Foot and Ankle Physical Exam 1. Gait analysis Physical Exam 2. Examination Standing The Big Picture: • Alignment • Swelling - Gait analysis 3. Examination Sitting - Exam standing • Neurovascular exam - Exam sitting • Skin • Range-of-motion / stability - Provocative maneuvers • Strength testing • Palpation 4. Provocative maneuvers

Gait

Gait Analysis

- Begins and ends with heel strike of same foot - Stance: heel strike → foot flat → toe off (push-off) Stride length: Distance between two Gait Intervals of Stance ipsilateral heel strikes 1st Interval: Heel strike → foot flat Step length: Distance between heel strikes Eccentric tib ant contraction of opposing limbs 2nd Interval: Foot flat → midstance Walking: One foot always on ground Eccentric gastrocs contraction

3rd Interval: Midstance → Toe off Running: Brief period with both feet of Concentric gastrocs contraction the ground

Walking velocity: Factor of stride length and (Swing: Concentric tib ant contraction) cadence

Pathologic Gait Gait analysis . . . Antalgic: Shortened stance on painful side 1. Overall alignment Steppage: Leg lifts higher to clear ground 2. Heel strike Calcaneal: Exaggerated heel weight-bearing • Heel contact? . . . posterior weakness • Foot slap? Waddling: Broad-based, pelvis drops towards 3. Midstance raised leg during swing • arch collapse? . . . proximal myopathy • Valgus/varus thrust? Trandelenburg: Trunk towards weak 4. Push-off side during stance 5. Observe from front, back, and side . . . abductor weakness Walk around the patient . . .

Exam Standing

Understand the foot as a tripod . . . Foot as Tripod . . .

Ground pressure Pes planus: ~ evenly distributed: - Medial overload

st -1 metatarsal head Pes cavus: - Lesser metatarsals - Lateral overload - Heel Pes planus

1. Pes planus 2. Pes planovalgus 3. Adult acquired flatfoot deformity 4. Posterior tibial tendon dysfunction (PTTD) 5. Foot pronation

- Hindfoot valgus - Forefoot abduction

Pes planus Pes cavovarus

- High arch - Hindfoot varus - 1st metatarsal plantarflexion (cavus) - Forefoot adduction • Low arch • Medial tenderness/swelling with PTTD Pes cavovarus Also . . . - Forefoot Alignment - Swelling - Skin changes

Examination Standing

Exam Sitting

Heel varus

Heel valgus Examination Sitting Stage III PTTD . . . Rigid Flatfoot

- Fixed Deformity - Accommodative orthotics/bracing - Arthrodesis

. . . Is any deformity rigid or flexible?

Examination Sitting Neurovascular exam . . . pulses

• Neurovascular exam • Skin • Range of motion • Strength testing • Palpation / Tenderness

Refer for vascular evaluation if not palpable Neurovascular exam . . . Skin . . .

“Focal” vs. “diffuse” IPK Semmes Weinstein monofilament: . . . 5.07 for protective sensation Accommodative orthotics vs. calf stretching

Range of Motion . . . Strength testing . . . Strength testing . . .

Grading Strength: 0/5 No contraction 1/5 Flicker, no movement 2/5 Movement but not against gravity 3/5 Moves against gravity 4/5 Against resistance 5/5 Full strength

Strength testing . . . Strength testing . . .

. . . heel walking elicits foot slap . . . Plantarflexion / gastrocsoleus Strength testing . . . Posterior tib Strength testing . . . peroneals

. . . start from abducted position to neutralize anterior tib

Subluxed peroneals . . . Palpation . . .

Joint Line (ankle) Hindfoot Medial and Lateral Palpation . . . Palpation . . .

Palpate against resistance, Medial ankle: Posterior Tibal Tendon leaving exam fingers free to palpate Rx: Boot then PT and orthotics

My preferred treatment . . .

Physical Therapy

6 weeks ______Alvarez RG, et al. Foot and Ankle Int’l, 2006 Lateral ankle . . . peroneals Palpation . . . 5th metatarsal base

Cast/Boot and NWB for Zone II/IIII

Anterior Process of Calcaneus Anterior Process of Calcaneus… CT if any doubt

Take home . . . Non- or touch-down weight-bearing in boot or cast . . . physical exam Palpation . . . Lisfranc Articulation Morton’s Neuroma

Diagnosis - webspace tenderness - Mulder’s click - Diagnostic lidocaine injection Image and/or refer for all acute injuries - MRI or ultrasound

Morton’s Neuroma Provocative Maneuvers

Initial rx: wide shoes, single injection, orthotics with metatarsal pad Toe Anterior Drawer Test . . . MTP Instability MP joint “drawer” test

Toe Anterior Drawer Test . . . MTP Instability Lesser MTP Instability Initial Treatment Options

- Taping - Splint - NSAIDs - Boot - Orthotics Initial rx: Budin splint, taping, boot, NSAIDs, orthotics “Budin” Splint: Surgery: shortening metatarsal osteotomy (6-12 weeks)

Heel Squeeze Test . . . Calcaneal Stress Fracture

Lateral wall tenderness . . . calcaneal stress fx WB as tolerated in a boot, check Vitamin D, DEXA? Ankle Instability . . . Silfverskiold Test

Talar Tilt Anterior Drawer

PT +/- orthotics with lateral post for chronic instability

Single-leg heel rise test for Thompson Test: Achilles Rupture Weak Posterior Tibial Tendon

Abnormal if: - unable to perform - heel stays in valgus

Rx: Surgery vs Functional Rehab (not just casting) 1. Gait analysis Physical Exam 2. Examination Standing • Alignment • Swelling 3. Examination Sitting • Skin • Range-of-motion / stability • Neurovascular exam • Strength testing • Palpation 4. Provocative maneuvers

1. Gait analysis Physical Exam 2. Examination Standing • Hip / spinal alignment • Crouch may be hip contracture Physical Examination of the Hip 3. Examination Sitting • Neurovascular exam • Skin • Range-of-motion / stability • Strength testing • Palpation 4. Provocative maneuvers Pathologic Gait Antalgic: Shortened stance on painful side Steppage: Leg lifts higher to clear ground Waddling: Broad-based, pelvis drops towards Gait Analysis raised leg during swing . . . proximal myopathy Trandelenburg: Trunk towards weak side during stance . . . abductor weakness

Look at posture…leaning forward might be spine

Exam Sitting . . . Exam Standing . . . - Inspection - Overall posture - Swelling, ecchymosis - Pelvic tilt - Palpation • Scoliosis - Abdomen / inguinal region • Leg length discrepancy - Lateral vs medial - Low back and posterior hip/pelvis - Crouch - Range of motion • Hip contracture - Flexion/extension • Spinal hyperlordosis - Internal/external rotation - Adductor contracture - Obligate external rotation with hip flexion . .. . CAM lesion Exam Sitting . . . Big picture . . .

- Strength Testing - Always consider joints above and join below - Hip flexors, ABductors, ADductors - Lateral pain and tenderness . . . - Distal muscles for spine helath - IT band, greater trochanter, radicular - Provocative testing - Log Roll (fracture, infection, RA, AVN, etc) - Medial pain . . . - Straight leg raise (radiculopathy) - Hip joint proper - Ober’s test (IT band, trochanteric bursitis) (arthritiis, fx, infection, AVN, impingement) - FABER (Flexion ABduction External Rotation) - Inguinal and abdominal pathology (e.g. hernia) • Impingement / Labral Tear - Posterior pain and tenderness . . . - FADIR (Flexion ADduction Internal Rotation - SI joint, radicular pain, hamstrings, ischium • Impingement

Thank you! Physical Examination of the Hip Physical Exam Common Causes of Hip Pain 1. Gait analysis 2. Examination Standing • Osteoarthritis • Hip / spinal alignment • Osteonecrosis • Crouch may be hip contracture • Sciatica 3. Examination Supine • Stress Fracture • Palpation • Infection • Range-of-motion • Impingement / labral tear • Strength testing • Trochanteric Bursitis • Distal pulses • IT Band Pathology 4. Provocative maneuvers

Gait Analysis Pathologic Gait Antalgic: Shortened stance on painful side Antalgic gait . . . Steppage: Leg lifts higher to clear ground Waddling: Broad-based, pelvis drops towards - “Limping” raised leg during swing - Shortened stance . . . proximal myopathy phase on painful / Trandelenburg: Trunk towards weak affected limb side during stance . . . abductor weakness

Look at posture…leaning forward might be spine

Steppage gait . . .

- Compensatory for foot drop - Exaggerated hip flexion allows foot on weak side to clear ground - Tibialis anterior weakness -RX: • AFO brace, • Refer, especially if acute Trandelenburg gait . . .

- Weak abductors - Superior gluteal nerve - Prior hip surgery Exam Standing

Exam Standing . . .

- Walk around the patient - Overall posture - Pelvic tilt Exam Supine • Scoliosis • Leg length discrepancy - Crouch • Hip contracture • Spinal hyperlordosis - Adductor contracture Exam Supine . . . Exam Supine . . . - Palpation… - Inspection - Swelling, ecchymosis • know your anatomy / landmarks - Palpation - Range of motion . . . . - Abdomen / inguinal region • Flexion: 110 - 120° - Lateral vs medial - Low back and posterior hip/pelvis • Extension: 10 - 15° - Range of motion • IR/ER: 30 - 40° / 40 – 60° - Flexion/extension - Internal/external rotation - Strength and sensation testing - Obligate external rotation with hip - Don’t forget distal pulses flexion . .. . CAM lesion

Exam Supine . . .

- Strength Testing - Hip flexors, ABductors, ADductors - Distal muscles for spine helath - Provocative testing - Log Roll (fracture, infection, RA, AVN, etc) Special Tests . . . - Straight leg raise (radiculopathy) - Ober’s test (IT band, trochanteric bursitis) - FABER (Flexion ABduction External Rotation) • Impingement / Labral Tear - FADIR (Flexion ADduction Internal Rotation • Impingement Log roll Straight-leg raise

- Lumbar nerve root irritation Insert Chiodo Log roll image - Positive: . . . radicular sx’s reproduced

Treatment: - PT, injections, time - Fracture - Refer if neurologic deficits - Infection - Advanced chronic pathology - Image and/or refer !

FadIR Test Faber / Patrick Test - Femoroacetabular Impingement (FAI) - SI joint - Intra-articular pathology - Inflammatory disease - Iliopsoas strain - SI joint

- Intra-articular pathology . . .orthoinfo.com AAOS - Inflammatory disease - Iliopsoas strain FAI RX: NSAIDs, injection, PT, arthroscopy Ober’s test Thomas test

- Iliotibial band - Contracted, inflamed, or painful - Leg lifts off table with - Positive: Affected leg remains contralateral hip flexion elevated / abducted after released - Test for hip flexion - Rx: PT, NSAIDs, rarely surgery contracture

Big picture . . . Gaenslen’s test - Always consider joints above and join below - Lateral pain and tenderness . . . • IT band, greater trochanter, radicular - Anterior / medial pain . . . • Hip joint proper (arthritis, fx, infection, AVN, impingement) • Inguinal and abdominal pathology (e.g. hernia) - Posterior pain and tenderness . . . • SI joint, radicular pain, hamstrings, ischium Anterior Hip Pain

• DDX: • Perform this exam • Order these tests • Treat with NSAIDs, Injection, referral

Lateral Hip Pain Posterior Hip Pain

• DDX: • DDX: • Perform this exam • Perform this exam • Order these tests • Order these tests • Treat with NSAID’s, Injection, referral • Treat with NSAID’s, Injection, referral