HISTORY

 

The first step in evaluating the feet, toes and ankle is to get a detailed history of present and prior incidences of this region. This information will give an examiner a better idea of what to look for when doing a physical examination as well as an appropriate action to take in treating this ailment. By asking the following questions not only does the examiner obtain vital information regarding the injury but also it begins a rapport between the patient and the examiner:

 

Location of pain

Asking the patient where the source of their pain arises from will give you an idea of what structures may be damaged in respect to the specific area as well as the pathology:

 

 

Foot and toes

• Retrocalcaneal pain: inflammation of retrocalcaneal bursa or Achilles tendon

• Heel pain: plantar fasciitis, heel spur

• Medial arch pain: tarsal tunnel syndrome, midfoot sprain, plantar faciitis, navicular fracture, tibialis posterior tendonitis

• Metatarsal pain: stress fracture

• Great toe pain: hallux rigidus, hallux abducto valgus, sesamoid fracture or inflammation, ingrown toe-nail

• Lateral arch pain: posterior tibial nerve compression, fifth metatarsal fracture, peroneal tendonitis

 

 

 

 

Ankle

• Anterior compartment: anterior talofibular ligament injury, anterior compartment syndrome, ostechondral fracture (1), talar fracture

• Lateral compartment: malleolus fracture, syndesmosis sprain, peroneal tendinitis, capsular impingement, inversion ankle sprain

• Medial compartment: malleolus fracture, eversion ankle sprain

• Posterior compartment: inflammation of retrocalcaneal bursa or Achilles tendon, rupture of Achilles tendon, subcutaneous calcaneal bursitis, calcanao-fibula ligament injury, calcaneal fracture

 

Onset of pain

The point at which the patient began to feel pain as well as the duration of the pain provides an idea of the nature and tissues involved with the injury.

 

• Acute onset: An acute onset of pain (pain that starts immediately after the trauma) may indicate bony trauma such as fractures as well as sprains and strains.

• Insidious onset: The gradual worsening of pain involved with insidious onset compared the immediate pain of an acute onset may indicate inflammation of a ligament or a muscle. This type of onset may also indicate an overuse of the muscle.

 

Mechanism of Injury

The mechanism of injury also helps determine the general area of structures that are injured. That is, a rolled ankle will typically affect structures in the ankle and so on.

 

Along with the mechanism of injury other important questions to ask about are:

 

• Surface: different surfaces require different amount of work and skill to maneuver them. Harder surfaces increase the load placed on the foot and ankle, softer surfaces increase the load on the muscles.

• Distance and duration of activity: increasing the amount of activity may put a large work load onto the foot muscles lowering its ability to accommodate the activity due to over use as well as on the body. If the patient has increased their training regiment dramatically this may result in increased stress, muscle fatigue and overuse injuries.

• Footwear: old or non-athletic shoes may not be able to provide adequate support for the activity performed. Ask the patient how long they have used their shoes for as well as what type. Also find out if they are using a separate pair for daily wear. It is also important to know if the patient wears orthotics as well, and why.

 

Previous history and other questions

A patient’s history with the area of injury may help determine the degree of injury as well as an idea of how to treat it.

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• Previous injury: If the patient has had a sprained ankle before, their chances of re-spraining it again is higher due to the scarring and loosening of ligaments from the previous injury as well as the effectiveness of their rehabilitation. Prior injuries to the ankle and foot may also result in a decreased sense of proprioception as well a change in gait which may both contribute to the present injury. Also find out when this injury occurred, the treatment the received as well as the rehabilitation process.

• Congential conditions: non-injury related conditions such as flat feet or claw toes may increase the chances for certain injuries to occur.

 

 Asking the following questions may also give you a sense of the injury as well as how to treat the injury

 

• Sounds: if the patient heard popping noises during the injury this may indicate bony trauma, dislocation or ligament tearin

• Description of symptoms: ask for a description of the pain. Is it dull, sharp or throbbing? Also asks what movements make the pain worse.

 

OBSERVATION

 

The minute the patient walks in the room, the examiner must begin the process of inspection by observing their gait or the use of assistance such as canes or crutches. A typical inspection of the foot, toes, and ankle begins when the patient is in a relaxed, natural ailment, and non-weight-bearing position. Then make inspection of the foot, toes, and ankle when the patient is in a weight-bearing position during standing or walking because structural components of the foot usually make alterations here due to foot irregularities. Compare the results of both.

 

Observation of the Foot

This will give us a general overview of how the foot differs from the neutral position and possible causes of common foot dysfunctions.

 

Foot Type: supinated, normal, or pronated; extreme deviation of pronated or supinated from neutral position is considered abnormal

Calluses and blisters: calluses develop from long-term pressure; blisters develop from increased pressure from the foot rubbing against the shoe or tinea pedis

 

Observation of the Toes

Common abnormalities seen in the toes

 

• Corns: thickening of stratum corneum

  • Hard corns: form in areas that experience a lot of pressure i.e. on toes

• Soft corns: form between the toes

• Ingrown toenail: corners of toenail intruding into skin; common in big toe

• Subungual hematoma: collection of blood under the nail, a dark purple appearance; common in big toe

 

General Toe malalignments

• Claw toes: curling of the toes caused by contracture of either interosseous or lumbrical muscles or both

• Morton’s alignment: 2^nd toe is longer than the 1^st because 1^st metatarsal is shorter than the 2nd

• Hammer toe: interosseous muscle not able to hold proximal phalanx in neutral position

• Hallux abducto valgus: subluxation of the 1^st MTP joint

  • Bunion formed medial border of 1^st MTP joint due to inflammation of a bursa

 

Medial Structures

• Medial longitudinal arch: medial longitudinal arch more prominent in non-weight-bearing position

 

Lateral Structures

• Fifth metatarsal: shaft of 5^th metatarsal typically straight; possible fracture if length of bone has contours

 

Dorsal Structures

• Tendons of long toe extensors and extensor digitorum brevis: observe for swelling, discoloration, or abnormal bony alignment

 

Plantar Structures

• Plantar warts: formed in callus skin due to weigh-bearing stress, sensation of “stepping on a pebble”

 

Posterior Structures

• Archilles tendon: in non-weight-bearing position tendon in alignment with tibia

• Calcaneus: retrocalcaneal exotosis or Hagluand’s deformity

 

General Observation of Ankles

Examiner must take notice when the patient enters the room on their weight-bearing status. Remember this is very similar to beginning your examination of the feet and toes. Observe ankles bilaterally for redness, swelling, or visible abnormalities and compare.

 

Lateral Structures

• Peroneal muscle group: look at length of muscle group and tendons to become more noticeable by active invert and evert of foot

• Distal one third of the fibula: look for contour and symmetry and should be superficial proximal to the lateral malleolus; possible fibular fracture if discontinuity in bone’s shaft or edema formed over fractured area

• Lateral malleolus: easy to identify; mild ankle sprain will cause swelling, making lateral malleolus less defined or formation of ecchymosis presents acute trauma (sprain or fracture)

 

Anterior Structures

• Appearance of the anterior lower leg: look for skin color or edema; anterior compartment syndrome will present reddening of skin or pitting edema

• Contour of the malleoli: normally a defined contour projecting from tibia and fibula, but if swelling occurs then less noticeable; syndesmotic sprain if there is edema between tibia and fibula above the distal tibiofibular joint and interosseous membrane

• Talus: observe for symmetry bilaterally on weight-bearing position; important to identify medial longitudinal arch for adequate support and if not well supported then medial angle of talus rotates inward and navicular drops inferiorly which causes tendinitis of the tibialis anterior/posterior muslces

   

• Sinus tarsi: normally a deep notch over the lateral side of the talus, but if injury were to occur the area fills with fluid due to injured anterior talofibular ligament or fractures of ankle

 

Medial Structures

• Medial malleolus: structure is superficial and has soft tissues lining it; if no edema or abnormalities present then it should look defined

• Medial longitudinal arch: normal concave appearance when non-weight-bearing and weight-bearing positon

• Pevs planus (flatfoot): superior aspect of talus leaning in more medially causing abnormal gait, increased stress in ligamentous and muscular structures

             

          Image above is an example of flatfoot with severe over-pronation (http://www.bostonrunningcompany.com/images/pronation.jpg)

• Pevs cavus: supinated foot causes high medial arch; high chance for ankle sprain or stress fracture due to limited shock-absorbing capacity

 

Posterior Structures

• Gastrocnemius-soleus complex: calf musculature in size, shape, and mass should look very similar on both legs. Possible abnormalities such has thrombophelitis will cause redness and swelling in posterior calf, atrophy of calf due to immobilization, and depression of skin caused by tearing of musculotendinous junction with Archilles tendon

• Archilles tendon: located from musculotendionous junction to insertion in the calcaneus and rupturing of the tendon will be obvious if tear is in middle to distal portion, but harder to observe if tear is in proximal portion

• Bursae: observe for swelling, redness, or other characteristics of inflammation regarding the calcaneal bursae

• Calcaneus: very defined and prominent and lined with soft tissues in medial and lateral border. Rectrocalcaneal pain causes thickening at the insertion of Archilles tendon and is due to footwear rubbing on this area.

 

 

PALPATION

Palpation can be done in conjunction with observation to better understand the injury. A good method for palpation is to start at tissues and structures adjacent to the site of pain and working towards it to cover other structures that may attribute to the pain. Remember to use firm, confident hands. This will make the patient more comfortable during the palpation. Also, while palpating, use force to find structures as some may be deeper than others.

 

Foot and Toes

Bony structures

 

 

 

A good sense of foot anatomy is helpful during the palpation of the foot. The bony structures of the foot are close together so it is important to know the landmarks that separate them from one another. With all bony structures note any deformity and crepitus as well as pain felt by the patient when palpating the structures.

 

• Phalanges: Bones of the toes.

• Metatarsals: Easily identifiable. Palpate from the metatarsalphlangeal joints down.

• Styloid tuberosity of the 5^th metatarsal: Located along the lateral side of the foot, the tuberosity is the most prominent point on the lateral side.

• Navicular: Palpate proximally from the first cuneiform. The medial border of the navicular will articulate with the first uniform.

• Navicular tuberosity: From the articulation with the 1^st cuneiform, move posteriorly  to find the prominent structure on the medial side of the foot.

• Cuneiforms: The 1^st cuneiform articulates with the base of the 1^st metatarsal.

• Cuboid: Palpate the styloid process then move promixmally and note a groove.

• Peroneal Tubercle: This tubercle is the most prominent landmark on the calcaneous located inferior and anterior to the lateral malleolus.

• Calcaneus: The heel.

 

Soft Tissue

 

Often times the muscles, tendons and ligaments are in close proximity to one another making it difficult to tell one structure from the next. However, there are a few procedures that both the examiner and subject can do make these structure more easily identifiable:

 

• Ligaments: Ligaments generally run from bone to bone at joints. After locating two articulating bony structures of a joint, thumb the area in between these two points like a guitar. That is the ligament of the joint.

• Muscles: Have the patient extend or flex the desired muscles against resistance. The resistance will allow the muscles to “pop” making them more easily identifiable.

• Tendons: Tendons are often hard to distinguish. Being located at the end of a muscle belly and attaching to bone, a prior knowledge of anatomy will help identify tendons.

 

Again, a good background in anatomy and landmarks of the foot will help identify the soft tissues of the foot. Tenderness, thickening and sensitivy are good indications of pathology to a ligament.

 

• Tibialis anterior tendon: To easily palpate the insertion of this tendon onto the 1^st cuneiform, have the subject invert and dorsiflex their ankle

• Extensor digitorum brevis: Lateral to the tibialis anterior tendon, have the patient extend their great to make this muscle tendon more palpable.

• Extensor digitorum longus: Have the patient extend their other 4 toes and follow the four tendons that are the tendons of this muscle.

• Spring ligament: Locate the substentacalum tali, a protusion of the calcaneus distal to the medial malleolus with one hand, and with the other locate the navicular tuberosity. Between these two points is the spring ligament. A pushing with the thumb will show that this ligament is “spring” like. Tenderness and thickening of this ligament may indicate forefoot sprains.

• Medial tendons: these tendons run posterior to the medial malleolus to the plantar surface of the foot.

  • Flexor hallucis longus: this tendon is more prominent by resisting flexion of the big to

  • Flexor digitorum longus: this tendon inserts on the plantar aspect of the 2^nd through 5^th to

  • Tibialis posterior: When the patient inverts the foot, this tendon is prominently seen inserting at the navicular tuberosity.

• Peroneal tendons: Before these tendons split off, they run below the lateral malleolus.  The peroneous brevis can be palpated at the styloid process of the 5^th MT. Injury to this tendon may result in pain at the base of the 5^th MT and cuboid bone.

• Plantar fascia: The fascia orginates at the calcaneus and attaches to the MT heads. Tenderness may indicate plantar faciitis.

• Dorsal pedis pulse: The dorsalis pedis arter lies between the extensor hallucis tendon and the extensor digitorum longus tendons. Compare this pulse with the opposite foot. If an absence or decrease in pulse evident, this may indicated vascular obstruction.

 

Ankle

Ankle palpation is divided into compartments of the ankle. Injury to these compartments will give a better idea of which structures may be injured.

 

 

 

Anterior/Medial:

 

• Shaft of the tibia: the smooth bony surface of the medial portion of the lower leg. Note any deformity or pain and pay attention to the tibial attachment with the toe flexors. These areas are commonly inflamed.

• Medial malleolus: Palpate the entire border of the malleolus and note any crepitus indicating a fracture.

• Deltoid ligament: This ligament encircles the lower portion of the medial malleolus. It is difficult to palpate individual segments so it is important to palpate the whole area.

• Talar domes: Have the patient plantar flex the ankle and note the structure that rises right above the talus. Pain in this area is indicative of ankle synovitis and impact injuries of the ankle.

• Navicular

• Medial calcaneus

• Plantar fasica

• Plantar MTP joint

 

Anterior/Lateral:

• Head of fibula/fibular shaft: When palpating the fibula, start at the head and work down towards the ankle. Pain of the fibula as well as discontinuity of bone may indicate a fracture

• Lateral malleolus: A forced inversion of the lateral malleolus may be due to avulsed ligaments around this region. Tenderness, swelling and crepitus are symptoms of this avulsion. The distal portion of the malleolus can also be “knocked off” from excessive eversion.

• Distal tibiofibular ligament: Located superiorly to the lateral malleoulus. Tenderness may indicate a syndesmotic ankle sprain.

• Styloid tuberosity of 5^th metatarsal: this structure can be avulsed by forceful contraction of the peroneous brevis muscle while trying to counteract inversion.

• Cuboid

• Peroneus longus and brevis: The tendons of both the longus and brevis are palpable along the posterior portion of the lateral malleolus. Where the peroneus longus passeses underneath the cuboid is a common site of rupture.

• Sinus Tarsi: Locate the indentation over the lateral talus. This area fills with fluid after anterior talofibular ligament injury or fractures around the region.

• Talofibular/Calcaneofibular ligaments: these ligaments are generally non palpable so knowing the regions and applying pressure to them help in the finding of injury:

  • Anterior talofibular ligament: runs diagonally in front of from the malleolus to the peroneal tubercle.

  • Posterior talofibular ligament: runs parallel to the plantar surface posterior to the malleolus. This ligament is only damaged in severe sprains or dislocations.

  • Calcaneofibular ligament: Runs parallel to the plant surface starting at the mallelous. This ligament is usually the second structure to be damaged during inversion sprains.

 

Posterior:

• Achilles tendon: Start to palpate this tendon from its attachment on the calcaneus to the muscles of the leg. It should feel firm and ropelike and increase in width as it travels proximally. A gap in the tendon may be indicative of tendonitis.

• Calcaneus: Pain in this area be due to calcaneal apophysitis.

• Subcutaneous/subtendinous calcaneal bursa: These structures are located within the Achilles tendon although not palpable. When inflamed, they fill with liquid indicating damage.

   

  References

   

  Starkey C, Ryan J.  Evaluation of Orthopedic and Athletic Injuries 2nd Edition.F.A. Davis Company 2002.

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