1. 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

2. Introduction Four Basic Elements to lower extremity foot exam Vascular
Neurological
Dermatological
Musculoskeletal

3. Vascular

4. The vascular history How far can you walk? Major Risk Factors Tobacco
Diabetes mellitus
HTN
Cardiac disease
CVA
Family history

5. Vascular evaluation: inspection
Skin color, temp
Skin thickness and texture
Digital hair
Toenail condition

6. Pedal Pulses Dorsalis pedis (DP) Posterior tibial (PT)
Perforating peroneal (PP)

7. Dorsalis pedis pulse
Palpate here
EHL Tendon

8. Dorsalis pedis pulse

9. Posterior tibial pulse
Medial malleolus
Palpate here

10. Posterior tibial pulse

11. Perforating peroneal pulse

12. Perforating peroneal pulse

13. Popliteal pulse

14. Popliteal pulse

15. Quantifying pedal pulses
Absent, Diminished, Palpable, Bounding
vs.
1+, 2+, 3+, 4+

16. Capillary Refill (SPVPFT)
The time it takes to completely fill the area of pallor
Normal: < 3 seconds
PAD: > 10 sec

17. Capillary refill technique
1. Place foot at heart level

18. Capillary refill technique
2. Squeeze blood from the hallux

19. Capillary refill technique

20. Capillary refill technique
3. Observe time for blood return

21. Capillary Refill (SPVPFT)
Common Errors
Digit below heart level
Residual venous blood

22. Doppler

23. Doppler technique

24. Doppler technique
Apply acoustic gel

25. Doppler Sounds
Normal PT
Abnormal DP
Normal hallux artery
Vein

26. Artery vs. Vein

27. Ankle Brachial Index

28. ABI Interpretation Ankle pressure/Brachial pressure Normal 1.0 – 1.2
Grossly abnormal <0.5

29. ABI Pitfalls Does not measure collateral flow
Cannot confirm flow distal to probe
Interpret results in diabetics with caution
Other diseases that may also have calcification deposition include: DM, chronic kidney disease, systemic lupus, chronic inflammatory conditions.

30. Neurological

31. Common LE neurological problems
DM neuropathy
IM neuroma
Tarsal tunnel syndrome
Nerve impingement
CVA

32. Neurological workup PMH, ROS: Any potential causes of neuropathy?
Diabetes mellitus
Prior surgery
Nerve injury
Medications
Lower back problems
CVA

33. Neurological workup
Personal History: Any potential causes of neuropathy?
EtOH abuse
Occupational exposures
Chemotherapy
HIV
Elderly
Many different causes
Also B12 deficiency.

34. Where’s the neurological problem?
Local
Regional
Sensory
Autonomic
Motor-UMN vs. LMN

35. UMN vs. LMN Upper Motor Neuron Lower 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

36. Neurological Physical Exam
Sensory examination
Motor examination
Sensory-motor examination
Gait

37. Neuropathy Workup: Physical Exam
Compare right to left
Compare distal to proximal
Nerve injuries can be subtle

38. Sensory Examination Depends on the subjective response of the patient
Focus your testing based on the HPI

39. Sensory Examination: Instruments
Safety pin
Semmes-Weinstein 10 gm monofilament
Q-tip
128 Hz tuning fork
Paper clip

40. Sensory Examination Vibratory Proprioception Pain Temperature
Pressure (protective sensation)
2 point discrimination
Light touch
Percussion

41. 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?

42. Sensory Examination: Dermatomes

43. Sensory Testing: Semmes-Weinstein Monofilament
Tests pressure sensation
Uses:
R/o LOPS
Map out sensory deficit

44. Sensory Testing: Semmes-Weinstein Monofilament
Prerequisites
Patient understanding
Non-callused skin

45. Sensory Testing: Semmes-Weinstein Monofilament
Prerequisites
Patient understanding
Non-callused skin

46. Sensory Testing: Semmes-Weinstein Monofilament
Demonstrate that this won’t hurt

47. Sensory Testing: Semmes-Weinstein Monofilament
Show the patient what to expect

48. Sensory Testing: Semmes-Weinstein Monofilament
Start distally

49. Sensory Testing: Semmes-Weinstein Monofilament
Bend the filament, then release

50. Sensory Testing: Semmes-Weinstein Monofilament

51. 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

52. Sensory Examination : Vibratory
128Hz tuning fork
Uses:
Check for early signs of neuropathy

53. Sensory Examination : Vibratory
Vibratory technique

54. 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.

55. 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.

56. Sensory-Motor Examination: Reflexes

57. Sensory-Motor Examination: Reflexes
Deep Tendon Reflexes
Achilles
Patellar
Superficial Reflexes
Babinski
Chaddock (lateral foot)
Oppenheim (shin)
Gordon’s (gastrocnemius)
Stransky’s (abduct 5th toe)

58. Sensory-Motor Examination: Reflexes
DTR Scoring
0 No response
1+ Diminished
2+ Normal
3+ Increased
4+ Hyperactive

59. Sensory-Motor Examination: Achilles DTR

60. Sensory-Motor Examination: Achilles DTR
Incorrect Technique

61. Sensory-Motor Examination: Babinski

62. Dermatological

63. Dermatological Evaluation
Inspection
Palpation

64. Dermatological Evaluation
Palpation
Temperature
Turgor
Texture
Edema

65. Dermatological Evaluation
Inspection
Skin color
Hyperkeratoses
Hydration
Scaling
Webspaces
Toenails

66. Skin Temperature

67. Skin Turgor

68. Skin Color: Dependent Rubor

69. Skin Color: Hyperpigmentation

70. Skin Color: Erythema

71. Edema

72. Describe this type of edema

73. One Hundred Dollar Edema

74. Hyperkeratoses

75. Hyperkeratoses: Corn Heloma durum HD Excrescence Hyperkeratotic papule
Heloma molle

76. Hyperkeratoses: Callus
Keratoma
Intractable Plantar Keratosis (IPK)
Tyloma

77. Corns & Calluses

78. Hydration: Xerosis

79. Tinea Pedis

80. Tinea Pedis

81. Atrophic skin

82. Toenails: Onychomycosis

83. Toenails: Onychomycosis

84. Toenails: Onychomycosis

85. Toenails: Onychomycosis

86. Onychogryphosis: Before

87. Onychogryphosis: and After

88. Toenails: Onychocryptosis

89. Toenails: Onychocryptosis

90. Ingrown toenails 2 1 3 4

92. Toenails: Clubbing
Degree between the proximal nail fold and nail normally less than 165 degrees. Associated with lung disease: lung cancer, complicated tuberculosis, lung abscess, cystic fibrosis

93. Interdigital Maceration

94. How to describe a lesion
Color
Number
Size
Grouping (discrete, confluent, scattered…)
Location
Texture (smooth, waxy, weeping, lichenified)
Symptoms
Shape

95. Lesion shapes

96. Primary vs. Secondary Lesions
Primary lesions
Arise from a change in normal skin
Secondary lesions
Arise from changes to pre-existing pathology

97. Primary lesion: Macule

98. Primary lesion: Macule

99. Primary lesion: Papule

100. Primary lesion: Papule

101. Primary Lesion: Bulla

102. Primary Lesion: Nodule

103. Secondary Lesion: Scale

104. Secondary Lesion: Fissure

105. Secondary Lesion: Ulcer

106. Secondary Lesion: Erosion

107. Malignant melanoma A = Asymmetry B = Border C = Color D = Diameter
E = Enlarging

108. Algorithm for unknown lesions

109. Diagnostic groups

110. Musculoskeletal

111. Musculoskeletal Exam Inspection Palpation Range of motion
Motor strength
Muscle tone
WB and NWB

112. Motor Testing: Inspection

113. Inspection
Bony prominences
Deformity
Symmetry
Wasting
Fasiculations

114. Hallux Abducto Valgus

115. Hammertoes

116. Bunion

117. Motor testing: Range of motion

118. Ankle Joint ROM

119. STJ ROM

120. 1st MPJ ROM

121. 1st MPJ ROM with distraction

122. 1st MPJ ROM with compression

123. Motor Testing: Muscle Tonus
Tonus (tone): The resistance felt when a limb is passively moved.
Tone can be hyper or hypo.

124. 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?

125. Motor Testing: Nerve roots

126. Motor Testing: Innervation

127. 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

128. Motor Testing: Strength (5)

129. Motor Testing: Strength (4)

130. Motor Testing: Strength (3)

131. Motor Testing: Strength (2)

132. Motor Testing: Other method

133. Gait Evaluation

134. 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

135. 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

136. Podiatric Service Urgent and prophylactic limb salvage surgery
Small procedures in clinic: nail avulsions, skin biopsy, injections

137. Thank You