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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
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Introduction
Four Basic Elements to lower extremity foot exam Vascular Neurological Dermatological Musculoskeletal
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Vascular
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The vascular history
How far can you walk?
Major Risk Factors Tobacco Diabetes mellitus HTN Cardiac disease CVA Family history
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Vascular evaluation: inspection
Skin color, temp Skin thickness and
texture
Digital hair
Toenail condition
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6
Pedal Pulses
Dorsalis pedis (DP)
Posterior tibial (PT)
Perforating peroneal (PP)
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7
Dorsalis pedis pulse
EHL Tendon
Palpate here
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Dorsalis pedis pulse
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Posterior tibial pulse
Palpate here
Medial malleolus
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Posterior tibial pulse
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Perforating peroneal pulse
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Perforating peroneal pulse
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Popliteal pulse
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Popliteal pulse
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Quantifying pedal pulses
Absent, Diminished, Palpable, Bounding
vs.
1+, 2+, 3+, 4+
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Capillary Refill (SPVPFT)
The time it takes to completely fill the area of pallor
Normal: < 3 seconds
PAD: > 10 sec
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Capillary refill technique
1. Place foot at heart level
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Capillary refill technique
2. Squeeze blood from the hallux
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Capillary refill technique
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Capillary refill technique
3. Observe time for blood return
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Capillary Refill (SPVPFT)
Common Errors
Digit below heart level
Residual venous blood
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Doppler
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Doppler technique
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Doppler technique
Apply acoustic gel
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Doppler Sounds
Normal PT
Normal hallux artery
Abnormal DP
Vein
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Artery vs. Vein
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Ankle Brachial Index
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ABI Interpretation
Ankle pressure/Brachial pressure
Normal 1.0 – 1.2
Grossly abnormal <0.5
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ABI Pitfalls
Does not measure collateral flow
Cannot confirm flow distal to probe
Interpret results in diabetics with caution
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Neurological
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Common LE neurological problems
DM neuropathy IM neuroma Tarsal tunnel
syndrome Nerve
impingement CVA
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Neurological workup
PMH, ROS: Any potential causes of neuropathy? Diabetes mellitus Prior surgery
Nerve injury Medications Lower back problems CVA
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Neurological workup
Personal History: Any potential causes of neuropathy? EtOH abuse Occupational exposures Chemotherapy HIV Elderly Many different causes
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Where’s the neurological problem?
Local Regional Sensory Autonomic Motor-UMN vs. LMN
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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
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Neurological Physical Exam
Sensory examination Motor examination Sensory-motor examination Gait
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Neuropathy Workup: Physical Exam
Compare right to left
Compare distal to proximal
Nerve injuries can be subtle
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Sensory Examination
Depends on the subjective response of the patient
Focus your testing based on the HPI
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Sensory Examination: Instruments
Safety pin
Semmes-Weinstein 10 gm
monofilament
Q-tip
128 Hz tuning fork
Paper clip
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Sensory Examination
Vibratory Proprioception Pain Temperature Pressure (protective
sensation) 2 point
discrimination Light touch Percussion
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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?
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Sensory Examination: Dermatomes
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Sensory Testing: Semmes-Weinstein Monofilament
Tests pressure sensation
Uses: R/o LOPS Map out
sensory deficit
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Sensory Testing: Semmes-Weinstein Monofilament
Prerequisites Patient
understanding Non-callused
skin
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Sensory Testing: Semmes-Weinstein Monofilament
Prerequisites Patient
understanding Non-callused
skin
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Sensory Testing: Semmes-Weinstein Monofilament
Demonstrate that this won’t hurt
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Sensory Testing: Semmes-Weinstein Monofilament
Show the patient what to expect
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Sensory Testing: Semmes-Weinstein Monofilament
Start distally
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Sensory Testing: Semmes-Weinstein Monofilament
Bend the filament, then release
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Sensory Testing: Semmes-Weinstein Monofilament
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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
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Sensory Examination : Vibratory
128Hz tuning fork
Uses: Check for early
signs of neuropathy
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53
Sensory Examination : Vibratory
Vibratory technique
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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.
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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.
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Sensory-Motor Examination: Reflexes
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Sensory-Motor Examination: Reflexes
Deep Tendon Reflexes
Achilles
Patellar
Superficial ReflexesBabinskiChaddock (lateral foot)Oppenheim (shin)Gordon’s (gastrocnemius)Stransky’s (abduct 5th toe)
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Sensory-Motor Examination: Reflexes
DTR Scoring0 No response
1+ Diminished
2+ Normal
3+ Increased
4+ Hyperactive
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Sensory-Motor Examination: Achilles DTR
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Sensory-Motor Examination: Achilles DTR
Incorrect Technique
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Sensory-Motor Examination: Babinski
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Dermatological
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Dermatological Evaluation
Inspection
Palpation
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Dermatological Evaluation
Palpation Temperature Turgor Texture Edema
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Dermatological Evaluation
Inspection Skin color Hyperkeratoses Hydration Scaling Webspaces Toenails
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Skin Temperature
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67
Skin Turgor
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Skin Color: Dependent Rubor
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Skin Color: Hyperpigmentation
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Skin Color: Erythema
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Edema
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Describe this type of edema
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One Hundred Dollar Edema
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Hyperkeratoses
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Hyperkeratoses: Corn
Heloma durum HD Excrescence Hyperkeratotic
papule Heloma molle
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Hyperkeratoses: Callus
Keratoma Intractable Plantar
Keratosis (IPK) Tyloma
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Corns & Calluses
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Hydration: Xerosis
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Tinea Pedis
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Tinea Pedis
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Atrophic skin
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Toenails: Onychomycosis
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Toenails: Onychomycosis
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Toenails: Onychomycosis
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Toenails: Onychomycosis
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Onychogryphosis: Before
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Onychogryphosis: and After
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Toenails: Onychocryptosis
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Toenails: Onychocryptosis
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Ingrown toenails
1 2
34
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Toenails: Clubbing
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Interdigital Maceration
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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
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Primary vs. Secondary Lesions
Primary lesions Arise from a
change in normal skin
Secondary lesions Arise from
changes to pre-existing pathology
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Primary lesion: Macule
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Primary lesion: Macule
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Primary lesion: Papule
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Primary lesion: Papule
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Primary Lesion: Bulla
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Primary Lesion: Nodule
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Secondary Lesion: Scale
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Secondary Lesion: Fissure
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Secondary Lesion: Ulcer
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Secondary Lesion: Erosion
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Malignant melanomaA = Asymmetry
B = Border
C = Color
D = Diameter
E = Enlarging
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Algorithm for unknown lesions
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Diagnostic groups
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Musculoskeletal
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Musculoskeletal Exam
Inspection Palpation Range of motion Motor strength Muscle tone WB and NWB
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Motor Testing: Inspection
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Inspection
Bony prominences Deformity Symmetry Wasting Fasiculations
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Hallux Abducto Valgus
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Hammertoes
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Bunion
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Motor testing: Range of motion
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Ankle Joint ROM
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STJ ROM
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1st MPJ ROM
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1st MPJ ROM with distraction
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1st MPJ ROM with compression
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Motor Testing: Muscle Tonus
Tonus (tone): The resistance felt when a limb is passively moved.
Tone can be hyper or hypo.
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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?
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Motor Testing: Nerve roots
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Motor Testing: Innervation
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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
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Motor Testing: Strength (5)
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Motor Testing: Strength (4)
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Motor Testing: Strength (3)
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Motor Testing: Strength (2)
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Motor Testing: Other method
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Gait Evaluation
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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
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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
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Podiatric Service
Urgent and prophylactic limb salvage surgery
Small procedures in clinic: nail avulsions, skin biopsy, injections
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Thank You