import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Foot Examination 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. ## Quick Reference One-Pager ## Introduction and Setup **Patient Positioning:** - Standing for alignment and functional tests - Seated for detailed examination - Walking for gait assessment **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:** - Hindfoot: Talus, calcaneus (subtalar joint) - Midfoot: Navicular, cuboid, cuneiforms (Chopart's and Lisfranc's joints) - Forefoot: Metatarsals and phalanges - Medial longitudinal arch: Maintained by plantar fascia, spring ligament, posterior tibial tendon ## Look (Inspection) ### Standing Assessment - **Hindfoot alignment**: Valgus (flatfoot), varus (cavus) - **"Too-many-toes" sign**: More than 1.5 toes visible laterally = forefoot abduction (flatfoot) - **Heel position**: Neutral, valgus, varus - **Calf bulk**: Compare sides - **Achilles tendon**: Alignment, thickening - **Medial arch**: Collapsed (flatfoot), exaggerated (cavus) - **Talar head prominence**: "Too much talus" in flatfoot - **Posterior tibial tendon**: Visible, swelling behind medial malleolus - **First ray position**: Elevated in cavus - **Lateral arch**: Should have slight concavity - **Peroneal tendons**: Behind lateral malleolus - **5th metatarsal base**: Prominence (styloid process) - **Sinus tarsi**: Fullness suggests pathology - **Callosity pattern**: Under metatarsal heads, heel - **Weight distribution**: Broadened forefoot in flatfoot - **Skin integrity**: Ulcers, cracks (diabetic foot) - **Arch imprint**: Flat = pes planus ### Seated/Supine Assessment - **Toe alignment**: Hallux valgus angle, lesser toe deformities - **MTP joint swelling**: RA, gout, OA - **Skin**: Dorsal corns, bunionette - **Extensor tendons**: Visible, intact - **Plantar fascia**: Thickening at heel - **Metatarsal heads**: Calluses indicate weight-bearing pattern - **Sesamoids**: Under 1st MTP - **Forefoot width**: Splayed in flatfoot **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+). ## Feel (Palpation) **Hindfoot:** 1. **Posterior tibial tendon**: Behind medial malleolus to navicular insertion 2. **Flexor hallucis longus**: Behind PTT, more posterior 3. **Spring ligament**: Plantar to talar head (soft tissue support of arch) 4. **Sustentaculum tali**: Medial calcaneal shelf **Midfoot:** 1. **Navicular tuberosity**: PTT insertion, accessory navicular 2. **Talonavicular joint**: Dorsomedial 3. **Calcaneocuboid joint**: Dorsolateral 4. **Cuneiform bones**: 3 bones, first is largest **Forefoot:** 1. **Metatarsal heads**: Plantar tenderness (metatarsalgia) 2. **1st MTP joint**: Medial (bunion), dorsal (OA) 3. **Lesser MTP joints**: Swelling, instability 4. **Web spaces**: Morton's neuroma (3rd web space) 5. **Sesamoids**: Under 1st metatarsal head **Plantar Surface:** 1. **Plantar fascia**: Origin at calcaneus (plantar fasciitis) 2. **Metatarsal fat pad**: Atrophy in elderly 3. **Calluses**: Indicate abnormal pressure ## Move (Range of Motion) **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. ## Special Tests ### Flatfoot Assessment ### Cavovarus Foot Assessment ### First Ray Assessment ### Neuroma and Metatarsalgia ### Equinus Assessment ## Gait Assessment **Key Observations:** - **Heel strike**: Present (normal) or absent (equinus, forefoot strike) - **Midstance**: Arch collapse timing, PTT function - **Push-off**: Single-limb heel raise function - **Forefoot loading**: Abnormal pattern suggests pathology **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 | ## Neurovascular Assessment **Sensory Testing (Critical in Diabetic Foot):** - Monofilament (10g Semmes-Weinstein): Tests protective sensation - Light touch: All dermatomes - Vibration: 128Hz tuning fork on bony prominences **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:** - Dorsalis pedis: Lateral to EHL tendon - Posterior tibial: Behind medial malleolus **Signs of Vascular Compromise:** - Hair loss on dorsum of foot - Trophic skin changes - Poor capillary refill (greater than 2 seconds) - Cool temperature - Dependent rubor **Ankle-Brachial Index (ABI):** - Normal: 0.9-1.3 - Mild disease: 0.7-0.9 - Moderate: 0.4-0.7 - Severe: less than 0.4 ## Complete the Examination **Always state to the examiner:** "To complete my examination, I would like to: - Examine the **ankle** in more detail - Assess **footwear** (wear pattern, orthotic use) - Examine the **spine and hips** (especially in cavus foot - CMT) - Perform **neurological assessment** (especially if cavus) - Obtain **weight-bearing X-rays** (AP, lateral, oblique)" ## Summary Presentation ## Common Conditions Table ## PTTD Staging ## Examiner Tips