With the patient in a standing position, the examiner should observe whether the patient’s hips and trunk are in normal position. Excessive lateral rotation of the hip or rotation of the trunk away from the opposite hip elevates the medial longitudinal arch of the foot, whereas medial rotation of the hip or trunk rotation toward the opposite hip tends to flatten the arch (Figure 13-7). Medial rotation of the hip can also cause pigeon toes, which is a condition more commonly associated with medial tibial torsion or rotation. If the iliotibial band is tight, the tightness may cause eversion and lateral rotation of the foot.

The examiner should also look at the tibia to note any local or general bone swelling (Figure 13-8). Does the tibia have a normal shape, or is it bowed? Is there any torsional deformity? The medial malleolus usually lies anterior to the lateral malleolus. Pigeon toes, or toe-in deformity, result from a medial tibial torsion deformity; it does not constitute a foot deformity (Table 13-2).

Figure 13-9 shows the anterosuperior view of the feet in the weight-bearing stance. The examiner should note whether there is any asymmetry, malalignment (Table 13-3), or excessive supination or pronation of the foot. Supination of the foot involves inversion and outward rotation of the heel, adduction of the forefoot with inward rotation at the tarsometatarsal joints to maintain contact with the ground and outward rotation at the midtarsal joints, and plantar flexion at the subtalar joint and midtarsal joints so that the medial longitudinal arch is accentuated (Figure 13-10, A). In addition, along with lateral rotation of the talus, there is lateral rotation of the leg in relation to the foot (Figure 13-11). Supination of the foot causes the proximal aspect of the tibia to move posteriorly. It is required during propulsion to give rigidity to the foot and requires less muscle work than pronation.

Pronation of the foot involves eversion and inward rotation of the heel, abduction of the forefoot with outward rotation at the tarsometatarsal joints and inward rotation at the midtarsal joints, and medial rotation of the talus causing medial rotation of the leg in relation to the foot, and dorsiflexion of the subtalar and midtarsal joints (Figure 13-12), resulting in a decrease in the medial longitudinal arch (Figure 13-10, B). This movement causes the proximal aspect of the tibia to move anteriorly. The pronated foot has greater subtalar motion than the supinated foot and requires more muscle work to maintain stance stability than the supinated foot. The foot is much more mobile in this position.

The definitions used in this chapter are the ones preferred by orthopedists and podiatrists. Anatomists and kinesiologists, such as Kapandji, refer to inversion as a combination of adduction and supination and to eversion as a combination of abduction and pronation.²⁷ Lipscomb and Ibrahim²⁸ and Williams and Warwick²⁹ have defined supination and pronation as opposite the terms just mentioned. Because of the confusion in terminology concerning the terms supination and pronation, readers of books and articles on the foot must be careful to discern exactly what each author means.

In the infant, the foot is normally pronated. As the child matures, the foot begins to supinate, accompanied by development of the medial longitudinal arch. The foot also appears to be more pronated in the infant because of the fat pad in the medial longitudinal arch.

The examiner should note how the patient stands and walks. Normally, in standing, 50% to 60% of the weight is taken on the heel and 40% to 50% is taken by the metatarsal heads. The foot assumes a slight toe-out position. This angle (the Fick angle) is approximately 12° to 18° from the sagittal axis of the body, developing from 5° in children (Figure 13-13).³⁰ Asymmetrical or excessive lateral rotation of the foot may be due to acetabular retroversion, femoral retrotorsion or femoral head neck abnormalities³¹ (see Chapter 11). During movement, the foot is subjected to high loading, and pathology may cause the gait to be altered. The cumulative force to which each foot is subjected during the day is the equivalent of 639 metric tons in a person who weighs approximately 90 kg, or the equivalent of walking 13 km per day.

When weight-bearing, if the relation of the foot to the ankle is normal, all of the metatarsal bones bear weight, and all of the metatarsal heads lie in the same transverse plane. The forefoot and hindfoot should be parallel to each other and to the floor. The midtarsal joints are in maximum pronation, and the subtalar joint is in neutral position. The subtalar and talocrural joints should be parallel to the floor. Finally, the posterior bisection of the calcaneus and distal one third of the leg should form two vertical, parallel lines.³²

If the examiner has noted any asymmetry in standing, the examiner should place the talus (or foot) in neutral (see the “Special Tests” section) to see if the asymmetry disappears. If the asymmetry is present in normal standing, it is a functional asymmetry. If it is still present when the foot is in neutral, it is also an anatomical or structural asymmetry, in which case a structural deformity is probably causing the asymmetry. Leg-heel and forefoot-heel alignment (see the “Special Tests” section) may also be checked, especially if asymmetry is present.

The examiner should note whether the patient uses a cane or other walking aid. Use of a cane in the opposite hand diminishes the stress on the ankle joint and foot by approximately one third.

Any prominent bumps or exostoses should be noted, as should any splaying (widening) of the forefoot. Splaying of the forefoot and metatarsus primus varus is more evident in weight-bearing. There are three types of forefoot,³³ based on the length of the metatarsal bones (Figure 13-14):

The examiner should note whether the toenails appear normal. Older individuals have more brittle nails. The examiner should look for warts, calluses, and corns. Warts are especially tender to the pinch (but not to direct pressure), but calluses are not. Plantar warts also tend to separate from the surrounding tissues, but calluses do not. Corns are similar to calluses but have a central nidus. They may be hard (on outside or upper aspect of toes) or soft (between toes) because of moisture.

Any swelling or pitting edema within the Achilles tendon, ankle, and foot should be noted (Figure 13-16). If there is any swelling, the examiner should note whether it is intracapsular or extracapsular. Swelling above the lateral malleolus may be related to a fibular fracture or disruption of the syndesmosis (“high” ankle sprain).^34,35 This injury takes a long time to heal and may involve the anterior and/or posterior tibiofibular ligament as well as the ligaments of the talocrural joint. Swelling posterior to the lateral malleolus may indicate peroneal retinacular injury. Lateral ankle sprains initially swell distal to the lateral malleolus, but swelling may spread into the foot if the capsule has been torn (Table 13-4).¹⁴ The examiner should also check the patient’s gait for the position of the foot at heel strike, at foot flat, and at toe off. The gait cycle is described in greater detail in Chapter 14.

Any vasomotor changes should be recorded, including loss of hair on the foot, toenail changes, osteoporosis as seen on radiographs, and possible differences in temperature between the limbs. Systemic diseases such as diabetes can also lead to foot problems as a result of altered sensation, which facilitates injury.

The examiner should look for any circulatory impairment or presence of varicose veins. Brick-red color or cyanosis when the limb is dependent is an indication of impairment. Does this condition change to rapid blanching, or does it stay normal on elevation of the limbs? Change indicates circulatory impairment.

From behind, the examiner compares the bulk of the calf muscles and notes any differences. Variation may be caused by peripheral nerve lesions, nerve root problems, or atrophy resulting from disuse after injury. The Achilles tendons on each side should be compared (see Figure 13-16, F). If a tendon appears to curve out (Figure 13-17), it may indicate a fallen medial longitudinal arch, resulting in a pes planus (flatfoot) condition (Helbing sign).³⁶

The examiner observes the calcaneus for normality of shape and position. Runners often build up bone and a callus on the heel, producing a “pump bump” (Haglund disease or deformity) as a result of pressure on the heel (Figure 13-18).^37–39

The malleoli are compared for positioning. Normally, the lateral malleolus extends farther distally than the medial malleolus; however, the medial malleolus extends farther anteriorly.

With the side view, the examiner is primarily observing the longitudinal arches of the foot (Figure 13-19). The examiner should note whether the medial arch is higher than the lateral arch (as would be expected). Differences in the arches may often be determined by looking at the footprint patterns (Figure 13-20). The footprint pattern can be established by putting a light film of baby oil and then powder on the patient’s foot and asking the patient to step down on a piece of colored paper.

The arches of the feet (Figure 13-21) are maintained by three mechanisms⁴⁰: (1) wedging of the interlocking tarsal and metatarsal bones; (2) tightening of the ligaments on the plantar aspect of the foot; and (3) the intrinsic and extrinsic muscles of the foot and their tendons, which help to support the arches. The longitudinal arches form a cone as a result of the angle of the metatarsal bones in relation to the floor. With the medial longitudinal arch being more evident, this angle is greater on the medial side. The angle formed by each of the metatarsals with the floor is shown in Figure 13-22.

The medial longitudinal arch consists of the calcaneal tuberosity, the talus, the navicular, three cuneiforms, and the first, second, and third metatarsal bones (Figures 13-23 and 13-24). This arch is maintained by the tibialis anterior, tibialis posterior, flexor digitorum longus, flexor hallucis longus, abductor hallucis, and flexor digitorum brevis muscles; the plantar fascia or aponeurosis; and the plantar calcaneonavicular ligament. The plantar aponeurosis plays a major role during the stance and push-off phases of gait, which helps to distribute Achilles tendon forces under the forefoot to the metatarsal heads and phalanges.⁴¹

The calcaneus, cuboid, and fourth and fifth metatarsal bones make up the lateral longitudinal arch (Figure 13-25). This arch is more stable and less adjustable than the medial longitudinal arch. The arch is maintained by the peroneus longus, peroneus brevis, peroneus tertius, abductor digiti minimi, and flexor digitorum brevis muscles; the plantar fascia; the long plantar ligament; and the short plantar ligament.⁴⁰

The transverse arch is maintained by the tibialis posterior, tibialis anterior, and peroneus longus muscles and the plantar fascia (Figure 13-26). This arch consists of the navicular, cuneiforms, cuboid, and metatarsal bones. The arch is sometimes divided into three parts: tarsal, posterior metatarsal, and anterior metatarsal. A loss of the anterior metatarsal arch results in callus formation under the heads of the metatarsal bones (especially the second and third metatarsal heads). The metatarsophalangeal joints are slightly extended when the patient is in the normal standing position because the longitudinal arches of the foot curve down toward the toes.⁴⁰

With the patient in a supine, non–weight-bearing position, the examiner should look for abnormalities, such as callosities, plantar warts, scars, and sinuses or pressure sores on the soles of the feet, as well as swelling, which is more prominent on the dorsum of the foot. In addition, by looking at the foot from anterior to posterior, as shown in Figure 13-27, the examiner can observe whether the patient has a “fallen” metatarsal arch. Normally, in the non–weight-bearing position, the arch is visible. If the arch falls, callosities are often found over the metatarsal heads. The arch may be reversed, or it may fall because of an equinus forefoot, pes cavus, rheumatoid arthritis, short heel cord, or hammertoes. Abnormal width of one ankle in relation to the other (Keen sign) may be caused by swelling, loss of integrity of the syndesmosis, or a malleolar fracture.

Young children should be assessed for clubfoot deformities, the most common of which is talipes equinovarus (Figures 13-28 and 13-29; Table 13-5). These types of deformities are often associated with other anomalies, such as spina bifida.

The examiner looks at the patient’s shoes, both inside and outside, for weight-bearing and wear patterns (Figures 13-46 and 13-47). With the normal foot, the greatest wear on the shoe is beneath the ball of the foot and slightly to the lateral side and the posterolateral aspect of the heel. If shoes are too small or too narrow, they may pinch the feet, causing deformities and affecting normal growth. If shoes are worn out, they offer little support. If shoes are stiff, they limit proper movement of the foot.

Platform-type or high-heeled shoes often cause painful knees, because the patient wearing these shoes usually walks with the knees flexed, which may increase the stress on the patella. Continuous wearing of high-heeled shoes may cause the calf muscles to contract and may lead to sore knees and a painful back, because the lumbar spine goes into increased lordotic posture to maintain the center of gravity in its normal position. In addition, these shoes increase the potential for ankle sprains and fractures because a raised center of gravity puts the wearer off balance.

High-heeled and pointed shoes often contribute to hallux valgus, bunions, march fractures, and Morton’s metatarsalgia that may result because the toes are being pushed together. Shoes with a negative heel may lead to hyperextension of the knees and patellofemoral syndrome. High-cut or high-top shoes that cover the medial and lateral malleoli offer more support than low-cut shoes or those that do not cover the malleoli.

Excessive bulging on the medial side of the shoe suggests a valgus or everted foot, whereas excessive bulging on the lateral side suggests an inverted foot. Drop foot resulting from musculature weakness scuffs the toe of the shoe. Oblique forefoot creases in the shoe indicate possible hallux rigidus; absence of forefoot creases indicates no toe-off action during gait.

Plantar flexion of the ankle is approximately 50° (see Figure 13-50, A), and the patient’s heel normally inverts when the movement is performed in weight bearing (Figure 13-51). If heel inversion does not occur, the foot is unstable, or there is tibialis posterior weakness or tightness.^37,65,66 The tibialis posterior muscle and tendon balance the pull of the peroneal muscles, protect the spring ligament, and invert and stabilize the hindfoot during toe off.⁶⁷ Pain in the spring ligament as well as the medial midfoot and hindfoot ligaments, hindfoot valgus, plantar flexed talar head, and forefoot abduction should lead the examiner to assessing the tibialis posterior for proper function.³⁷

Dorsiflexion of the ankle is usually 20° past the anatomical position (plantigrade), which is with the foot at 90° to the bones of the leg (see Figure 13-50, B). For normal locomotion, 10° of dorsiflexion and 20° to 25° of plantar flexion at the ankle are required. Functional dorsiflexion may be measured by the ankle lunge test .^68,69 For this weight-bearing test, the patient is asked to place one foot perpendicular to a wall and lunge the same knee toward the wall (Figure 13-52, A). The foot is progressively moved away from the wall until the knee barely touches the wall and the foot remains flat on the floor. The distance from the wall to the big toe is measured (Figure 13-52, B). Both sides are compared. If desired, the angle of the tibial shaft to a vertical line can also be measured (Figure 13-53). Differences between sides may be due to a tight Achilles tendon or talocrural restriction.⁷⁰

Supination is 45° to 60° and pronation is 15° to 30°, although individuals vary (see Figure 13-50, C and D). It is more important to compare the movement with that of the patient’s normal side (Figures 13-54 and 13-55). Supination combines the movements of inversion, adduction, and plantar flexion; pronation combines the movements of eversion, abduction, and dorsiflexion of the foot and ankle. As the patient does the movement, the examiner should watch for the possibility of subluxation of various tendons. The peroneal tendons are especially prone to subluxation, and their subluxation is evident on eversion (Figure 13-56). If tibialis anterior is weak, supination is affected. If the peronei are weak or the tendons sublux, pronation is affected.

Movement of the toes occurs at the metatarsophalangeal and proximal and distal interphalangeal joints (see Figure 13-50, E and F). Extension of the great toe occurs primarily at the metatarsophalangeal joint (70°); there is minimal or no extension at the interphalangeal joint. For the great toe, 45° flexion occurs at the metatarsophalangeal joint, and 90° occurs at the interphalangeal joint.

For the lateral four toes, extension occurs primarily at the metatarsophalangeal (40°) and distal interphalangeal joints (30°). Extension at the proximal interphalangeal joints is negligible. For the lateral four toes, 40° flexion occurs at the metatarsophalangeal joints, 35° occurs at the proximal interphalangeal joints, and 60° occurs at the distal interphalangeal joints.

Abduction and adduction of the toes are measured with the second toe as midline. Although the ROM of abduction can be measured, this is not usually done. The common practice is to ask the patient to spread the toes and then bring them back together (see Figure 13-50, G and H). The amount and quality of movement are compared with those of the unaffected side.

If the history has indicated that weight-bearing or non–weight-bearing combined or repetitive movements or sustained postures result in symptoms, these movements should also be tested. The examiner should ask the patient to walk on the toes, heels, and outer and inner borders of the feet. These actions indicate the patient’s muscle power and control and the functional ROM. With a third-degree strain (rupture) of the Achilles tendon, the patient is not able to walk on the toes. Lack of dorsiflexion makes it difficult for the patient to walk on the heels. When the patient walks on the inner or outer borders of the feet, pain and difficulty are experienced in the presence of a subtalar lesion.

The examiner should also check the efficiency of the toes. Are the toes straight and parallel? Is the patient able to flex, extend, adduct, and abduct the toes? The toes have a primarily ambulatory function, although, with training, they can develop a prehensile function. The toes extend the weight-bearing area forward and, by so doing, reduce the load on the metatarsal heads. The great toe also has a primary function of pushing off during gait.

When assessing the active movements, the examiner must remember that peripheral nerve injuries may alter the pattern of movement. For example, the common peroneal nerve may be injured, because it winds around the head of the fibula, resulting in altered nerve conduction to the peroneus longus and brevis muscles (superficial peroneal nerve) or the tibialis anterior, extensor digitorum longus, and extensor hallucis longus (deep peroneal nerve).⁷¹ In such cases, the movements controlled by these muscles are altered. In addition, there are sensory changes that must be noted.