HISTORY

The first step in evaluating the feet, toes and ankle is to get a detailed history of present and prior incidences of this region. This information will give an examiner a better idea of what to look for when doing a physical examination as well as an appropriate action to take in treating this ailment. By asking the following questions not only does the examiner obtain vital information regarding the injury but also it begins a rapport between the patient and the examiner:

 

Location of pain

Asking the patient where the source of their pain arises from will give you an idea of what structures may be damaged in respect to the specific area as well as the pathology:

 

 

Foot and toes

• Retrocalcaneal pain: inflammation of retrocalcaneal bursa or Achilles tendon

• Heel pain: plantar fasciitis, heel spur

• Medial arch pain: tarsal tunnel syndrome, midfoot sprain, plantar faciitis, navicular fracture, tibialis posterior tendonitis

• Metatarsal pain: stress fracture

• Great toe pain: hallux rigidus, hallux abducto valgus, sesamoid fracture or inflammation, ingrown toe-nail

• Lateral arch pain: posterior tibial nerve compression, fifth metatarsal fracture, peroneal tendonitis

Ankle

• Anterior compartment: anterior talofibular ligament injury, anterior compartment syndrome, ostechondral fracture (1), talar fracture

• Lateral compartment: malleolus fracture, syndesmosis sprain, peroneal tendinitis, capsular impingement, inversion ankle sprain

• Medial compartment: malleolus fracture, eversion ankle sprain

• Posterior compartment: inflammation of retrocalcaneal bursa or Achilles tendon, rupture of Achilles tendon, subcutaneous calcaneal bursitis, calcanao-fibula ligament injury (2), calcaneal fracture

 

Onset of pain

The point at which the patient began to feel pain as well as the duration of the pain provides an idea of the nature and tissues involved with the injury.

 

Acute onset

An acute onset of pain (pain that starts immediately after the trauma) may indicate bony trauma such as fractures as well as sprains and strains.

 

Insidious onset

The gradual worsening of pain involved with insidious onset compared the immediate pain of an acute onset may indicate inflammation of a ligament or a muscle. This type of onset may also indicate an overuse of the muscle.

 

Mechanism of Injury

The mechanism of injury also helps determine the general area of structures that are injured. That is, a rolled ankle will typically affect structures in the ankle and so on.

 

Along with the mechanism of injury other important questions to ask about are:

 

• Surface: different surfaces require different amount of work and skill to maneuver them. Harder surfaces increase the load placed on the foot and ankle, softer surfaces increase the load on the muscles.

• Distance and duration of activity: increasing the amount of activity may put a large work load onto the foot muscles lowering its ability to accommodate the activity due to over use as well as on the body. If the patient has increased their training regiment dramatically this may result in increased stress, muscle fatigue and overuse injuries.

• Footwear: old or non-athletic shoes may not be able to provide adequate support for the activity performed. Ask the patient how long they have used their shoes for as well as what type. Also find out if they are using a separate pair for daily wear. It is also important to know if the patient wears orthotics as well, and why.

Previous history and other questions

A patient’s history with the area of injury may help determine the degree of injury as well as an idea of how to treat it.

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• Previous injury: If the patient has had a sprained ankle before, their chances of re-spraining it again is higher due to the scarring and loosening of ligaments from the previous injury as well as the effectiveness of their rehabilitation. Prior injuries to the ankle and foot may also result in a decreased sense of proprioception as well a change in gait which may both contribute to the present injury. Also find out when this injury occurred, the treatment the received as well as the rehabilitation process.

• Congential conditions: non-injury related conditions such as flat feet or claw toes may increase the chances for certain injuries to occur.

 

 

Asking the following questions may also give you a sense of the injury as well as how to treat the injury

• Sounds: if the patient heard popping noises during the injury this may indicate bony trauma, dislocation or ligament tearin

• Description of symptoms: ask for a description of the pain. Is it dull, sharp or throbbing? Also asks what movements make the pain worse.

 

 

OBSERVATION

The minute the patient walks in the room, the examiner must begin the process of inspection by observing their gait or the use of assistance such as canes or crutches. A typical inspection of the foot, toes, and ankle begins when the patient is in a relaxed, natural ailment, and non-weight-bearing position. Then make inspection of the foot, toes, and ankle when the patient is in a weight-bearing position during standing or walking because structural components of the foot usually make alterations here due to foot irregularities. Compare the results of both.

 

Observation of the Foot

This will give us a general overview of how the foot differs from the neutral position and possible causes of common foot dysfunctions.

 

Foot Type: supinated, normal, or pronated; extreme deviation of pronated or supinated from neutral position is considered abnormal

Calluses and blisters: calluses develop from long-term pressure; blisters develop by increased pressure from the foot rubbing against the shoe or tinea pedis

 

Observation of the Toes

Common abnormalities seen in the toes

 

General Toe alignment

• Claw toes: curling of the toes caused by contracture of either interosseous or lumbrical muscles or both

• Morton’s alignment: 2^nd toe is longer than the 1^st because 1^st metatarsal is shorter than the 2nd

• Hammer toe: interosseous muscle not able to hold proximal phalanx in neutral position

• Hallux abducto valgus: subluxation of the 1^st MTP joint

• Bunion formed medial border of 1^st MTP joint due to inflammation of a bursa

• Corns: thickening of stratum corneum

  • Hard corns: form in areas that experience a lot of pressure i.e. on toes

  • Soft corns: form between the toes

• Ingrown toenail: corners of toenail intruding into skin; common in big toe

• Subungual hermatoma: collection of blood under the nail, a dark purple appearance; common in big toe

 

Observation of the Medial Structures

• Medial longitudinal arch: medial longitudinal arch more prominent in non-weight-bearing position

   

Observation of the Lateral Structures

• Fifth metatarsal: shaft of 5^th metatarsal typically straight; possible fracture if length of bone has contours

   

Observation of the Dorsal Structures

• Tendons of long toe extensors and extensor digitorum brevis: observe for swelling, discoloration, or abnormal bony alignment

   

Observation of the Plantar Structures

• Plantar warts: formed in callus skin due to weigh-bearing stress, sensation of “stepping on a pebble”

   

Observation of the Posterior Structures

• Archilles tendon: in non-weight-bearing position tendon in alignment with tibia

• Calcaneus: retrocalcaneal exotosis or Hagluand’s deformity

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