(A) Visual examination
1. Swelling of the ankle joint.
The common causes are ankle tendon injury, fracture, ankle tuberculosis, osteoarthritis and other causes of swelling.
2. Foot and ankle deformities.
(1) Horseshoe foot: when walking, the forefoot is on the ground with weight, the ankle joint is plantar flexed and the heel is hanging up.
(2) supinated toe foot: when walking, the foot follows the ground to bear weight, the ankle joint remains in the dorsal extension position, and the forefoot is supinated.
(3) In-turned foot: the sole of the foot is turned inward, and the lateral edge of the dorsum of the foot is on the ground when walking.
(4) Exostosis: the sole of the foot is turned outward, and the medial edge of the foot is on the ground when walking.
(5) flat foot: the longitudinal arch of the foot collapses and flattens, the heel is turned out, and the forefoot is abducted.
(6) high arch foot: the longitudinal arch of the foot is abnormally high, walking heel and metatarsal head on the ground.
3, toe deformity.
(1) Toe ectropion: outward deviation of the toes combined with inversion of the first metatarsal, widening of the gap between the first and second metatarsals, and often thickened bursa under the skin of the first metatarsal head, often accompanied by flat feet.
(2) Inversion of the toes: Inward deviation of the toes, rare.
(3) Claw-like toe: manifested by hyperextension of the metatarsophalangeal joint, flexion of the interphalangeal joint, and often callus on the back of the toe, with the second toe being the most common.
(4) Hammer toe: The main manifestation is the deformity of the proximal interphalangeal joint flexion.
(5) Overlapping little toe: congenital deformity, mostly bilateral, little toe over the 4th toe.
4.Toenail deformity.
(1) ingrown toenail: the edge of the toenail is embedded in the soft tissue when it grows.
(2) nail warts: caused by trauma or periostitis. Toenail warts can jack up the toe bone, gradually thicken the toenail, and worsen the pain.
(2) Motor examination.
1. Ankle dorsiflexion Ask the patient to sit on the side of the examination bed, with both knees flexed at 90° and both lower legs dangling, and ask the patient to make ankle dorsiflexion from a neutral position, which can reach 30° normally.
2. Plantar flexion of the ankle joint During the examination, the patient is asked to perform plantar flexion of the ankle joint in the same position as before. The patient is instructed to perform a plantarflexion of the ankle joint at 45°.
3.Heel talocrural joint inversion During the examination, the patient should be in the same position as before, and should be asked to perform inward turning movement of the foot, which can reach 30° normally.
4.Heel talocrural joint valgus In the same position as before, the patient is asked to perform valgus movement of the foot, and the normal valgus can reach 30°.
5.Internal and abduction of the intertarsal joint During the examination, the physician holds the patient’s heel with one hand to keep it in a neutral position. The other hand holds the anterior part of the patient’s foot and performs passive inversion and abduction activities, with a normal passive inversion activity of up to 2 degrees and a passive abduction activity of up to 10 degrees. There is no voluntary inward and outward motion of this joint in normal time.
6. Flexion and dorsiflexion of the first metatarsophalangeal joint The joint can be flexed up to 30-40° and dorsiflexed up to 45°.
7. Movement of the toes can be checked by passive activity.
(iii) Palpation.
1.Bone palpation Check the medial side first, the lth metatarsal head and the lth metatarsophalangeal joint, then check the navicular tuberosity along the inner edge of the foot proximally, and touch the talar head immediately proximal to the navicular bone of the foot. The medial talar nodes can be palpated behind the distal end of the medial ankle, noting any change in bone contour and whether there is tenderness.
Palpate the lateral side of the foot and palpate the 5th metatarsal ramus along the 5th metatarsal toward the proximal end to check for swelling and tenderness; examine the outer ankle and its anterior and inferior tarsal sinus, and palpate the neck of the talus by applying finger pressure to its deep part, and palpate for tenderness. At the proximal end of the talus, the lower tibiofibular joint was examined for separation.
In the posterior region of the foot, the heel bone is examined medially on the metatarsal surface of the heel, the medial heel node is palpated, and its bony contour is palpated, and the presence of pressure pain is noted.
When examining the metatarsal surface of the foot, examine the metatarsal heads one by one for any pressure pain. Pay attention to whether the transverse arch of the anterior part of the foot is normal.
2. Soft tissue palpation Palpate the medial side of the 1st metatarsophalangeal joint for skin thickening and bursa, and for tenderness. Palpate the medial collateral ligament of the ankle joint below the medial ankle, and palpate the posterior tibial tendon, long toe flexor tendon, posterior tibial artery, tibial nerve, ( ) long flexor tendon between the medial ankle and Achilles tendon, noting whether there is tenderness in the tendon and ligament, whether there is weakened pulsation in the artery, and whether there is tenderness and numbness in the nerve. The two sides were compared.
The anterior tibial tendon, the long extensor tendon, the dorsalis pedis artery, and the long extensor tendon were examined on the dorsal surface of the foot, noting the tension of the tendons, the presence of tenderness and defects, and the strength of the arterial pulsation.
On the anterior, inferior, and posterior aspects of the outer ankle, examine the anterior talofibular ligament, heel-fibular ligament, and posterior talofibular ligament for tenderness.
On the posterior aspect of the foot, examine the Achilles tendon for tenderness. The posterior Achilles bursa and Achilles tendon bursa were examined for localized thickening and tenderness.
Palpation of the plantar surface of the foot for nodularity and tenderness. If there is deformity of the toes, note the presence of callus and corns at the site of pressure and the presence of tenderness.
(iv) Special examination.
The patient lies prone with the foot hanging on the side of the examination bed, and the physician squeezes the triceps muscle of the patient’s calf with his hand, causing plantarflexion of the ankle as normal.
2.Ankle dorsiflexion test This test is to identify gastrocnemius and flounder muscle contracture. If the ankle joint cannot be dorsiflexed when the knee is extended or flexed, it means that the flounder muscle is contracted. If the ankle joint can be dorsiflexed when the knee is flexed and cannot be dorsiflexed when the knee is extended, it means that the gastrocnemius muscle is contracted.
3.Ankle extension test, also known as Homans test, is performed by asking the patient to straighten the calf and then forcefully dorsiflex the ankle joint. It suggests that there is deep vein thrombophlebitis in the lower leg.
4.Forefoot squeeze test The patient is in supine position, the doctor holds the patient’s forefoot with his hand and squeezes it laterally, if there is severe pain, it is a positive sign, suggesting a metatarsal fracture.
5.Heel axis measurement Patients in standing position, if the midline of the calf and the longitudinal axis of the heel are the same as normal, if the heel axis is skewed to the lateral or medial midline of the calf; indicates an inversion or valgus deformity of the foot.
6.Measurement of the long axis of the foot and the two ankle lines The patient is in the supine position, from the plantar surface of the foot, the long axis of the foot intersects with the two ankle lines, and the normal long axis of the foot is inclined to the tibial side by 5°, so the normal angle of the intersection of the two lines should be 95°. If the two lines intersect at right angles, that is, the forefoot abduction deformity.
7, foot index measurement foot flat on the table, from the highest foot to the distance of the table for the height of the arch; from the heel to the tip of the second toe length for the foot length.
Normal foot index = foot length / arch height × 100 ≈ 29 ~ 31 flat foot index less than 29, serious index below 25, high arch foot index greater than 3l.
8, the top angle of the foot measurement of the l metatarsal head, the inner ankle, the heel node three points connected into a triangle, the top angle of 95 ° is normal.
High arched foot top angle of about 60 °, flat foot top angle of 105-120 °. The bottom angle on the side of the heel bone is normally 60°, the flat foot is about 50-55°, and the high arched foot is about 65-70°.