Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Physical Examination and Imaging
KEY FACTS
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A thorough physical examination includes the following components:
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Inspection
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Palpation
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Assessment of motion
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Strength testing
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Examination of vascular status
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Stability assessment
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Evaluation of alignment
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Assessment for gastrocnemius contracture
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Assessment of 1st-ray mobility
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Inspect for swelling, scars, skin condition, pigmented lesions, calluses, and shoe condition.
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Describe all tenderness anatomically.
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Proper positioning of the foot and limb is essential for an accurate and reproducible physical exam, particularly during assessment of motion, stability testing, and when evaluating the gastrocnemius and 1st-ray mobility.
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Radiographic stress testing can allow the clinician to precisely quantify any instability.
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Comparison to the contralateral side can be more easily performed in the office.
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Weight matters; heavy patients who lose weight can eliminate foot pain.
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Are there any other joints involved? The patient’s problem could be an inflammatory arthropathy.
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Does the patient smell of smoke? Nicotine inhibits bone and wound healing, leading to higher surgical complication rates.
Heavy callusing under the 1st metatarsal head suggests a cavus foot.
Equinus measured with hindfoot in neutral and knee extended is shown. The examiner’s thumb is over the medial navicular to maintain neutrality of the hindfoot.
Improved dorsiflexion with knee bent implies gastrocnemius equinus.
Anterior drawer test of the ankle is shown. Stabilize the tibia and translate slightly plantar flexed foot anteriorly.
Inspection, Palpation, and Motion
Inspection
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Examination may begin with the patient sitting on an elevated table with the leg at eye level for the physician.
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The location and amount of swelling is noted.
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Swelling may be diffuse from peripheral edema.
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Swelling may be focal as with inflammation of tendonitis or single-joint arthritis.
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Previous wounds are noted in order to understand the role of previous injury or surgery in current pathology.
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Pigmented lesions should be noted.
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Subungual hematomas are common.
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A pigmented subungual lesion that does not grow out with time raises the possibility of melanoma.
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Is the skin shiny, “wooden,” &/or with loss of hair?
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This could indicate an underlying vasculopathy.
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Is the skin tight with poor flexibility?
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This is seen with chronic hyperglycemia.
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Does the patient have calluses?
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Calluses are the clue to where the patient is bearing the most weight.
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It is normal to have mild callusing under the 1st metatarsal head or the heel.
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Callusing under the 2nd metatarsal head is an indirect sign of 1st-ray hypermobility/instability.
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Heavy calluses under the 1st metatarsal head may be present in the cavus foot.
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Thick calluses under the heel will be seen with calcaneus deformity from a weak Achilles.
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Calluses under the navicular may be seen with a collapsed arch (pathologic flatfoot).
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Look at the shoes.
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Many patients with forefoot deformities will be wearing shoes that are too small for the deformity.
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A switch to proper-fitting shoes may relieve symptoms.
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Wear under the lateral shoe suggests cavus or varus alignment, while medial wear is visible with valgus or flatfoot deformity.
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Some wear on the heel lateral to midline is normal for many people, though.
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Palpation
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Most structures in the foot are superficial and directly palpable.
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Describe the tenderness anatomically.
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For example, instead of saying “lateral foot or ankle tenderness,” say where it is exactly.
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Is it the base of the 5th metatarsal, the anterior process of the calcaneus, the peroneal tendons, the distal fibular tip, or the anterior talofibular ligament?
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