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PHYSICAL EXAMINATION OF THE FOOT AND ANKLE

Sarah J ane O. Elizalde

INSPECTION
Inspe ! !he e"!ernal appearan e #$ !he sh#e and

$##!. ex. The shoes of an individual with flat feet usually have broken m edial counters due to the prominence of the Talar head.

O%ser&e !he pa!ien!'s $##! and an(le as !he) %ear

*ei+h! , for it is in the weight-bearing position that m ost abnormal conditions manifest themselves. C#,n! !he !#es !# -a(e er!ain !ha! !here are !he ,s!#-ar) $i&e. E&al,a!e !he +eneral shape #$ !he $##!.

Inspe ! !he $##! and an(le $#r #%&i#,s ,nila!eral #r

%ila!eral s*ellin+.

PALPATION
Medial Aspe ! Head #$ !he $irs! -e!a!arsal %#ne and !he

Me!a!ars#phalan+eal .#in! palpable at the ball of the foot. Note any associated bony excrescences involving the head of the m etatarsal.

Head #$ !he $irs!

the area surrounding the

Me!a!arsal %#ne

prom inent head of the first metatarsal bone and the first m etatarsophalangeal joint is the site of allux valgus.

Head #$ !he Tal,s the medial side of the Talar head

is immediately proxim al to the navicular.

Medial Malle#l,s / the malleolus embraces the

m edial aspect of the talus, adding bony stability to the ankle joint. !t articulates with one-third of the m edial side of the talus.

S,s!en!a ,l,- Tali supports the talus and serves as

an attachment for the spring ligament.

Medial T,%er le #$ !he Tal,s point of insertion for

the posterior aspect of the ankle"s m edial collateral ligam ent.

L a!eral Aspe ! Fi$!h Me!a!arsal 0#ne1 Fi$!h -e!a!ars#phalan+eal

.#in!

Cal ane,s

Per#neal !,%er le lies

on the calcaneus, distal to the lateral m alleolus.

L a!eral Malle#l,s / located at the distal end of the

fibula, extends further distally and is m ore posterior than the medial malleolus.

SOFT TISS2E PALPATION


3ONE I / Head #$ !he Firs! Me!a!arsal 0#ne

the area surrounding the prominent head of the first m etatarsal bone and the first metatarsophalangeal joint is the site of allux valgus. The medial aspect of the m etatarsal head is also a common site for gout. 3#ne II / Na&i ,lar T,%er le and !he Talar head the plantar portion of the talar head articulates with the sustentaculum tali and the anterior portion with the posterior aspect of the navicular. !n pes planus #flat foot$ the talar head displaces m edially and plantarward resulting in the loss of the m edial longitudinal arch. % callosity may develop over the prom inent talar head.

3#ne III / Medial Malle#l,s

the m edial collateral ligament of the ankle joint is palpable just inferior to the m edial malleolus. % broad strong ligament, the deltoid"s si&e and strength com pensate for the comparatively short length of the m edial malleolus. Ti%ialis p#s!eri#r !end#n / this tendon is m ost prominent when the patient inverts and plantar flexes his foot. !t is both palpable and visible where it passes im mediately behind and inferior to the m edial m alleolus.

Fle"#r di+i!#r,- l#n+,s !end#n- have the patient flex his toes while you resist his motion. ' ou should be able to feel its m otion imm ediately behind the tibialis posterior, just above the medial m alleolus. Fle"#r hall, is l#n+,s !end#n- lies on the posterior aspect of the ankle joint. P#s!eri#r !i%ial ar!er)- lies between the tendons of the flexor digitorum longus and the flexor hallucis longus m uscle.

Ti%ial ner&e4 located immediately posterior and lateral to the posterior tibial artery. L #n+ saphen#,s &ein-(isible imm ediately anterior to the m edial malleolus. (aricosities fre)uently involve this vein.

3#ne I5 Ti%ialis an!eri#r !end#n E"!ens#r hall, is l#n+,s !end#n D#rsal pedal ar!er) E"!ens#r di+i!#r,- l#n+,s !end#n

3#ne 5 L a!eral Malle#l,s An!eri#r !al#$i%,lar li+a-en! Cal ane#$i%,lar li+a-en! P#s!eri#r !al#$i%,lar li+a-en! 3#ne 5I Sin,s !arsi 3#ne 5II Head #$ !he $i$!h -e!a!arsal

3#ne 5III Cal ane,s 3#ne IX Plan!ar s,r$a e #$ !he $##!

3#ne X / T#es Cla* T#es hyperextension of the

m etatarsophalangeal joints and flexion of the proximal and distal interphalangeal joints* often associated with pes a&,s.

Ha--er T#es - typified by the hyperextension of the

m etatarsophalangeal joint and distal interphalangeal joint and flexion of the proximal interphalangeal joint.

C#rns m ost fre)uently situated in areas of excessive

pressure, especially on the fifth toe.

TESTS FO6 ANKLE JOINT STA0ILITY

Anterior Draw sign test


+lace one hand on the anterior aspect of the lower tibia

and grip the calcaneus in the palm of your other hand. ,raw the calcaneus and talus anteriorly while pushing the tibia posteriorly.

-nder abnormal conditions however, the talus slides

anteriorly from under the cover of the ankle mortise. ' ou m ay feel a .clunk/ as it m oves. #0 $ draw sign.

A !i&e 6an+e #$ M#!i#n


To test Plan!ar $le"i#n and !#e -#!i#n, ask the

patient to walk on his toes.

To test d#rsi$le"i#n, instruct the patient to walk on his

heels.

To test in&ersi#n, have the patient walk on the lateral

borders of his feet.

To test e&ersi#n, instruct the patient to walk on the

m edial borders of his feet.

M,s le Tes!in+
1 main functional categories#muscles of the foot$2 3. ,orsiflexors 1. +lantar flexors ,456!789:456 Ti%ialis an!eri#r ask the patient to walk on his heels

with his feet inverted. !ndividuals having weak anterior tibial muscles are unable to perform this functional dorsiflexion-inversion test and m ay exhibit .foot-drop/ or .steppage gait/.

Fle"#r di+i!#r,- l#n+,s stabili&e the calcaneus and

have the patient bend or curl his toes. 4ppose this flexion by trying to bend the toes into dorsiflexion. %gain, the toes should be unyielding. Ti%ialis p#s!eri#r have the patient plantar flex and invert his foot while you resist his motion.

PL ANTA6 FL EXO6S Per#ne,s l#n+,s and %re&is

4 ask the patient to walk on the medial borders of his feet, as he does so, the tendons of the peronei should become prom inent where they turn around the lateral m alleolus. 7as!r# ne-i,s and s#le,s - ask the patient to walk on his toes , then instruct the patient to jump up and down on the balls of his feet one at a tim e, to force the calf m uscles to support almost two and one-half times the body"s weight.

Fle"#r hall, is l#n+,s !end#n

- sim ply observe the patient"s gait. The m uscles"s action is integral to the sm ooth toe-off phase of gait. Fle"#r di+i!#r,- l#n+,s - stabili&e the calcaneus and have the patient bend or curl his toes and oppose this flexion by trying to bend the toes into dorsiflexion. Ti%ialis p#s!eri#r - have the patient sit on the exam ination table and stabili&e his foot, have him plantar flex and invert his foot while you resist his motion.

6e$le" Tes!s
A hilles !end#n re$le"

- ask the patient to sit on the edge of the examining table with his legs dangling, and put the tendon into slight stratch by gently dorsiflexing the foot. 8ocate the tendon accurately by placing your thumb and fingers into the soft tissue depressions on either side of it. Tap the tendon with the flat end of a neurologic ham mer using a wrist-flexing action to induce a sudden involuntary plantar flexion.

SPECIAL TESTS
An(le d#rsi$le"i#n !es!

- flex the knee joint.

H#-an's si+n

- forcibly dorsiflex the patient"s ankle when his leg is extended. +ain in the calf resulting from this maneuver is a positive om an"s sign. Tenderness elicited upon deep palpation of the calf m uscle is further evidence of deep vein thrombophlebitis.

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