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