amy splitter, dpm acmc division chief, division of podiatry assistant professor, california school...
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PODIATRY ESSENTIALS THE BASIC FOOT EXAM
Amy Splitter, DPMACMC Division Chief, Division of PodiatryAssistant Professor, California School of
Podiatric Medicine at Samuel Merritt University
Introduction
Four Basic Elements to lower extremity foot exam Vascular Neurological Dermatological Musculoskeletal
Vascular
The vascular history
How far can you walk?
Major Risk Factors Tobacco Diabetes mellitus HTN Cardiac disease CVA Family history
Vascular evaluation: inspection
Skin color, temp Skin thickness and
texture
Digital hair
Toenail condition
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Pedal Pulses
Dorsalis pedis (DP)
Posterior tibial (PT)
Perforating peroneal (PP)
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Dorsalis pedis pulse
EHL Tendon
Palpate here
Dorsalis pedis pulse
Posterior tibial pulse
Palpate here
Medial malleolus
Posterior tibial pulse
Perforating peroneal pulse
Perforating peroneal pulse
Popliteal pulse
Popliteal pulse
Quantifying pedal pulses
Absent, Diminished, Palpable, Bounding
vs.
1+, 2+, 3+, 4+
Capillary Refill (SPVPFT)
The time it takes to completely fill the area of pallor
Normal: < 3 seconds
PAD: > 10 sec
Capillary refill technique
1. Place foot at heart level
Capillary refill technique
2. Squeeze blood from the hallux
Capillary refill technique
Capillary refill technique
3. Observe time for blood return
Capillary Refill (SPVPFT)
Common Errors
Digit below heart level
Residual venous blood
Doppler
Doppler technique
Doppler technique
Apply acoustic gel
Doppler Sounds
Normal PT
Normal hallux artery
Abnormal DP
Vein
Artery vs. Vein
Ankle Brachial Index
ABI Interpretation
Ankle pressure/Brachial pressure
Normal 1.0 – 1.2
Grossly abnormal <0.5
ABI Pitfalls
Does not measure collateral flow
Cannot confirm flow distal to probe
Interpret results in diabetics with caution
Neurological
Common LE neurological problems
DM neuropathy IM neuroma Tarsal tunnel
syndrome Nerve
impingement CVA
Neurological workup
PMH, ROS: Any potential causes of neuropathy? Diabetes mellitus Prior surgery
Nerve injury Medications Lower back problems CVA
Neurological workup
Personal History: Any potential causes of neuropathy? EtOH abuse Occupational exposures Chemotherapy HIV Elderly Many different causes
Where’s the neurological problem?
Local Regional Sensory Autonomic Motor-UMN vs. LMN
UMN vs. LMN
Upper Motor Neuron
Affects groups of muscles
Only slight atrophy Spasticity with
hyperreflexia No fasiculations Normal nerve
conduction studies
Lower Motor Neuron
Affects individual muscles
Atrophy Flaccidity,
hypotonia and hyporeflexia
Fasiculations Abnormal nerve
conduction studies
Neurological Physical Exam
Sensory examination Motor examination Sensory-motor examination Gait
Neuropathy Workup: Physical Exam
Compare right to left
Compare distal to proximal
Nerve injuries can be subtle
Sensory Examination
Depends on the subjective response of the patient
Focus your testing based on the HPI
Sensory Examination: Instruments
Safety pin
Semmes-Weinstein 10 gm
monofilament
Q-tip
128 Hz tuning fork
Paper clip
Sensory Examination
Vibratory Proprioception Pain Temperature Pressure (protective
sensation) 2 point
discrimination Light touch Percussion
Sensory Examination
For each sensory test, you should consider the following: Which nerve is being tested? Which dermatome is being tested? What spinal pathway is being used?
Sensory Examination: Dermatomes
Sensory Testing: Semmes-Weinstein Monofilament
Tests pressure sensation
Uses: R/o LOPS Map out
sensory deficit
Sensory Testing: Semmes-Weinstein Monofilament
Prerequisites Patient
understanding Non-callused
skin
Sensory Testing: Semmes-Weinstein Monofilament
Prerequisites Patient
understanding Non-callused
skin
Sensory Testing: Semmes-Weinstein Monofilament
Demonstrate that this won’t hurt
Sensory Testing: Semmes-Weinstein Monofilament
Show the patient what to expect
Sensory Testing: Semmes-Weinstein Monofilament
Start distally
Sensory Testing: Semmes-Weinstein Monofilament
Bend the filament, then release
Sensory Testing: Semmes-Weinstein Monofilament
Sensory Testing: Semmes-Weinstein Monofilament
Result interpretation
No LOPS if patient can feel distal medial and lateral plantar nerves.
LOPS is present if patient cannot feel distally
Sensory Examination : Vibratory
128Hz tuning fork
Uses: Check for early
signs of neuropathy
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Sensory Examination : Vibratory
Vibratory technique
Sensory Examination : Vibratory
Result interpretation Normal: Pt can state
when the vibration stops (within 5 seconds)
Abnormal: Vibration continues for 10 seconds after pt states the vibration has ended.
Sensory Examination: Vocabulary
Paresthesia: An abnormal sensation Anesthesia: Complete loss of sensation Hypoesthesia: Diminished sensation (aka
hypesthesia) Allodynia: Pain from a non-painful
stimulus Hyperpathia: Pain out of proportion to
the stimulus. Pain continues post-stimulation.
Sensory-Motor Examination: Reflexes
Sensory-Motor Examination: Reflexes
Deep Tendon Reflexes
Achilles
Patellar
Superficial ReflexesBabinskiChaddock (lateral foot)Oppenheim (shin)Gordon’s (gastrocnemius)Stransky’s (abduct 5th toe)
Sensory-Motor Examination: Reflexes
DTR Scoring0 No response
1+ Diminished
2+ Normal
3+ Increased
4+ Hyperactive
Sensory-Motor Examination: Achilles DTR
Sensory-Motor Examination: Achilles DTR
Incorrect Technique
Sensory-Motor Examination: Babinski
Dermatological
Dermatological Evaluation
Inspection
Palpation
Dermatological Evaluation
Palpation Temperature Turgor Texture Edema
Dermatological Evaluation
Inspection Skin color Hyperkeratoses Hydration Scaling Webspaces Toenails
Skin Temperature
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Skin Turgor
Skin Color: Dependent Rubor
Skin Color: Hyperpigmentation
Skin Color: Erythema
Edema
Describe this type of edema
One Hundred Dollar Edema
Hyperkeratoses
Hyperkeratoses: Corn
Heloma durum HD Excrescence Hyperkeratotic
papule Heloma molle
Hyperkeratoses: Callus
Keratoma Intractable Plantar
Keratosis (IPK) Tyloma
Corns & Calluses
Hydration: Xerosis
Tinea Pedis
Tinea Pedis
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Atrophic skin
Toenails: Onychomycosis
Toenails: Onychomycosis
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Toenails: Onychomycosis
Toenails: Onychomycosis
Onychogryphosis: Before
Onychogryphosis: and After
Toenails: Onychocryptosis
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Toenails: Onychocryptosis
Ingrown toenails
1 2
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Toenails: Clubbing
Interdigital Maceration
How to describe a lesion
Color Number Size Grouping (discrete, confluent, scattered…) Location Texture (smooth, waxy, weeping,
lichenified) Symptoms Shape
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Lesion shapes
Primary vs. Secondary Lesions
Primary lesions Arise from a
change in normal skin
Secondary lesions Arise from
changes to pre-existing pathology
Primary lesion: Macule
Primary lesion: Macule
Primary lesion: Papule
Primary lesion: Papule
Primary Lesion: Bulla
Primary Lesion: Nodule
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Secondary Lesion: Scale
Secondary Lesion: Fissure
Secondary Lesion: Ulcer
Secondary Lesion: Erosion
Malignant melanomaA = Asymmetry
B = Border
C = Color
D = Diameter
E = Enlarging
Algorithm for unknown lesions
Diagnostic groups
Musculoskeletal
Musculoskeletal Exam
Inspection Palpation Range of motion Motor strength Muscle tone WB and NWB
Motor Testing: Inspection
Inspection
Bony prominences Deformity Symmetry Wasting Fasiculations
Hallux Abducto Valgus
Hammertoes
Bunion
Motor testing: Range of motion
Ankle Joint ROM
STJ ROM
1st MPJ ROM
1st MPJ ROM with distraction
1st MPJ ROM with compression
Motor Testing: Muscle Tonus
Tonus (tone): The resistance felt when a limb is passively moved.
Tone can be hyper or hypo.
Motor Testing: Strength
For each muscle being tested, you should consider the following:
Which nerve innervates the muscle?
What nerve root is associated with the muscle movement?
Motor Testing: Nerve roots
Motor Testing: Innervation
Motor Testing: Strength
5 Full motor power
4 Active movement against some resistance
3 Weak contraction against gravity
2 Active movement w/o gravity
1 minimal contraction w/o joint movement
0 no contraction
Motor Testing: Strength (5)
Motor Testing: Strength (4)
Motor Testing: Strength (3)
Motor Testing: Strength (2)
Motor Testing: Other method
Gait Evaluation
Discussion
Appropriate referrals to the podiatry department
Handout for diabetic exam/referral What is a podiatric emergency? Annual diabetic exams
Determination of high risk versus low risk patients for ulceration and amputation
Podiatric Service
Elective surgery: bunion, hammertoe, arthroscopy, soft tissue mass excision Deformity correction: pes cavus, pes planus
Trauma: Fracture care Digits Metatarsals Ankle Talus Calcaneus
Podiatric Service
Urgent and prophylactic limb salvage surgery
Small procedures in clinic: nail avulsions, skin biopsy, injections
Thank You