Transcript Podiatry essentials the basic foot exam

Amy Splitter, DPM
ACMC Division Chief, Division of Podiatry
Assistant Professor, California School of
Podiatric Medicine at Samuel Merritt
University
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Four Basic Elements to lower extremity foot
exam
Vascular
 Neurological
 Dermatological
 Musculoskeletal
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How far can you
walk?
Major Risk Factors
 Tobacco
 Diabetes mellitus
 HTN
 Cardiac disease
 CVA
 Family history
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Skin color, temp
Skin thickness and
texture
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Digital hair
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Toenail condition
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Dorsalis pedis (DP)
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Posterior tibial (PT)
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Perforating
peroneal (PP)
6
Palpate here
EHL Tendon
7
Medial malleolus
Palpate here
Absent,
Diminished,
Palpable,
Bounding
vs.
1+, 2+, 3+, 4+
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The time it takes to
completely fill the
area of pallor
Normal:
<3
seconds
PAD: > 10 sec
1. Place foot at heart level
2. Squeeze blood from the
hallux
3. Observe time for blood
return
Common Errors
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Digit below heart
level
Residual venous
blood
Apply acoustic gel
Normal PT
Normal hallux artery
Abnormal DP
Vein
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Ankle
pressure/Brachial
pressure
Normal 1.0 – 1.2
Grossly abnormal
<0.5
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Does not measure
collateral flow
Cannot confirm
flow distal to probe
Interpret results in
diabetics with
caution
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DM neuropathy
IM neuroma
Tarsal tunnel
syndrome
Nerve
impingement
CVA
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PMH, ROS: Any potential causes of neuropathy?
 Diabetes mellitus
 Prior surgery
 Nerve injury
 Medications
 Lower back problems
 CVA

Personal History: Any potential causes of
neuropathy?
EtOH abuse
 Occupational exposures
 Chemotherapy
 HIV
 Elderly
 Many different causes
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Local
Regional
Sensory
Autonomic
Motor-UMN vs. LMN
Upper Motor Neuron
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Affects groups of
muscles
Only slight atrophy
Spasticity with
hyperreflexia
No fasiculations
Normal nerve
conduction studies
Lower Motor Neuron
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Affects individual
muscles
Atrophy
Flaccidity, hypotonia
and hyporeflexia
Fasiculations
Abnormal nerve
conduction studies
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Sensory examination
Motor examination
Sensory-motor examination
Gait
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Compare right to left
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Compare distal to proximal
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Nerve injuries can be subtle
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Depends on the subjective response of the
patient
Focus your testing based on the HPI
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Safety pin
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Semmes-Weinstein 10 gm monofilament
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Q-tip
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128 Hz tuning fork
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Paper clip
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Vibratory
Proprioception
Pain
Temperature
Pressure (protective
sensation)
2 point discrimination
Light touch
Percussion
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For each sensory test, you should consider
the following:
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Which nerve is being tested?
Which dermatome is being tested?
What spinal pathway is being used?
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Tests pressure
sensation
Uses:
 R/o LOPS
 Map out sensory
deficit
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Prerequisites
 Patient
understanding
 Non-callused skin
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Prerequisites
 Patient
understanding
 Non-callused skin
Demonstrate that this won’t hurt
Show the patient what to expect
Start distally
Bend the filament, then release
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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128Hz tuning fork
Uses:
 Check for early
signs of
neuropathy
Vibratory technique
53
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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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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.
Deep
Tendon Reflexes
Achilles
Patellar
Superficial
Reflexes

Babinski

Chaddock (lateral foot)
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Oppenheim (shin)
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Gordon’s (gastrocnemius)

Stransky’s (abduct 5th toe)
DTR Scoring
0
No response
1+
Diminished
2+
Normal
3+
Increased
4+
Hyperactive
Incorrect Technique
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Inspection
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Palpation
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Palpation
Temperature
Turgor
Texture
Edema
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Inspection
Skin color
Hyperkeratoses
Hydration
Scaling
Webspaces
Toenails
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Heloma durum
HD
Excrescence
Hyperkeratotic
papule
Heloma molle
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Keratoma
Intractable Plantar
Keratosis (IPK)
Tyloma
81
84
89
1
3
2
4
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Color
Number
Size
Grouping (discrete, confluent, scattered…)
Location
Texture (smooth, waxy, weeping, lichenified)
Symptoms
Shape
95
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Primary lesions
 Arise from a
change in normal
skin
Secondary lesions
 Arise from
changes to preexisting
pathology
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A = Asymmetry
B = Border
C = Color
D = Diameter
E = Enlarging
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Inspection
Palpation
Range of motion
Motor strength
Muscle tone
WB and NWB
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Bony prominences
Deformity
Symmetry
Wasting
Fasiculations
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Tonus (tone): The
resistance felt
when a limb is
passively moved.
Tone can be hyper
or hypo.
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For each muscle being tested, you should
consider the following:

Which nerve innervates the muscle?
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What nerve root is associated with the muscle
movement?
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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Appropriate referrals to the podiatry
department
Handout for diabetic exam/referral
What is a podiatric emergency?
Annual diabetic exams
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Determination of high risk versus low risk patients
for ulceration and amputation
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Elective surgery: bunion, hammertoe,
arthroscopy, soft tissue mass excision
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Deformity correction: pes cavus, pes planus
Trauma: Fracture care
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Digits
Metatarsals
Ankle
Talus
Calcaneus
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Urgent and prophylactic limb salvage surgery
Small procedures in clinic: nail avulsions, skin
biopsy, injections