History
All: treatments to date (PT, injections, orthotics), previous treating physicians, exact anatomic location of problem, exacerbating activities (when does it hurt), night pain, shoewear.
For injuries: mechanism, date, previous injuries to that area.
Metatarsalgia: pt feels like they are stepping on a marble/rock.
Radiating pain/numbness.
PMH
RA, DM, CAD, COPD, obesity, previous orthopedic injury
Meds
Especially anticoagulants, rheumatoid agents
Allergy
Social History
Tobacco products, employment (does job require standing)
FH
ROS
Physical Exam
All: neurovascular status, standing alignment of foot and/or ankle (pes planus, cavus, hindfoot varus [peek-a-boo heel], hindfoot valgus [too-many-toes sign], hallux valgus, hammertoes)
Swelling, ecchymosis
Gait
Ankle injury: TTP (peroneal tendons, PTT, med/lat malleolus, ant-med talar dome [OCD], base of 5th mt, sinus tarsi [lat process talus], deltoid ligament, ATFL/CFL/PTFL), alignment, active/passive ROM, strength, swelling, ecchymosis, erythema, open wounds, peroneal tendon subluxation, stability of ankle joint (anterior drawer and compare to opp side).
Heel pain: TTP exact location (medial plantar [PF origin, along PF], central plantar, posterior [Achilles tendon insertion, 2-3 cm proximal], ankle motion, swelling
Cavovarus foot: coleman block test (if corrects, varus is driven by 1st mt, if not varus is fixed through the heel)
PTTD: palpate PTT, not swelling, note pes planus, correctable or fixed, single (can they do it) and double limb (does hindfoot valgus correct) heel rises, hypermobility of 1st ray, DF with knee f/e, note forefoot abduction
Metatarsalgia: TTP directly under mt heads, increased pain with WB (especially barefoot), callosity under mt heads, prominent mt heads, note cascade of toes, hammertoes, hallux valgus
Mortons neuroma: TTP between mt heads (3-4 most common), shooting pain into toes with palpation, moulder’s test (lateral compression of all mt heads reproduces pain and numbness in affected area.
Bunion: medial prominence, severity of deformity MTP & IP, flexibility (correctibility) of deformity, is toe pronated/DF/PF, callous, axial grind test, ROM at MTP, hypermobility of 1st ray, associated ht, crossover toe
Radiographic exam (standing)
Ankle: alignment, bony abnormalities (fx, syndesmotic injury, OCD, arthritis, lat process talus)
Foot
Lateral: posterior heel ([Achilles tendonitis/tendinosis] calcification at Achilles tendon insertion, soft tissue swelling anterior to Achilles, [pf] calcification at pf origin), os trigonum, haglund’s deformity, talo-1st mt axis (pes planus/cavus), layering of mt (cavus), hammertoes.
AP: talo-1st mt axis (pes planus), look for accessory bones, tarsal coalition,1st mt should line up with med cuneiform and 2nd mt with mid cuneiform and distance btwn 1st & 2nd mt (lisfranc), measure HV angle, IMA, HV interphalangeus angle, DMAA, bunionette deformity, look for bony abnormalities (Jone’s fx).
Oblique: 3rd mt should line up with lat cuneiform and 4th mt with cuboid (lisfranc)
Plan:
Ankle injury: operative vs. non-operative (PT, lace-up ankle brace, rest, NSAID’s, immobilization, MRI if it has been going on for a while). If cavovarus foot, archrival orthotic (if corrects with coleman block, cavus foot can lead to increased pressure along the lateral border of the foot [stress fx, Jone’s fx]).
Heel pain (Achilles tendinosis, Achilles tendonitis, plantar fasciitis, central fat pad atrophy, lateral plantar nerve irritation): immobilize in boot if severe, stretching (handouts, 5 x/day), physical therapy, orthotics (heel cups [pf, cfpa], gel sleeves [Achilles]), 3/8” heel lift (Achilles), NSAID’s, night splints (pf), injections if no improvement in pf, surgical debridements if necessary (pf, Achilles [maffuli’s, open with or without FDL transfer], haglunds resection, resection of os trigonum).
PTTD: boot immobilization if severe, physical therapy, orthotics (arch supports, medial heel wedge, UCBL, Arizona brace), NSAID’s, operative (debridement, FDL transfer, lateral column lengthening, medial closing wedge osteotomy, fusion of 1st TMT joint, triple arthrodesis).
Arthritis: fusion, tendon interpositional arthroplasties, joint replacements, NSAID’s, orthotics (Arizona brace, etc).
Metatarsalgia: mt pads for shoes, wide toe box shoe, operative (mt head resection [RA], weil osteotomy)
Mortons neuroma (interdigital neuritis): wide toe-box shoes, mt pads, injection around nerve, operative (neuroma resection)
Bunion: wide toe-box shoes, when painful operate (PMO, Lapidus, Chevron osteotomy, 1st MTP fusion [RA], Ludloff osteotomy, Aiken osteotomy, distal soft tissue re-alignment, Keller resection [elderly])
1st MTP arthritis: steel shank or carbon fiber insert in shoe, operative (1st MTP fusion, cheilectomy, interpositional arthroplasty, joint replacement)
Hammer toe: budin splint, gel sleeve, operate (PIP arthroplasty, flexor-to-extensor transfers)