kin191 a. ch.4. foot. toes. evaluation. fall 2007

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FOOT/TOES EVALUATIONFOOT/TOES EVALUATION

KIN 191AKIN 191AAdvanced Assessment of Advanced Assessment of Lower Extremity InjuriesLower Extremity Injuries

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INTRODUCTIONINTRODUCTION

EVALUATION HISTORY INSPECTION/OBSERVATION PALPATION ROM TESTING LIGAMENTOUS AND CAPSULAR TESTING NEUROLOGIC EXAMINATION

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Location of pain Retrocalcaneal

• Retrocalcaneal bursitis Typically isolated to

specific anatomic location

• Achilles tendinitis Tends to be more diffuse

in nature

• Os trigonum syndrome Will discuss later

44

Location of pain Heel

• Heel spur Bony projection typically Bony projection typically

from medial calcaneal from medial calcaneal tubercletubercle

• Plantar fasciitis May or may not be May or may not be

associated with heel associated with heel spur, they may occur spur, they may occur simultaneously, but may simultaneously, but may be independentbe independent

• Fat pad contusionFat pad contusion

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Location of pain Medial arch

• Tarsal tunnel syndrome Neuro condition so presents Neuro condition so presents

with neuro sx. (radiating, paresthesia) with neuro sx. (radiating, paresthesia)

• Midfoot sprain• Plantar fasciitis• Navicular fracture• Pes planus/Pes cavus• Tibialis posterior tendinitis

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Pes PlanusPes Planus Pes CavusPes Cavus

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Location of pain Lateral arch

• Fracture of 5th Metatarsal• Peroneal tendinitis• Posterior tibial nerve

compression Presents with neuro sx.

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Location of pain Metatarsal

• Fractures• Stress fractures• Metatarsalgia• Neuromas

99

Location of pain Great toe

• Hallux valgus• Hallux rigidus• Sesamoiditis

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HISTORYHISTORY

Onset and MOIOnset and MOI Acute onsetAcute onset

• Metatarsal/phalangeal fractureMetatarsal/phalangeal fracture• Ligamentous/capsular sprainLigamentous/capsular sprain• Muscular strainMuscular strain

Insidious onsetInsidious onset• Playing surfacePlaying surface• Training changes: distance, duration, intensityTraining changes: distance, duration, intensity• Footwear changesFootwear changes

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INSPECTION/OBSERVATIONINSPECTION/OBSERVATION

Starts with initial presentation prior to Starts with initial presentation prior to formal evaluation commencementformal evaluation commencement AmbulationAmbulation Gross deformityGross deformity DiscolorationDiscoloration SwellingSwelling Weight bearing vs. non-weight bearingWeight bearing vs. non-weight bearing Inspect footwear if possibleInspect footwear if possible

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Foot typeFoot type PronatedPronated NeutralNeutral SupinatedSupinated

Calluses/blisters/corns/wartsCalluses/blisters/corns/warts

General Inspection of the FootGeneral Inspection of the Foot

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General toe alignmentGeneral toe alignment Morton’s toeMorton’s toe

• Hypertrophy of the second MTHypertrophy of the second MT Claw toesClaw toes

• Hyperextension of the MTP jointHyperextension of the MTP joint and and flexion of the PIP flexion of the PIP and DIP jointsand DIP joints

Hammer toesHammer toes• Hyperextension of the MTP and DIP joints and flexion Hyperextension of the MTP and DIP joints and flexion

of the PIP jointsof the PIP joints Mallet toesMallet toes

• Flexion of the DIP jointsFlexion of the DIP joints

Inspection of the ToesInspection of the Toes

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Hallux valgusHallux valgus• The big toe begins to The big toe begins to

deviate away from the deviate away from the midline of the footmidline of the foot

• BunionBunion A bunion is a painful A bunion is a painful

swelling of the fluid-filled swelling of the fluid-filled sac (bursa) at the base of sac (bursa) at the base of the big toe. the big toe.

A smaller bunionette A smaller bunionette (tailor’s bunion) may form (tailor’s bunion) may form on the 5on the 5thth MTP joint MTP joint

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Ingrown toenailIngrown toenail Subungual hematomaSubungual hematoma

• The formation of a hematoma beneath the nailThe formation of a hematoma beneath the nail

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Inspection of the medial structureInspection of the medial structure Medial longitudinal archMedial longitudinal arch

Inspection of the lateral structureInspection of the lateral structure Fifth metatarsal (length and deviation)Fifth metatarsal (length and deviation)

Inspection of the plantar surfaceInspection of the plantar surface Plantar wartsPlantar warts

Inspection of the posterior structuresInspection of the posterior structures Achilles tendonAchilles tendon CalcaneusCalcaneus

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Non-weight bearing inspection of foot and Non-weight bearing inspection of foot and calcaneal alignmentcalcaneal alignment Assessment of talar positionAssessment of talar position Mobility of the first rayMobility of the first ray

Inspection of foot alignmentInspection of foot alignment Foot postureFoot posture

• Forefoot varus and valgusForefoot varus and valgus• Rearfoot varus and valgusRearfoot varus and valgus

Plantarflexed 1Plantarflexed 1stst ray ray

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Forefoot Forefoot VarusVarus

Rearfoot Rearfoot VarusVarus

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Forefoot Forefoot ValgusValgus

Rearfoot Rearfoot ValgusValgus

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Feiss’s Line for Navicular DropFeiss’s Line for Navicular Drop

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Feiss’ s Line for Navicular DropFeiss’ s Line for Navicular Drop PP: PP: Sitting with the feet off the end of the tableSitting with the feet off the end of the table

EP: EP: Positioned at the patient’s feetPositioned at the patient’s feet

EVP:EVP: With NWB, identifies and marks the apex of the medial malleolus and With NWB, identifies and marks the apex of the medial malleolus and

plantar aspect of the 1plantar aspect of the 1stst MTP joint MTP joint A line is drawn between two marks / Mark the navicular tubercleA line is drawn between two marks / Mark the navicular tubercle Stands with the feet approximately 1 ft apart with evenly weightedStands with the feet approximately 1 ft apart with evenly weighted The new position of navicular is markedThe new position of navicular is marked

PT: PT: A navicular drop 2/3 or greater the distance of the floorA navicular drop 2/3 or greater the distance of the floor

IM: IM: Hyperpronated footHyperpronated foot

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Medial StructuresMedial Structures First MTP joint (1)First MTP joint (1) First metatarsal (2)First metatarsal (2) First cuneiform (3)First cuneiform (3) Navicular (4)Navicular (4) Navicular tuberosity (5)Navicular tuberosity (5) Talar head (6)Talar head (6) Sustentaculum tali (7)Sustentaculum tali (7) Spring ligament (8)Spring ligament (8) Medial talar tubercle (9)Medial talar tubercle (9) Calcaneus (10)Calcaneus (10) Medial tendons (11)Medial tendons (11)

• Flexor hallucis longusFlexor hallucis longus• Flexor digitorum longusFlexor digitorum longus• Tibialis posteriorTibialis posterior

PALPATIONPALPATION

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Lateral structuresLateral structures Fifth MTP joint (1)Fifth MTP joint (1) Fifth metatarsals (2)Fifth metatarsals (2) Styloid tuberosity (3)Styloid tuberosity (3) Cuboid (4)Cuboid (4) Peroneal tubercle (5)Peroneal tubercle (5) Lateral border of the Lateral border of the

calcaneus (6)calcaneus (6) Peroneal tendons (7)Peroneal tendons (7)

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Dorsal StructuresDorsal Structures Rays (1)Rays (1) / / Cuneiforms (2)Cuneiforms (2) / / Navicular (3)Navicular (3) Dome of the talus (4)Dome of the talus (4) / / Sinus tarsi (5)Sinus tarsi (5) Extensor digitorum brevis (6)Extensor digitorum brevis (6) Inferior extensor retinaculum (7)Inferior extensor retinaculum (7) / / Tibialis anterior(8)Tibialis anterior(8) Extensor hallucis longus (9)Extensor hallucis longus (9) / / Extensor digitorum longus (10)Extensor digitorum longus (10) / / Dorsalis pedis pulse (11)Dorsalis pedis pulse (11)

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Plantar StructuresPlantar Structures Medial calcaneal tubercle (1)Medial calcaneal tubercle (1) Plantar fascia (2)Plantar fascia (2) Intermetatarsal neuroma (3)Intermetatarsal neuroma (3) Metatarsal heads (4)Metatarsal heads (4) Sesamoid bones of Sesamoid bones of

the great toe (5)the great toe (5)

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RANGE OF MOTION TESTINGRANGE OF MOTION TESTING

Active Range of Motion (AROM)Active Range of Motion (AROM) Passive Range of Motion (PROM)Passive Range of Motion (PROM)

Normal form end-feel: flexion and extensionNormal form end-feel: flexion and extension Resisted Range of Motion (RROM)Resisted Range of Motion (RROM)

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GoniometryGoniometry

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LIGAMENTOUS AND LIGAMENTOUS AND CAPSULAR TESTINGCAPSULAR TESTING

Metatarsophalangeal Metatarsophalangeal (MTP) (MTP) and and Interphalangeal Interphalangeal (IP) (IP) jointsjoints

Intermetatarsal jointsIntermetatarsal joints Tarsometatarsal jointsTarsometatarsal joints Midtarsal jointsMidtarsal joints

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Valgus/Varus Test of MTP/IP JointsValgus/Varus Test of MTP/IP Joints

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Valgus/Varus Test of MTP/IP JointsValgus/Varus Test of MTP/IP Joints PP: Supine w/ knee extended or sitting w/ knee flexedPP: Supine w/ knee extended or sitting w/ knee flexed EP: EP:

Standing or sittingStanding or sitting Proximal bone stabilized close to the joint to be testedProximal bone stabilized close to the joint to be tested The bone distal to the joint being tested grasped near the middle The bone distal to the joint being tested grasped near the middle

of its shaftof its shaft EVP: EVP: ValgusValgus the distal bone is moved laterally the distal bone is moved laterally

Varus Varus the distal bone is moved medially the distal bone is moved medially

PT: PT: Pain/LaxityPain/Laxity

IM:IM: Valgus test: MCL sprainsValgus test: MCL sprains Varus test: LCL sprainsVarus test: LCL sprains

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Intermetatarsal Glide TestIntermetatarsal Glide Test

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Intermetatarsal Glide TestIntermetatarsal Glide Test PP: Supine w/ knee extended or sitting w/ knee flexed PP: Supine w/ knee extended or sitting w/ knee flexed EP: EP:

StandingStanding One hand grasps the first MT headOne hand grasps the first MT head Other hand grasps the second MT headOther hand grasps the second MT head

EVP: EVP: The two MT heads are moved opposite directions The two MT heads are moved opposite directions

(plantarly and dorsally and vice versa)(plantarly and dorsally and vice versa) PT: PT: Pain/LaxityPain/Laxity

IM:IM: Transverse metatarsal ligament, interosseous ligament sprainsTransverse metatarsal ligament, interosseous ligament sprains Pain w/ the presence of laxity: may indicate a neuromaPain w/ the presence of laxity: may indicate a neuroma

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Tarsometatarsal Joint Glide TestTarsometatarsal Joint Glide Test

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Tarsometatarsal Joint Glide TestTarsometatarsal Joint Glide Test PP: PP: Supine, knee flexed and the heel stabilized by the edge of Supine, knee flexed and the heel stabilized by the edge of

the tablethe table

EP: EP: Standing or sittingStanding or sitting One hand grasps the distal tarsal rowOne hand grasps the distal tarsal row Other hand grasps the metatarsal being glidedOther hand grasps the metatarsal being glided

EVP: EVP: The metatarsal is glided dorsally on the tarsal and then The metatarsal is glided dorsally on the tarsal and then

glided plantarly on the tarsalglided plantarly on the tarsal PT: PT: Pain/ Pain/ ↑ or ↓ glide↑ or ↓ glide

IM:IM: Increased glide: ligamentous laxityIncreased glide: ligamentous laxity Decrease glide: joint adhesionsDecrease glide: joint adhesions

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Midtarsal Joint Glide TestMidtarsal Joint Glide Test

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Intermetatarsal Glide TestIntermetatarsal Glide Test PP: PP: Supine or sittingSupine or sitting, , knee flexed and the heel stabilized by knee flexed and the heel stabilized by

the edge of the tablethe edge of the table

EP: EP: Standing or sittingStanding or sitting One hand grasps the plantar and dorsal aspect of one tarsalOne hand grasps the plantar and dorsal aspect of one tarsal Other hand grasps the adjacent tarsal in a similar mannerOther hand grasps the adjacent tarsal in a similar manner

EVP: EVP: One tarsal is glided dorsally and plantarly on theOne tarsal is glided dorsally and plantarly on the

stabilized tarsalstabilized tarsal PT: PT: Pain/ Pain/ ↑ or ↓ glide↑ or ↓ glide

IM: IM: Increased glide: ligamentous laxityIncreased glide: ligamentous laxity Decrease glide: joint adhesionsDecrease glide: joint adhesions

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NEUROLOGIC EVALUATIONNEUROLOGIC EVALUATION

Dermatomes (L4 – S2)Dermatomes (L4 – S2) Myotomes (L4 – S2)Myotomes (L4 – S2) Reflexes (L4-S2)Reflexes (L4-S2) Tinel’s sign (Tarsal Tunnel)Tinel’s sign (Tarsal Tunnel) Specific nerve testing – sensory/motorSpecific nerve testing – sensory/motor

Tibial nerveTibial nerve Deep branch of peroneal nerveDeep branch of peroneal nerve Superficial branch of peroneal nerveSuperficial branch of peroneal nerve

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Peripheral Neurological SymptomsPeripheral Neurological Symptoms

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VASCULAR EVALUATIONVASCULAR EVALUATION

Dorsalis pedis artery (anterior tibial a.)Dorsalis pedis artery (anterior tibial a.)

Posterior tibial artery (medial and lateral plantar Posterior tibial artery (medial and lateral plantar branches)branches)

Capillary refill (nailbeds/toe ends)Capillary refill (nailbeds/toe ends)

Skin temperature/colorSkin temperature/color