Complete foot examination covering hindfoot alignment, midfoot assessment, forefoot pathology, and evaluation of common conditions including flatfoot, cavus foot, hallux valgus, and diabetic foot.
The foot examination requires systematic assessment of the hindfoot, midfoot, and forefoot. Key concepts include differentiating flexible from rigid flatfoot, recognizing PTTD (posterior tibial tendon dysfunction), and understanding the windlass mechanism. The Coleman block test is critical for cavovarus foot.
High-Yield Exam Summary
Patient Positioning:
Exposure: Both feet and ankles exposed, observe with and without shoes
Consent Script: "I'm going to examine your feet. I'll start by watching you walk, then look at both feet standing and sitting. Please tell me if anything is painful."
Key Anatomy:
Too-Many-Toes Sign: Stand behind patient. If you can see more than 1.5 lateral toes on the affected side, there is forefoot abduction relative to the hindfoot. This is characteristic of adult acquired flatfoot (PTTD Stage II+).
Hindfoot:
Midfoot:
Forefoot:
Plantar Surface:
| movement | normalRange | technique | keyPoints |
|---|---|---|---|
| Subtalar Inversion | 0-30° | Cup heel, invert | Hindfoot motion |
| Subtalar Eversion | 0-15° | Cup heel, evert | Limited in coalition |
| Transverse Tarsal | Variable | Lock subtalar, rotate forefoot | Supple vs rigid midfoot |
| First MTP Dorsiflexion | 0-70° | Extend big toe | Hallux rigidus if limited |
| First MTP Plantarflexion | 0-45° | Flex big toe | Usually preserved |
| Lesser MTP/IP | Variable | Test each joint | Fixed vs flexible deformities |
Subtalar Motion: The calcaneus moves in inversion/eversion under the talus. This is the key joint for hindfoot flexibility. Reduced subtalar motion suggests tarsal coalition, previous fracture, or arthritis.
Posterior tibial tendon function and hindfoot flexibility
Inability to perform single heel raise, OR heel does not invert during rise
Posterior tibial tendon dysfunction (Stage II+), weak calf, neurological deficit
Ability to detect true positives
Ability to exclude false positives
Assess hindfoot flexibility
Hindfoot corrects from valgus to varus = flexible; remains in valgus = rigid
Flexible flatfoot if corrects, rigid/fixed deformity if does not correct
Ability to detect true positives
Ability to exclude false positives
Test integrity of plantar fascia and arch mechanics
Arch reconstitutes (medial longitudinal arch rises)
Flexible flatfoot (arch restored by windlass mechanism). No reconstitution = rigid flatfoot or plantar fascia insufficiency
Ability to detect true positives
Ability to exclude false positives
Non-weight-bearing equivalent of Jack test
Arch reconstitutes with hallux dorsiflexion
Intact windlass mechanism
Ability to detect true positives
Ability to exclude false positives
Determine if hindfoot varus is forefoot-driven or fixed
Hindfoot corrects from varus to neutral = forefoot-driven (flexible); remains in varus = fixed hindfoot
Forefoot-driven cavovarus (corrects) vs fixed hindfoot varus (does not correct). Determines surgical planning.
Ability to detect true positives
Ability to exclude false positives
Identify hindfoot varus
Medial heel visible (peeking) on either side of ankle
Hindfoot varus (cavus foot)
Ability to detect true positives
Ability to exclude false positives
Assess hypermobility or rigidity of first ray
Excessive dorsiflexion indicates hypermobility; restricted motion indicates rigidity
First ray hypermobility (can cause metatarsalgia, hallux valgus recurrence) or rigidity (hallux rigidus precursor)
Ability to detect true positives
Ability to exclude false positives
Detect interdigital neuroma
Palpable and sometimes audible click as neuroma subluxes between metatarsal heads
Morton's neuroma (interdigital neuroma)
Ability to detect true positives
Ability to exclude false positives
Localize interdigital pathology
Tenderness, reproduction of shooting pain to toes
Morton's neuroma, interdigital bursitis
Ability to detect true positives
Ability to exclude false positives
Differentiate gastrocnemius from soleus equinus
Improved dorsiflexion with knee flexion = isolated gastrocnemius tightness
Gastrocnemius equinus if dorsiflexion improves; Achilles/soleus equinus if no improvement. Important for surgical decision (gastrocnemius recession vs TAL)
Ability to detect true positives
Ability to exclude false positives
Key Observations:
Specific Gait Patterns:
| Pattern | Observation | Indicates |
|---|---|---|
| Antalgic | Short stance on affected side | Pain |
| Equinus | Toe-walking | Achilles/gastrocnemius tightness |
| Flatfoot | Arch collapse, late heel rise | PTTD |
| High-stepping | Excessive hip/knee flexion | Foot drop |
Sensory Testing (Critical in Diabetic Foot):
Motor Testing:
| Muscle | Nerve | Root | Test |
|---|---|---|---|
| Tibialis anterior | Deep peroneal | L4,5 | Ankle dorsiflexion |
| EHL | Deep peroneal | L5 | Great toe extension |
| Peronei | Superficial peroneal | L5,S1 | Foot eversion |
| Gastrocnemius/Soleus | Tibial | S1,2 | Plantarflexion |
| Tibialis posterior | Tibial | L4,5 | Inversion |
| FHL | Tibial | S1,2 | Great toe flexion |
Pulses:
Signs of Vascular Compromise:
Ankle-Brachial Index (ABI):
Always state to the examiner:
"To complete my examination, I would like to:
"55-year-old woman with progressive medial foot and ankle pain, difficulty walking long distances."
| condition | look | feel | move | specialTests |
|---|---|---|---|---|
| Adult Flatfoot (PTTD) | Hindfoot valgus, arch collapse | PTT tenderness | No single heel raise | Too-many-toes +, Jack test corrects |
| Cavovarus Foot | High arch, hindfoot varus | Lateral overload calluses | May be rigid | Coleman block determines flexibility |
| Hallux Rigidus | Dorsal osteophyte 1st MTP | 1st MTP tender dorsally | Limited dorsiflexion | Grind test + |
| Morton's Neuroma | Normal | Web space tenderness (3rd) | Normal | Mulder's click + |
| Plantar Fasciitis | Normal | Medial calcaneal tenderness | Tight gastrocnemius | Windlass increases pain |
| stage | deformity | flexibility | findings | treatment |
|---|---|---|---|---|
| Stage I | None | Normal alignment | PTT tendinopathy, swelling, pain | Non-operative (orthosis, PT) |
| Stage II | Flexible flatfoot | Correctable hindfoot valgus | Too-many-toes, failed single heel raise | Reconstruction (calcaneal osteotomy + FDL transfer) |
| Stage III | Rigid flatfoot | Fixed hindfoot valgus | Subtalar arthritis, rigid deformity | Triple arthrodesis |
| Stage IV | Valgus tilt of talus | Fixed + ankle involvement | Deltoid insufficiency, ankle tilt | Tibiotalocalcaneal fusion |
High-Yield Exam Summary