amy splitter, dpm acmc division chief, division of podiatry assistant professor, california school...

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