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Normal arch

Cavus foot

Flat foot

Figure 20-49 Common foot abnormalities.

Test the range of motion at the subtalar joint, which includes eversion and inversion. With the patient lying prone on the examination table, hold the patient's leg in one of your hands, and move the heel with your other hand into inversion and eversion. Measure the excursion of the heel with regard to the bisection of the lower one third of the leg. This technique is illustrated in Figure 20-50. The average range of motion of the subtalar joint is 20° of inversion and 10° of eversion.

Test the range of motion at the midtarsal joint, which includes eversion and inversion. With the patient in the prone position, stabilize the heel with one of your hands, and rotate the forefoot into inversion and eversion. Measure excursion of the plane of the metatarsal heads with regard to the bisection of the heel. This technique is illustrated in Figure 20-51.

The movements of the metatarsophalangeal joints are tested individually. Palpate the head of each metatarsal and the base of each proximal phalanx, as well as the groove between them. Is tenderness or joint effusion present?

The Achilles tendon, which is the combined tendon of the gastrocnemius and soleus muscles, may rupture. You can test for its integrity by direct observation and having the patient jump up and down on the balls of the feet or walk on the toes. Another test for its integrity is known as the Thompson-Doherty squeeze test. This test is performed by squeezing the calf while you observe the motion of the foot. Normally, squeezing produces plantar flexion;a ruptured tendon produces little or no motion. When examining the tendon for continuity, remember that the most common place for rupture is approximately 1 to 2 inches (2.5 to 5.0 cm)

Figure 20-50 Evaluating the range of motion at the subtalar joint.

proximal to its insertion on the calcaneus. This lies within a region of poorest blood supply that is often referred to as the ''watershed area.''

Describe abnormalities of the joints, including hallux abductovalgus (bunion), and deformities and flexion contractures of the lower digits (hammer toes). Figure 20-52 shows hallux abductovalgus deformity, flexion contractures of the interphalangeal joints, and bowstringing of the extensor tendons. This is a typical presentation in the geriatric age group. Note the hyperkeratotic lesion over the right bunion from shoe pressure.

Palpate the soft tissue over the first metatarsophalangeal joint. Is bursal inflammation caused by pressure, friction, or urate deposition? Measure the range of motion of the joint. Dorsiflexion of the hallux is measured against the bisection of the first metatarsal. The normal dorsal range of motion is 65° to 75°. Limitation of motion of this joint is termed hallux limitus and is most commonly caused by osteoarthritis.

Bunion deformities can be a source of undue pressure in diabetic patients, leading to ulceration and infection. A large pressure ulceration over the medial eminence of the first metatarsophalangeal joint resulting from shoe irritation in a diabetic patient is shown in Figure 20-53.

Figure 20-54 depicts ulceration over the distal interphalangeal joint of the fourth toe of a patient with chronic tophaceous gout. Note the bunion deformity and underlapping hallux. An acute attack of gout commonly manifests with severe pain, swelling, and inflammation in the first metatarsophalangeal joint, a condition termed podagra. Podagra in a patient with acute gout is pictured in Figure 20-55. Notice the erythema of the left hallux and the generalized swelling of the left foot.

Examine the lesser metatarsophalangeal joints. Grasp the metatarsophalangeal joints between your thumb and index finger, and attempt to compress the forefoot. Pain elicited by this maneuver is often an early sign of rheumatoid arthritis. This test is demonstrated in Figure 20-56.

Figure 20-53 Hallux abductovalgus deformity and ulceration.

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