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Podiatry essentials the basic foot exam

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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


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

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