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Table of Contents
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Postural Examination1
Weight-Bearing Position, Anterior View
- The examiner needs to observe whether the patient's hips and trunk are in normal position. Excessive lateral rotation of the hip or rotation of the trunk away from the opposite hip elevates the medial longitudinal arch of the foot. On the other hand, medial rotation of the hip or trunk rotation toward the opposite hip tends to flatten the arch and can also cause pigeon toes. If the iliotibial band is tight, it may cause eversion and lateral rotation of the foot.
- The examiner should also look for any tibial torsion and should assess the location of the medial malleolus in comparison to the lateral malleolus.
- Care needs to be taken to note whether there is any asymmetry, malalignment, or excessive pronation or supination of the foot.
- The examiner should note how the patient stands and walks. The foot should be in a slightly toe-out position and the forefoot and hindfoot should be parallel to each other and to the floor.
- If there is asymmetry in standing the examiner should place the talus in neutral to see if the asymmetry disappears.
- Any skin abnormalities should be noted, such as bumps, warts, calluses, and corns. The examiner should also look for abnormalities of the toenails as well as any swelling or pitting edema around the ankle or foot.
- Vasomotor changes should be noted, including loss of hair on the foot, osteoporosis and temperature differences between the limbs. Varicose veins and/or other circulatory impairments should be recorded.
Image from: http://medicalimages.allrefer.com/large/corns-and-calluses.jpg
Weight-Bearing Position, Posterior View
- Bulk of the calf muscles should be noted and the Achilles tendons on each side should be compared. A tendon that curves out may indicate a fallen medial longitudinal arch, which would result in pes planus (flat foot). The calcaneus and malleoli should also be observed for normality of shape and position.
Image from: http://drugline.org/img/ail/2045_2058_1.jpg
Image from: http://www.ordesignslv.com/images/pes_planus.gif
Weight-Bearing Position, Medial View
- The longitudinal arches of the foot are the primary concern in this view. The examiner should note whether the medial arch is higher than the lateral arch, which should be expected.
Image from: http://www.footbalance.com/sites/default/files/medial_arches_en_2.jpg
Supine
- The examiner should look for abnormalities such as callosities, plantar warts, scars and/or sores as well as swelling on the dorsum of the foot. They should also look for a fallen metatarsal arch and children should be assessed for clubfoot deformities.
Image from: http://o.quizlet.com/i/tdGv2mZs3_1wuV7XrwkCwg_m.jpg
Prone2
- The examiner should bisect the tibia and calcaneus with a marker to look for varus/valgus of the calcaneus. After non-weight-bearing evaluation the examiner can ask the patient to return to standing to see if the varus/valgus of the calcaneus changes.
- The therapist should identify subtalar neutral by pushing the 5th metatarsal cephalad. Any callouses or warts should be noted as well.
Image from: http://morphopedics.wdfiles.com/local--files/ankle-joint/Rearfoot%20Valgus.Varus%202.jpg
Shoe Examination1
-The examiner should look at the inside and outside of the patient's shoes for weight-bearing and wear patterns. With a normal foot, the greatest wear on the shoe is beneath the ball of the foot and slightly to the lateral side and posterolateral aspect of the heel. If the patient's shoes are to small or too narrow, they may pinch the feet, causing deformities and affecting normal growth. If the shoes are worn out they will offer little support and if the shoes are stiff, they limit proper movement of the foot.
Gait Evaluation and Active Movements1
- The patient should be asked to perform forwards, backwards, and sideways movements. The therapist should also ask the patient to perform heel and toe walking as well as walking on the lateral and medial borders of the foot.
- Squatting should be performed with heels on and off the ground.
- Balancing on one leg and on the ball of the foot should be asked of the patient.
- The examiner should ask the patient to perform heel and toe hopping and jumping.
- Dorsiflexion should be measured in standing.
Palpation2
The examiner should palpate the anterior, posterior, medial and lateral aspects of the foot to feel for bilateral symmetry or asymmetry as well as any skin or bony deformities.
Clearing Joints
The following joints above the foot should be cleared to rule out any referring issues that may be causing the pain. All of these joints do not have to be cleared for every evaluation. It is up to the practitioner to determine which they feel are appropriate.
Sacroiliac Joint(refer to first segment of video)
Lumbar Spine:
Hip:
Knee:
Ankle:
Range of Motion Testing3
Normal ROM for the foot are as followed:
| Motion | Normal |
|---|---|
| Plantarflexion | 50o |
| Dorsiflexion | 20o |
| Inversion | 35o |
| Eversion | 15o |
| MTP/IP Flexion | N/A |
| MTP/IP Extension | N/A |
| First MTP Flexion | 30o |
| First MTP Extension | 70o |
| First MTP Abduction | N/A |
| First MTP Adduction | N/A |
Quick tests are performed first to see if any motions are markedly different from the unaffected side. AROM is always tested before PROM. Patient is instructed to do motion and ROM measurement may be taken. Then the examiner passively pushes motion into the patient's full available range. Only motions with deficits are measured by the following ways:
Plantarflexion/Dorsiflexion: Patient is supine or sitting with a pillow under slightly flexed knee.
Axis: Distal to, but in line with, lateral malleolus at intersection of lines through lateral midline of fibula and lateral midline of 5th metatarsal.
Stationary arm: Lateral midline of fibula, in line with the fibular head.
Moving arm: Lateral midline of 5th metatarsal
Inversion/Eversion: Patient is short-sitting with ankle in anatomical position.
Axis: Anterior aspect of talocrural joint, midway between medial and lateral malleoli
Stationary arm: Anterior midline of tibia, in line with tibial crest
Moving arm: Anterior midline of second metatarsal
Image from: http://www.t-nation.com/img/photos/2008/08-030-training/image008.gif
MTP or IP Flexion/Extension: Patient is supine or seated with ankle in neutral position
Axis: Dorsal midline of joint
Stationary arm: Dorsal midline of proximal bone of joint
Moving arm: Dorsal midline of distal bone of joint
First MTP joint Flexion/Extension: Patient is supine or seated with ankle in neutral.
Axis: Medial aspect of first MTP joint
Stationary arm: Medial midline of first metatarsal
Moving arm: Medial midline of proximal phalanx of great toe
MTP Extension
MTP Flexion
First MTP joint Abduction/Adduction: Patient is supine or seated with ankle in neutral position.
Axis: Dorsal midline of first MTP joint
Stationary arm: Dorsal midline of first metatarsal
Moving arm: Dorsal midline of proximal phalanx of great toe
Manual Muscle Testing4
Quick break tests for testing the strength of muscles can be performed. For the foot evaluation, plantarflexion, dorsiflexion, inversion, eversion, metatarsalphalangeal and interphalangeal flexion and extension can be performed. Abduction and adduction of the MTP joints can also be tested. Patient is asked to go through ROM to be tested than go halfway between neutral and full range. The examiner then applies resistance in the opposite direction. To perform a full through range manual muscle test, refer to Hislop and Montgomery.
Passive Physiological Motions1
Pronation (eversion, abduction and dorsiflexion) and supination(inversion, adduction and plantarflexion) of the foot and toe motions, as needed, can be performed.
Accessory Motions1
Subtalar Joint
Medial and Lateral Tilt: Patient is prone with knee flexed to 90 degrees. Examiner places one hand on the dorsum of the ankle where the talus lies to stabilize. The other hand cups the calcaneus and tilts it in the frontal plane medially and laterally.
Posterior-Anterior: Patient is prone with knee flexed to 90 degrees. Talus is stabilized with one hand and calcaneus is pushed anteriorly with the other hand.
Midtarsal Joints (calcaneocuboid and talonavicular)
Anterior Posterior Glide: Patient can be prone with knee flexed to 90 degrees or supine with knee extended. Proximal structure (calcaneus or talus) is stabilized while distal structure (cuboid or navicular, respectively) is mobilized from the anterior (dorsum of the foot) to the posterior direction.
Talonavicular:
Calcaneocuboid:
Tarsometatarsal and Intermetatarsal joints
Anterior Posterior Glide: Patient can be prone with knee flexed to 90 degrees or supine with knee extended. Tarsal bone is stabilized for the TMT joint while the metatarsal is forced toward the dorsum of the foot. For the IMT joints, one metatrsal is stabilized while the other one is pushed toward the dorsum of the foot.
Metatarsophalangeal and Interphalangeal Joints
Anterior Posterior Glide: Patient is supine and long sitting. Stabilize proximal segment and apply a posterior directed force on the distal segment.
Distal Distraction: Patient is prone with knee flexed to 90 degrees. The proximal structure of the joint is stabilized while a longitudinal force is applied to the distal structure.
Medial and Lateral Glides:Patient is supine and long sitting with feet off the table. Stabilize proximal segment and apply a medial and/or lateral glide to the distal segment.
Special Tests1
Tests for Neutral Position of the Talus:
Neutral position of the talus (weight bearing):
Patient stands with feet in a relaxed standing position. One foot is tested at a time. Examiner palpates the head of the talus on the dorsal aspect of the foot with the thumb and index finger. The patient rotates their trunk to the left and right. This causes the tibia to medially and laterally rotate thus causing the talus to pronate and supinate. When the foot is positioned so that the talar head can't be felt on either side, then the subtalar joint is said to be in neutral in weight bearing.
During this test the amount of navicular drop can be measured. This quantifies the amount of midfoot mobility the individual has. Using a ruler, the examiner first measures the navicular at it's most prominent point in STJN and then measures the height again in normal relaxed standing. The difference indicates the amount of foot pronation or flattening of the medial longitudinal arch during weight bearing. A measurement greater than 10 mm is considered pathological.
Neutral position of the talus (prone):
Neutral position of the talus can also be performed in supine.
Tests for Alignment: used to determine the relation of the leg to the hindfoot and of the hindfoot to the forefoot
Leg-heel Alignment: Patient lies in prone with the feet extending over the edge of the examining table. The midline of the calcaneus is marked at the Achilles tendon insertion. Another mark is placed about 1 cm distal to the previous mark and as close to the midline of the calcaneus as possible. These 2 marks are joined and are known as the calcaneal line. Next, the examiner makes 2 marks on the lower third of the leg in the middle. These 2 marks are the tibial line which represents the longitudinal axis of the tibia. The subtalar joint is put into neutral. If the lines are parallel or in slight varus (2-8 degrees), the alignment is considered normal. If the heel is inverted, the patient has hindfoot varus, if it is everted, the patient has valgus.
Forefoot-heel Alignment: Patient lies in supine with the feet extending over the edge of the table. Subtalar joint is placed in neutral. While maintaining this position, the midtarsal joints are pronated maximally. The examiner observes the relationship between the vertical axis of the heel and the plane of the 2nd through 4th metatarsals. The plane should be perpendicular to the axis. If the medial side of the foot is raised, the patient has forefoot varus. If the lateral side of the foot is raised, the patient has forefoot valgus.
Coleman Block Test: This test differentiates a hindfoot varus from a forefoot valgus or a hindfoot varus from a tight tibialis posterior. If the patient has a hindfoot varus in standing, the examiner places a lift or block under the lateral side of the forefoot. If the hindfoot varus is corrected, it indicates the hindfoot is flexible. The hindfoot varus is possibly due to a plantarflexed first ray or a valgus forefoot. If it isn't corrected, the tibialis posterior is tight.
Tests for Tibial Torsion: The examiner must realize that some lateral tibial torsion (13-18 degrees in adults, less in children) is normal. If it is more than 18 degrees, it is referred to as a toe out position and less than 13 degrees, a toe in position. Excessive in-toeing can be caused by medial tibial or femoral torsion or excessive femoral anteversion.
Sitting: The patient sits with the knees flexed to 90 degrees over the end of the examining table. The examiner places the thumb of one hand over the apex of the malleolus and the index finger over the apex of the other malleolus. The axes of the knee and ankle should be at an angle of 12 to 18 degrees secondary to lateral rotation of the tibia.
Test for tibial torsion can also be performed in supine or prone.
"Too Many Toes" Sign: The patient stands in a normal relaxed position while the examiner views the posterior aspect of the patient. If the heel is in valgus, the forefoot abducted or the tibia laterally rotated more than normal (tibial torsion), the examiner can see more toes on the affected side compared with the normal side.
Tests for Ligamentous Instability
Talar Tilt: The patient lies in the supine or side-lying position with the foot relaxed. The knee may be slightly flexed to relax the gastrocnemius. A positive test is indicated by increased mobility of the calcaneous. The foot is held in the anatomical position and the talus is tilted from side to side into adduction and abduction. Adduction tests the calcaneofibular ligament and to some degree the anterior talofibular ligament. Abduction stresses the deltoid ligament, primarily the tibionavicular, tibiocalcaneal and posterior tibiotalar ligaments.
Other tests 5:
Morton's neuroma: Examiner grasps lateral side of 5th metatarsal and medial side of 1st metatarsal and squeezes. A positive sign is exquisite pain, burning, shooting or tingling in between metatarsal heads.
Homan's sign:** Examiner palpates deep between heads of patient's gastrocnemius or forcibly dorsiflexes patient's ankle when knee is fully extended. A positive sign is increased pain in the calf and is indicative of a deep vein thrombophlebitis (DVT).
Half Squat:6 Patient should perform half squat to provide information on maximum pronated position. This mimics loading response and early midstance positions during gait and gives information on the foot's effect on the kinetic chain.
**Test should not be performed if patient has known or suspected DVT.
Dermatome Testing1
Patient lies supine with the skin on both lower extremities exposed. Examiner then uses hand or object to test following areas bilaterally by plotting points across the dermatome region. Patient is asked if the sensations feels the same or different on each side.
L2- groin area
L3- medial thigh
L4- medial knee
L5- dorsum of big toe
S1- lateral heel
S2- medial heel
http://img.tfd.com/dorland/thumbs/dermatome.jpg--
Myotome Testing1
A quick myotome screen can be performed in supine for all nerve roots except for S1. Resisted break tests are performed for each action.
L2- hip flexion
L3- knee extension
L4- ankle dorsiflexion
L5- big toe extension
S1- plantarflexion*
*The S1 myotome screen is performed with the patient in single leg stance in which they then perform 20 heel raises.
Reflex Testing1
L4- pateller knee jerk
Image from: http://www.tabers.com/tabersonline/ub?cmd=repview&type=tabers_21&name=a310p0S1-
S1- achilles tendon reflex
Image from: http://o.quizlet.com/i/2n9ZGyI0qq_HGywRoj148g_m.jpg
Upper Motor Neuron Testing1
If patients present with bilateral numbness and tingling in their upper or lower extremities, upper motor neuron testing should be performed.
Babinski Sign: The patient is supine. A swipe on the plantar aspect of the foot from the lateral portion of the heel to the medial portion of the ball of the foot by the end of a reflex hammer is performed. A positive test is indicated by a flaring of the toes.
Clonus: The patient is supine. Examiner supports the leg under the knee with one hand and holds the plantar aspect of the foot in the other hand. A quick flick of the patient's foot into dorsiflexion is performed. A positive test is indicated by the patient reflexively pushing back into the examiners hands.
Neural Tension Tests1
All patients should be tested for neural tension. Examiner is looking for the comparable sign and/or a stretching sensation that lessens when the distal structure is moved toward the movement. Which test(s) is used is determined by area of symptoms.
Straight leg raise: This test is performed if area of symptoms run down the posterior area of the leg. Patient is supine and examiner slowly lifts leg until end range. They then pick head up off of table into flexion. If symptoms or pain worsen with neck flexion and improve with neck extension, neural tension test is positive.
Prone knee bend: This test is performed if area of symptoms run down the anterior side of the leg. Patient is prone and examiner slowly bends knee on affected side. Symptoms or pain is checked. The hip is then flexed and symptoms or pain is checked again. Distal segment cannot be moved to differentiate between neural and muscle tension.
Slump test:
References
Magee D. Orthopedic physical assesment. Fifth ed. Missouri: Saunders; 2008:1-1138.
Craig J. Foot and ankle assessment. 2012.
Bandy W, Reese N. Joint range of motion and muscle length testing. Second ed. Missouri: Elsevier; 2010.
Hislop H, Montgomery J. Daniels and worthingham's muscle testing: Techniques of manual examination. eighth ed. Elsevier; 2007.
Baxter RE. Pocketguide to musculoskeletal assessment. Second ed. Missouri: Elsevier; 2003: 187-201.
Craig, J. Foot and Ankle Biomechanics. 2012.
