, Extension, Hyper-Flexion, Hyper-Extension, Inversion, Eversion, Abduction, Adduction Muscles: _________________ _________________ _________________ _________________ Special Tests: Movement(s) _________________ _________________ _________________ _________________ + Positive Passive _______ _______ _______ _______ Active ______ ______ ______ ______ Muscle Testing_ ______________ ______________ ______________ ______________ - Negative Tinel’s Test – Tap over the posterior tibial nerve Morton’sTest – Plantar Flex/ Invert the ankle, apply pressure to the heads of the metatarsals Tap Test – Tap the distal ends of the phalanges Displacement Test – Displace the proximal and distal ends of the each involved boney structure Pulse – Dorsal Pedis Artery Pulse – Posterior Tibial Artery Mid-foot stress tests Assessment of Injuries: Fracture - Jones Fracture - Stress Fracture Strain - Arch Sprain Strain Strain/Sprain Bursitis Avulsion Luxation Subluxation Puncture Abrasion Sore Tendinitis Contusion Impingment Seasmoiditis Heel spur Turf Toe Rupture Laceration Incised Morton’s Neuroma Nerve Problem Plantar Fasciitis Sever’s Disease Other:______________________ Comments and Treatment Plan:_________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Physician Referral / Medication(s): ______________________________________ ____________________________________________________________________ ____________________________________________________________________ Location: _____Home _____ Away Surface: ____ Track ____ Turf Sport: ____ Baseball ____ Soccer ____ Tennis ______Game ____ Grass _____Practice ____ Dirt ____ Gym ____Other ____ Basketball ____ Cross Country ___ Football ____ Softball ____ Swim/Dive ___ Equestrian ____ Track ____ Volleyball Signatures: Athlete_______________________ Physician___________________ Athletic Trainer________________________ AT Student___________________
