Expose the whole lower leg and foot.
Examine the soles of the patient's shoes for signs of asymmetrical wear
Look for side to side asymmetry or abnormal contact w/ the ground
Walking Gait - look for a high stepping gait (foot drop, equinovarus), antalgic gait (ankle, hindfoot or midfoot pain) and short propulsive phase (forefoot pain)
Look at the patient standing (and then sitting).
- Limb alignment (especially genu valgus with flat feet)
- Look at the foot shapes and positions.
- Medial arch - obliterated in pes planus, exaggerated in pes cavus (NB - look at lower back for signs of spina bifida or neurofibromatosis)
- Hindfoot (from behind) - varus (pes cavus) or valgus (pes planus). Ask patient to stand on tiptoes and see if deformity corrects (= mobile subtalar joint).
- 'Too many toes' sign = looking from behind more toes are seen on the lateral side of the leg. This occurs in pes planus, splayed forefoot.
The patient should sit on the examination couch with both lower legs hanging over the side. The examiner should sit on a chair at a lower level than the couch.
Overall Foot Shape:
- neutral or rectus foot - no overall deformity
- flat foot - heel valgus, low arch, commonly forefoot abduction and supination. The subtalar joint is commonly in the overpronated position in stance and may be even more so on walking. Distinguish between flexible and rigid flat feet by asking the patient to stand on tiptoe to see if the arch re-appears and the heel goes into varus. Then do a single foot tiptoe test to look for tibialis posterior insufficiency. The "too many toes sign" demonstrates forefoot abduction. Manipulate the subtalar joint to identify a rigid hindfoot suggesting arthritis or a tarsal coalition. Exclude a neurological cause by appropriate examination.
- cavus foot - typically with a plantar flexed first ray, high arch and forefoot pronation. In many cases the hindfoot is in varus and this may be fixed or mobile. Use the Coleman block test to tell the difference. Pes cavus may be associated with spinal anomalies (especially if asymmetrical) or with hereditary sensorimotor neuropathies such as Charcot-Marie-Tooth disease.
- skewfoot - hindfoot valgus and forefoot adduction. Do the same tests for hindfoot correction as in flatfoot. Manipulate the forefoot to determine correctability of adduction.
- metatarsus adductus - neutral hindfoot and adduction of the metatarsus (some patients have some forefoot supination too). Commonly seen in pre-school children when it is usually correctable, but also in adults when it is often relatively fixed but usually in itself asymptomatic.
