Download Foot and Arch Evaluation

Foot and Arch Evaluation
1. History
• Chief Complaint:
A. What happened?
B. Is it a sharp or dull pain?
C. How long have you had the pain?
D. Can you pinpoint the pain?
E. Do you have any numbness or tingling?
• Mechanism:
A. How did it happen?
B. What was felt or heard?
• Previous History:
A. Have you injured this before?
2. Observation
• Swelling
• Discoloration
• Deformity
A. Mallet toe
− Flexure contracture of the distal interphalangeal joint (DIP). Usually
occurs with an avulsion fracture of the flexor tendon
B. Claw toe
− Hyperextension of the metatarsophalangeal joint (MTP) and flexion of the
distal and proximal interphalangeal joint (PIP). It is result of a
neurological problems, or muscle, or both
C. Hammer toe
− Hyperextention of the MTP joint, and flexion contracture of the PIP joint.
This deformity may be congenital, from a poorly fitted shoe, or muscular
dysfunction
D. Callous formation
− Between the 2nd and 3rd metatarsals indicate a fallen metatarsal arch
− Over the interphalangeal joint indicates Hammer toes
− Over the interphalangeal joint and the end of the toe indicates Claw toes
E. Hallux valgus deformity (bunion) and Tailor’s bunions (bunionettes)
− Valgus deformity at the 1st MTP joint or 5th MTP joint. It is usually a
result from a trauma or ill-fitting shoes. It also could result from callus
formation, bursal thickening, and excess bone formation.
F. Hallux Rigidus
− Degerative or arthritic changes resulting to fusion and rigidity at the 1st
MTP. Characterized with decresed ROM and palpable tenderness
G. Ingrown toenail
− Nail growing into the lateral nailfold and enters the skin. Initially seen
with pain and swelling. If not treated early, the penetrated skin becomes
severly inflamed and purulent.
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
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Arches (wt bearing/non-wt bearing)
A. Medial/ lateral longitudinal, transverse
B. Pes Planus (flat feet)
C. Pes Cavus (high arches)
D. Supple flat feet
E. Rigid flat feet
Shoes
A. Pronation and supination of the foot
Alignment
A. Forefoot valgus/varus
B. Rearfoot valgus/varus
3. Check the bones for fractures
• Proper location and palpation
A. Tibia
− Medial Malleolus
− Shaft
B. Fibula
− Lateral Mallelous
− Shaft
− Head of fibula
C. Talus
− Talar head
− Dome of talus
− Medial tubercle
D. Calcaneous
− Calcaneal tubercle
− Sustentaculum tali
E. Tarsals
− Navicular
♦ Navicular tubercle
− First cuneiform
− Second cuneiform
− Third cuneiform
− Cuboid
F. Metatarsals
− Head of each metatarsals
− Base of each metatarasals
− Styloid process of the 5th metatarsal (*base of the 5th)
G. Sesamoids
− Distal head of the first metatarsals
H. Phalanges
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
4. Check the ligaments
• Lateral aspect
A. Anterior tibiofibular
B. Posterior tibiofibular
C. Anterior talofibular
D. Posterior talofibular
E. Lateral talocalcaneal
F. Calcaneofibular
•
•
•
Medial aspect
A. Deltoid
− Tibiocalcaneal
− Anterior tibiotalar
− Posterior tibiotalar
− Tibionavicular
B. Posterior talotibial
C. Posterior talocalcaneal
D. Plantar calcaneonavicular
(“Spring Ligament”)
Plantar aspect
A. Plantar Fascia: stress over the distal metatarsal heads
Phalanges
A. Metatarsa-Phalangeal joint collaterals
B. Interphalangeal joint collaterals
5. Check the muscular tendons and soft tissue
• Lateral aspect
A. Peroneus Longus
B. Peroneus Brevis
C. Peroneal retinaculum (superior/ inferior)
• Medial aspect
A. Tibialis posterior (“Tom”)
B. Flexor digitorum longus (“Dick”)
C. Flexor hallucis longus (“Harry”)
• Anterior aspect
A. Extensor hallucis longus
B. Extensor digitorum longus
C. Tibialis anterior
D. Extensor retinaculum (superior/ inferior)
• Posterior aspect⇒Achilles tendon
A. Gastrocnemius
B. Soleus
C. Plantaris
D. Bursa
− Retrocalcaneal (deep and superficial)
♦ Retrocalcaneal bursitis (pump bump)
− Calcaneal
• Plantar aspect
A. Flexor digitorum brevis
B. Flexor hallucis brevis
C. Adductor hallucis
D. Abductor hallucis
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
E. Flexor digiti quinti
6. Compare the Range of Motion (ROM)
• Compare bilaterally
• Stabilize both legs when testing
• Active Range of Motion (AROM)
A. Dorsiflexion: 20°
− Primary muscle: tibialis anterior
− Secondary muscle: extensor hallucis longus, extensor digitorum longus
B. Plantarflextion: 50°
− Gastrocnemius
− Soleus
− Plantaris
C. Inversion: 5°
− Tibialis posterior
− Tibialis anterior
D. Eversion: 5°
− Peroneus longus
− Peroneus brevis
E. Forefoot adduction: 20°
G. Forefoot abduction: 10°
H. Toe flexion: 45°
− Flexor digitorum longus
− Flexor digitorum brevis
− Flexor hallucus longus
− Flexor hallucus brevis
I. Toe extention: 70°~90°
− Extensor digitorum longus
− Extensor digitorum brevis
− Extensor hallucis longus
− Extensor hallucis brevis
• Passive Range of Motion (PROM): Perform the same motion as AROM
7. Manual Muscle Testing
• Stabilize both legs when testing
• Compare bilaterally, starting with the non injured ankle
• Perform both concentric and eccentric tests
A. Dorsiflexion.
B. Plantarflexion
C. Inversion
D. Eversion
E. Great Toe flexion
− Flexor Hallucis Longus: Athlete is supine or sitting. Stabilize the MTP
joint and put the ankle into a neutral position. Have the athlete flex their
great toe
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
F. Toe Flexion (digit 2-5)
− Flexor Digitorum Longus: Athlete is supine or sitting. Stabilize the MTP
joint and put the ankle into a neutral position. Have the athlete flex their
toes.
G. Great Toe extension
− Extensor Hallucis Longus & Brevis: Athlete is supine or sitting. Stabilize
the MTP joint and put the ankle into slight PF. Have the athlete extend
their great toe.
H. Toe Extension (digit 2-5)
− Extensor Digitorum Longus & Brevis: Athlete is supine or sitting.
Stabilize the MTP joint and put the ankle into slight PF. Have the athlete
extend their great toe.
8. Orthopedic special tests
A. Morton’s test
− This test assesses the case of a Morton’s neuroma
♦ Position: athlete is supine, with the foot relaxed
♦ Procedure: grasp the midfoot region and squeeze the metatarsal heads
together
♦ Positive sign: increase pain between the 2nd and 3rd metatarsals
B. Valgus/Varus stress test of the toe(s)
− This test will assess the integrity of the collateral ligaments in the toes
♦ Position: athlete foot is relaxed
♦ Hand placement: one hand is placed at the proximal part of the joint
for stability and the other hand is placed at the distal end of the joint
♦ Procedure: apply valgus/varus test
♦ Positive sign: increase pain and laxity at the joint
C. Pulse
− Posterior tibial pulse
♦ Located behind the medial malleolus
− Dorsal pedal pulse
♦ Located between the 1st and 2nd metatarsal
D. Neurological tests
− Achilles reflex test
♦ Position: athlete is sitting with the knee flexed to 90°, and the foot
relaxed and non-weight bearing
♦ Hand placement: lightly hold the plantar aspect of the foot
♦ Procedure: hit the mid part of the tendon. You should feel the foot
dorsiflex
♦ Positive sign: no reflex. This indicates a S 1 nerve impairment
− Tinel’s sign⇒ look at ankle eval
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
− Dermatomes
(From: Orthopedic Physical Assessment 3rd Ed.)
− Myotomes
♦ Hip flexion (L1-2)
♦ Knee extension (L3-4)
♦ Ankle dorsiflexion (L4)
♦ Big Toe extension (L5)
♦ Ankle eversion or hip extension (S1)
♦ Knee flexion (S2)
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.