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Note
Medical knowledge is constantly changing. As new information becomes
available, changes in treatment, procedures, equipment and the use of
drugs become necessary. The authors and the publishers have taken care
to ensure that the information given in this text is accurate and up to date.
However, readers are strongly advised to confirm that the information,
especially with regard to drug usage, complies with the latest legislation
and standards of practice.
-
www.elsevierhealth.com
health sciences
Linda Merriman PhD MPhil DPodM MChS CertEd Warren Turner BSc(Hons) DPodM
Dean, School of Health and Social Sciences, Associate Dean, School of Podiatry, University
Coventry University, UK College Northampton, UK
Many textbooks make reference to the assess- Systems Examination covers the separate com-
ment of the lower limb but very few are dedi- ponents of lower limb assessment: medical and
cated entirely to this purpose. Those that are tend social history, vascular, neurological, orthopaedics,
to focus on only one of the components of the skin and appendages and footwear assessments.
process, e.g. skin disorders or on a specific client Details relating to anatomy and physiology have
group such as paediatrics. The purpose of this been discussed where relevant. Again, the chapters
book is to produce a textbook which encom- in this section have been updated as part of the
passes all aspects of lower limb assessment. second edition. The chapter on the assessment of
Problems affecting the lower limb can lead to dis- skin and its appendages has been rewritten, as has
comfort, pain, reduction or loss of mobility and the chapter on the locomotor system, which has
loss of time from work. Effective and efficient been renamed orthopaedic assessment to reflect
management of these problems can only be more accurately the content of the chapter.
based on a thorough assessment. Laboratory and Hospital Investigations
Throughout the book the term 'practitioner' is focuses on those tests which may be performed
used in its broadest sense to denote any person to confirm, support or clarify the clinical exami-
who has an interest in the management of lower nation: blood analysis, urine analysis, microbial
limb problems. Although the podiatrist has a identification, histopathology, radiographic
natural claim to specialising in caring for the imaging and methods of quantifying gait and
foot, the range of practitioners with an interest in foot-ground interface systems. These chapters
the lower limb includes bioengineers, diabetolo- have been updated for the second edition.
gists, general medical practitioners, nurses, occu- Reliance on tests without the appropriate clinical
pational therapists, orthopaedic surgeons, examination is unwise, creates higher costs, may
orthotists, physiotherapists and rheumatologists. worry the patient unnecessarily and overworks
This is the second edition of this textbook and, support departments. It is intended that this part
like the first edition, it is divided into four parts: of the book demonstrates when and how these
Approaching the Patient, Systems Examination, tests can be used to aid the assessment process.
Laboratory and Hospital Investigations and The last part of the book, Specific Client
Specific Client Groups. Groups, looks at the main areas of foot disease:
Approaching the Patient provides an introduc- the at-risk foot, the child's foot, sport injuries and
tion to the assessment process and covers in the painful foot. For the second edition two new
detail the assessment interview, the presenting chapters have been added to this section: assess-
problem and the reliability and validity of clini- ment of the elderly and pre- and postoperative
cal measurement. For the second edition these assessment. The addition of these chapters reflects
chapters have been reviewed and updated. the developments within podiatry. The elderly
x PREFACE
form by far the largest client group receiving foot Case histories and comments support some of
treatment; it is, therefore, important that the the chapters, particularly those in Systems
specific needs of this client group are addressed Examination and Specific Client Groups. These
in this textbook. Over the last 10 years there has have been used to illustrate certain points and
been a growth in the number of surgical proce- reflect real life experiences. Where appropriate,
dures performed, under local analgesia, by podi- black and white photographs, figures and tables
atrists. Assessing a patient for surgery under have also been used to support and further illus-
local analgesia requires the practitioner to be trate points raised in the text. A section of colour
aware of the specific issues related to this type of plates has been specifically used to support
treatment as they do differ from those result- Chapters 6, 9 and 17. Each chapter has been ref-
ing from surgery under general anaesthesia. erenced and some indicate Further Reading.
Although Systems Examination covers the range Clearly there is more than one approach to
of assessments and can be applied to all age undertaking an assessment. Assessment of the
groups, the assessment of children and sports Lower Limb has been written to support good
people is worthy of independent discussion. Pain practice in a wide range of outlets for all profes-
in the foot can arise due to a multitude of factors, sionals with an interest in the foot. Whatever
affects all age groups and has a highly morbid approach the practitioner adopts, it is hoped that
affect on our lives; for this reason, it has been this text will be a valuable asset.
given a separate chapter. The early diagnosis of
the at-risk foot is recognised as a means of reduc-
ing morbidity, mortality and minimising the cost
of in-hospital care for these patients. Linda Merriman, Warren Turner, 2002
Acknowledgements
We are indebted to those who have given their This book is dedicated to Jackie McLeod
help and encouragement throughout the devel- Roberts in recognition of her contribution to
opment and production of this second edition: in podiatry and in particular her work in the
particular, our family and friends. Ukraine, developing and improving footcare ser-
A big thank you to all the contributors for their vices for people with diabetes. Jackie's pioneer-
time and effort in updating and/or rewriting ing work has made a significant difference to
their chapters. We would also like to thank Ann these people.
Marie Carr for her help with the new chapter on
assessment of the elderly.
Plate 2
Typical ischaemic
ulceration
overlying a hallux
Plate 1 An ischaemic foot. The superficial tissues are abductovalgus in
atrophied. The fifth ray has been excised. a patient with
chronic peripheral
vascular disease.
Plate 13
Dorsal corn.
Plate 12
Extravasation within callus due to prolonged high pressure .
..
Plate 14 Plantar keratoderma.
Plate 15 Bullous pemphigoid.
5'
L£UCoCYTES TRACE ~ MODERATE LAROE
••
from a lung NEG. j< !
tumour). 2 minutes
NITRITE
60seconds
PRoTE1H
&D seconds
pH
60seconds
NON·
BLOOD HAEMOI.Yleo HAEMDLY2£O
• ••
NEG. lllACE TRACE
&Dseconds
SPECIRC GRAVITY
45seconds
KfTONE
40seconds
GLUCOSE
•
30seconds NEG.
Plate 28 Multistix 8SG: the range of biochemical tests
available from one urine sample (reproduced by kind Ii@nk,''''''
permission of Bayer Diagnostics UK Ltd).
CHAPTER TITLE 7
Plate 29
Dry fissures
develop when
the skin is too
brittle to
conform to
external and
internal
mechanical
stresses
(tension and
shear
particularly).
They are a
frequent
complication of
anhidrosis and
atrophy.
Introduction 3
Why undertake a primary patient assessment? 3
Time management 7
Re-assessment 7
Confidentiality 9
Summary 10
INTRODUCTION
Patients present with a range of signs and symp-
toms for which they are seeking relief and if
possible a cure. However, before this can be
achieved, it is essential to undertake a primary
patient assessment. Ineffective and inappropri-
ate treatment may result if the practitioner has
not taken into account information obtained
from the assessment. This chapter explores why
it is necessary to undertake an assessment and
considers specific aspects of the assessment
process.
• identify patients who need immediate whole area before such measures can be used
attention with confidence.
• serve as a predictor for those 'at risk'.
On account of the demands on time it is often
Making a diagnosis
necessary for the practitioner to differentiate
between those patients who need immediate Arriving at a diagnosis is a complex activity.
attention and those who do not. Table 1.2 sum- Studies of clinical reasoning show that practi-
marises the presenting problems which should tioners use one or more of the following
be given high priority. In clinics where there are approaches (Higgs & Jones 2000):
lengthy waiting lists patients may be screened
• hypothetico-deductive reasoning
initially to assess whether they have one or more
• pattern recognition
problems which appear in Table 1.2 and are then
• interpretative model.
given immediate treatment.
The term 'at risk' usually denotes those Hypothetico-deductive reasoning is based on
patients at risk of developing ulceration and generating hypotheses using clinical data and
infection. Identifying those at risk is a complex knowledge. These hypotheses are tested through
task. Currently, research into risk factors related further inquiry during the assessment. The evi-
to lower limb problems is sparse and thus it is dence gained is evaluated in relation to existing
difficult to produce risk assessment methods that knowledge and a conclusion reached on the basis
are robust and valid. Considerable research has of probability (Gale 1982).
been undertaken into the risk assessment of pres- Pattern recognition is a process of recognising
sure ulcers (Lothian 1987). In relation to the the similarity between a set of signs and symp-
lower limb some work has been undertaken into toms. The important aspect of the use of cate-
developing methods of risk assessment to iden- gorisation in clinical reasoning is the link
tify diabetics at risk of developing diabetic ulcers practitioners make between the pattern they are
(Zahra 1998). Further work is needed in this currently observing and previous cases showing
the same or similar patterns.
The interpretative model is very different
Table 1.2 Presenting problems which should be given high
priority
from the other two models. This approach is
based on the practitioner gaining a deep under-
Problem Features standing of the patient's perspective and the
Pain Constant, weightbearing and
influence of contextual factors. Protagonists of
non-weightbearing this approach believe that the meaning patients
Affects patient's normal daily give to their problems, including their under-
activities
standing of and their feelings about their
Infection Raised temperature (pyrexia) problem, can significantly influence their levels
Sign of acute inflammation
Signs of spreading cellulitis of pain tolerance, disability and the eventual
Lymphangitis, lymphadenitis outcome (Ferurestein & Beattie 1995).
Ulceration Loss of skin Studies have shown that with all these
Mayor may not be painful approaches there is an association between clinical
May expose underlying tissues
reasoning and knowledge (Higgs & Jones 2000).
Acute swelling Unrelieved pain There is a symbiotic relationship between the
Very noticeable swelling
May have associated signs of knowledge base of practitioners and their clinical
inflammation reasoning ability. It is not possible to develop
Abnormal skin changes Distinct colour change problem-solving skills in the absence of cognitive
Discharge may be malodorous knowledge related to the specific problem.
Itching There are three partners in the assessment
Bleeding
process; the practitioner, the patient and the
6 APPROACHING THE PATIENT
wider environment. The ability of a practitioner Table 1.3 Factors which should be taken into
consideration when making a differential diagnosis
to undertake an effective assessment and make a
diagnosis is influenced by a range of factors: Social history Age
Gender
• personal values, beliefs and perceptions Race
• knowledge base related to the problem(s) Social habits
Occupation
• reasoning skills (cognition and metacognition) Leisure pursuits
• previous clinical experience
Medical history Family history
• familiarity with similar cases. Medication
There can be enormous differences between Symptoms Onset
practitioners, both in their assessment findings Type of pain
Aggravated by/relieved by
and their diagnoses. For example, Comroe & Seasonal variation
Botelho (1947) described a study in which 22 Signs Site
doctors were asked to examine 20 patients and Appearance
note whether cyanosis was present. Under con- Symmetry
trolled conditions these patient were assessed for Specific tests Imaging techniques
cyanosis by oximeter. When the results of the Urinalysis
Microbiology
clinical assessment were compared with the Blood analysis
oximeter results, it was found that only 53% of Biopsy
the doctors diagnosed cyanosis in subjects with Foot pressure analysis
Electrical conductive studies
extremely low oxygen content: 26% said cyanosis
was present in subjects with normal oxygen
content. Curran & Jagger (1997) found poor
agreement between podiatrists when diagnosing droses), whereas other conditions have specific
common conditions of the leg and foot. presenting features (e.g. the sudden, acute, noc-
Agreement improved when a patient expert turnal pain associated with gout).
system was used. Expert patient systems are The patient is the key partner in the assess-
increasingly being used, in particular in medicine ment process. Some patients want to playa
(Adams et al 1986). These computer-based greater role in decision making and their health
systems provide practitioners with a wealth of care management. Additionally, patients are
information and are used to guide and direct increasingly being seen as consumers of health
clinical decision making. care. As such, they have expectations of the type
Unfortunately, making a diagnosis is not a and quality of the health services they receive.
precise science: errors can and do occur. Patients' perceptions, beliefs and expectations
Practitioners should always keep an open mind related to their lower limb problems can be
when making a diagnosis, reflect on the process influenced by the following factors:
they have used, keep up to date with current lit-
• home environment
erature and technology and request a second
• work environment
opinion when unsure.
Sometimes the practitioner may have gener- • culture
• socioeconomic status
ated more than one possible diagnosis; in these
instances the practitioner has to undertake a dif- • language skills
• general state of health.
ferential diagnosis, i.e. decide which is the most
likely from a number of possibilities. When arriv- The above factors can affect patients' needs,
ing at a differential diagnosis the practitioner communication skills and, ultimately, the choices
should take into account the factors listed in they make.
Table 1.3. For example, a number of conditions The wider health environment and context
affect specific age groups (e.g, the osteo chon- cannot be ignored in the assessment process.
ASSESSMENT 7
Health care is a political issue and government can assist in identifying the most appropriate
policy changes can radically affect available ser- treatment and help to produce an accurate prog-
vices. Finance is another major influencing factor nosis. For example, if the cause of pain in the foot
that may limit the range of clinical and labora- is chronic ischaemia due to atherosclerosis, the
tory tests that may be used. Conversely, techno- prognosis may be poor unless radical (bypass)
logical advances have led to improved clinical surgery is performed. Conversely if the foot pain
and laboratory test equipment. Employing is due to acute ischaemia that has occurred as a
organisations can affect the assessment process in result of hosiery constricting the peripheral circu-
a variety of ways, e.g. use of specific frameworks lation, the prognosis is good and advice may be all
of operation. Profession-specific frameworks and that is required. Unfortunately, it is not always
the status of knowledge within the profession possible to isolate the cause; in these cases the
can also be influencing factors. term idiopathic (unknown cause) is used.
signed and dated by the practitioner making the Retrospective and prospective analysis of
alteration. patient records is commonly used for clinical
It is recommended that abbreviations should and epidemiological research, audit and plan-
be avoided (Bradshaw & Braid 1999). The use of ning. If well documented, they can provide a
profession-specific abbreviations can be particu- wealth of information. However, one of the
larly problematic in multi-authored patient problems with patient records is that there is no
records, which are completed by more than one standardised manner in which information is
health care profession. However, the use of collected. For example, the use of clinical terms
abbreviations in patient records is common. can be ambiguous.
Curran (1994) noted that 97% of respondents The International Statistical Classification of
used clinical abbreviations in their podiatric Diseases, Injuries and Causes of Death was estab-
treatment records. lished by the World Health Organization as a
All entries should be dated and signed. In par- universal system for collecting data. The system
ticular, details regarding the patient's medication was originally designed for mortality statistics
should always be dated, as the medication may but has evolved to cover a broad range of dis-
have been changed by the time the patient eases. It is updated every 10 years to keep abreast
attends for the next appointment. The patient's of the constantly changing information base. This
name or the patient identifier should appear on system can be used to record diseases for the
every page. Records should always be written in purpose of clinical and epidemiological research
such a way as not to be offensive or contain sub- and audit.
jective opinions. In an increasingly litigious society it is impor-
Most professional bodies provide guidance on tant that high standards of record keeping
recording information in patient records. For are maintained. The St Paul International
example, the Society of Chiropodists and Insurance Company Limited (1991) states that
Podiatrists (2000) produce Guidelines on the 35-40% of all malpractice claims in the United
Minimum Standards in Clinical Practice, which States cannot be defended because of 'documen-
contain specific information on record keeping. tation problems'. The Society of Chiropodists
Bradshaw & Braid (1999) identified the following and Podiatrists (1998) found that inadequate
four reasons for poor record keeping: patient records were the main reason why
• illegible handwriting legal claims against state-registered chiropodists
• incomplete information succeeded.
• inaccurate information
• ambiguous abbreviations.
It is suggested that practitioners as part of their CONFIDENTIALITY
continuing professional development receive The information volunteered by the patient and
periodic reminders and refresher sessions related recorded in the patient's notes should be treated
to record keeping (Bradshaw & Braid 1999). It has as confidential and not divulged to any other
been found that regular audit of medical records party without the consent of the patient.
improves record keeping (Donnelly 1995). However, the information can be made avail-
The information recorded from the assessment able to all those involved with the care of that
may be used for: patient.
• ensuring contraindicated treatments are not Patient records, whether in manual or elec-
used tronic format, are subject to the Data Protection
• clinical and epidemiological research Act 1998, which became effective from March
• audit 2000. This means that patients have the right of
• planning access, for a pre-set fee, to information stored
• legal purposes. about them. The act gives rights to individuals in
10 APPROACHING THE PATIENT
REFERENCES
Adams I D, Chan M, Clifford P 1986 Computer aided Gale J 1982 Some cognitive components of the diagnostic
diagnosis of abdominal pain: a multi centre study. British thinking process. British Journal of Educational
Medical Journal 293: 80-84 Psychology 52: 64-72
Bradshaw T, Braid S 1999 The practice of recording clinical Higgs J, Jones M 2000 Clinical reasoning in the health
treatment and audit of practice - an overview for professions, 2nd edn. Butterworth-Heinemann, London
podiatrists. British Journal of Podiatry 2(1): 8-12 Lothian P 1987 The practical assessment of pressure sore
Comroe J H, Botelho S 1947 The unreliability of cyanosis in risk. CARE Science and Practice 5(4): 3-7
the recognition of arterial anoxemia. American Journal of Sandler G 1979 Costs of unnecessary tests. British Medical
the Medical Sciences 214: 1-6 Journal 1: 1686-1688
Curran M 1994 Use of abbreviations in chiropody /podiatry. Society of Chiropodists and Podiatrists 1998 Defensive
Journal of British Podiatric Medicine 49(5): 71-72 practice (editorial). Podiatry Now 1(1): 1
Curran M, Jagger C 1997 Interobserver variability in the Society of Chiropodists and Podiatrists 2000 Guidelines on
diagnosis of foot and leg disorders using a computer minimum standards of clinical practice, December
expert system. The Foot 7: 7-10 St Paul International Insurance Company Limited 1991
Data Protection Act 1998 EC Data Protection Directive Defensible documentation. St Paul House, 61-63 London
(95/46/EC) Rd, Redhill, Surrey RHI INA (information leaflet for
Donnelly A 1995 Improve your nurses' record collection. health care professionals)
Nursing Management 2(3): 18-19 Zahra J 1998 Can podiatrists predict diabetic foot ulcers
Ferurestein M, Beattie P 1995 Biobehavioural factors affecting using a risk assessment card? British Journal of Podiatry
pain and disability in low back pain: mechanisms and 1(3): 79-88
assessment. Physical Therapy 75: 267-280
CHAPTER CONTENTS
Introduction 11
Is an interview different from a normal
conversation? 11
Aims of the assessment interview 12
The assessment
Communicating effectively 12
interview
Questioning skills 13
Listening skills 15 M. Hanley
Non-verbal communication skills 16
Stereotyping 21
Documenting the assessment interview 21
Summary 26 INTRODUCTION
Research has shown that the interview, as
opposed to any other method of assessment such
as clinical tests and examinations, is the most
efficient method in reaching an initial diagnosis
(Sandler 1979). This chapter examines the
purpose of the interview, the skills required to
communicate effectively, how the interview
should be structured and the pitfalls to avoid. It
concludes by examining the features of a good
assessment interview.
• A written record of the interview is usually centred, compared with 21% classed as patient-
kept. centred (Byrne & Long 1976).
Information gathered collectively from the
Practitioners may be involved with other types
interview and examination should facilitate the
of conversation with patients, which require
identification of the patient's health problem
additional skills such as counselling, teaching
and, where appropriate, a diagnosis can be
and advising. These are discussed in the accom-
made. However, as well as aiding the diagnostic
panying text to this book: Clinical skills in treating
process, the interview serves other important
the foot.
purposes:
• The information gained may be of help when
Aims of the assessment interview drawing up a treatment plan. For example, the
interview can provide a picture of the patient's
The assessment interview is a conversation with
social circumstances, which may affect the
a purpose, which takes place between the practi-
manner of, or the actual advice given.
tioner and the patient. Patients present with
• It provides an opportunity to gain the
problems, which may have physical, psychologi-
patient's trust and confidence in you as a
cal and social dimensions. Patients often have
practitioner.
their own ideas and concerns about the problems
• It facilitates the development of a therapeutic
they present with, and about the medical care
relationship between the health care
that they mayor may not receive. Likewise, prac-
practitioner and the patient.
titioners approach the interview with percep-
tions of their role. These will have been However, not all health care students are
influenced by training, past experiences, atti- aware of how to communicate effectively and, as
tudes and beliefs. The availability of resources a result, communication skills training is becom-
and facilities will contribute to the practitioner's ing a common part of the curriculum in health
response to the patient. It is essential that the care courses (Hargie et a11998, Sleight 1995).
practitioner and the patient develop common
ground during the interview and that both are
COMMUNICATING EFFECTIVELY
aware of each other's perspectives. If this cannot
be achieved the interview may be an unsatisfac- Since the interview plays a particularly
tory experience for both of them. significant role in the assessment of the patient, it
The prime purpose of the interview is for the is important to ensure that the meeting is suc-
cause of the patient's concerns to be identified cessful. In other words, good communication
and appropriate action taken. This is best skills are essential if you are to achieve an effec-
achieved by the patient and the practitioner tive assessment interview. What is meant by
working in partnership to reduce or resolve these communication? In its simplest form it can be
concerns. seen as the transmission of information from one
It is essential that the practitioner provides person and the receiving of information by
ample opportunity for the patient to convey his another. Unfortunately, the communication
concerns and worries. In other words, the inter- process is not that simple; if it were there would
view should be patient-centred. Research has not be communication breakdowns or misunder-
shown that this is not always the case. A few standing between people as to what has been
years after qualification most practitioners are said.
confident that they are good at taking histories Communication can be influenced by charac-
and explaining things to patients. Is this teristics of the sender (e.g. ability to express ideas
confidence justified? A detailed analysis of the clearly, verbal skills, attitude toward the patient),
recordings of over 2500 doctor/patient inter- the receiver (e.g. the extent to which the receiver
views showed that 77% of them were doctor- is paying attention, ability to hear and under-
THE ASSESSMENT INTERVIEW 13
Closed questions serve useful purposes during • Show empathy. Authier (1986) defined
the assessment interview. They provide a quick empathy as: '[being] attuned to the way another
means of gaining and verifying information. person is feeling and conveying that
Patients often find them easier to answer than the understanding in a language he/she
more open type of question. They can be used to understands' .
focus the assessment interview in a particular • Use language that is simple, direct and
direction. On the other hand, if used too much understandable. Avoid medical and technical
they limit what the patient can say. As a result the terms. The 'fog index' can be used to assess
patient may not volunteer important informa- the complexity of a piece of communication
tion. (Table 2.1). It is primarily used in written
Leading questions. Leading questions should communication but has also been used,
be avoided where possible. In general, they give although less frequently, to analyse the
responses that the professional expects to receive. complexity of the spoken word. It involves a
Examples of leading questions are: mathematical equation that produces a score.
For example, tabloid newspapers have a fog
• You don't smoke, do you?
index score between 3 and 6, whereas
• That doesn't hurt, does it?
government policy documents can achieve a
• You said you get the pain a lot; that must
score of 20+. Applying the fog index to
mean you get it every day?
spoken communication or a foot health
While you may get the answer you want or education leaflet will give an indication of the
expect to hear, it does not necessarily mean it is complexity of that particular communication.
true! If it receives a high fog index score, the
In addition to a specific style of question, the average patient may find it very difficult to
practitioner may also use a range of interview understand.
techniques to elaborate further on the issues • Avoid presenting the patient with a long list
raised. These techniques are often referred to as of conditions. This is especially important
probes. Probing questions are a very useful during medical history taking. It is unlikely
adjunct to both open and closed questions. In that a patient has experienced more than
general they aim at finding out more from the one or two of the problems on a list. Patients
patient. In particular, they are useful in gaining may fall into the habit of replying 'no' to
in-depth rather than superficial information. all the items on the list and fail to respond
Examples include: in the affirmative to ones they do suffer
from. Strategies that can be used to avoid this
• Could you describe the type of pain it is?
situation include a pre-assessment ques-
• What makes you think it might be linked to
tionnaire (see Ch. 5) or breaking up the
your circulation?
list of closed questions with some open
You might also use silence as a probe to questions.
encourage the patient to expand on a given
answer, or say 'yes', 'uh-hm' or simply nod,
techniques that are particularly useful when Table 2.1 The fog index
you feel the patients may have more to say
Take a passage of about 100 words, ending in a full stop.
and are thinking about expanding their Work out the average sentence length. This is achieved by
answer. dividing the number of sentences into 100. Then work out
the number of words of three or more syllables. Ignore two-
syllable words that have become three syllables with plural
General pointers when questioning patients or endings like -ed or -ing, technical words and proper
nouns. Add the average sentence length to the number of
The following points should be borne in mind difficult words and multiply by 0.4. The result will give you
the reading score (fog index)
when interviewing patients:
THE ASSESSMENT INTERVIEW 15
• Don't ask the patient more than one question mation from the patient it can be used for
at a time. For example, if asking a closed-type giving information to him.
question do not say, 'Could you tell me when • Some patients, on account of a range of
you first noticed the condition, when the pain circumstances such as deafness, speech deficit
is worse and what makes it better?'. By the or language difference, may not be able to
end of the question the patient will have communicate with the practitioner. In these
forgotten the first part. instances it is important that the practitioner
• Attempt to get the patient to give you involves someone known to the patient to
an honest answer using his or her own communicate on his behalf, e.g. relative,
words. Avoid putting words into the patient's friend or carer.
mouth. • The patient may have difficulty listening and
• Clarify inconsistencies in what the patient tells interpreting what you are saying through fear,
you. anxiety, physical discomfort or mental
• Get the patient to explain what he means by confusion. Be aware of non-verbal and verbal
using certain terms, e.g. 'nagging pain'. Your messages that can give clues to the patient's
interpretation of this term may differ from the emotional state.
patient's.
• Pauses are an integral part of any com-
Listening skills
munication. They allow time for participants
to take in and analyse what has been Listening is an active not a passive skill. Many
communicated and provide time for a people ask questions but do not listen to the
response to be formulated. Allow the patient response. A common example is the general
time to think how he wishes to answer your introductory question: 'How are you?'. Most
question. Avoid appearing as if you are responses tend to be in the affirmative: 'Fine',
undertaking an interrogation. 'OK'. Occasionally, someone responds by saying
• In the early stages of the interview it is often they have not been too well, only to get the
better to use the term 'concern' rather than response from the supposed listener: 'Great;
'problem'. Asking patients what concerns pleased to hear everything is fine'. Similarly, do
them may elicit a very different response from not limit your attention to that which you want
asking them what the problem is. Some to hear or expect to hear. Listen to all that is being
patients may feel they do not have a problem said and watch the patient's non-verbal behav-
as such but are worried about some symptom iour. The average rate of speech is 100-200 words
or sign they have noticed. Asking them what a minute; however, we can assimilate the spoken
concerns them may get them to reveal this word at around 400 words per minute. As a
rather than a denial that they have any result the listener has 'extra time' to understand
problems. and interpret what is being said. If you have
• Asking personal and intimate questions can asked a question you should listen to all of the
be very difficult. Do not start the interview answer. Often when trying to understand the
with this type of question; wait until further clinical nature of a patient's problem, there is a
into the interview when hopefully the patient great temptation to listen to the first part of an
is more at ease with you. Try to avoid answer and then to immediately use this infor-
showing any embarrassment when asking an mation to try and make a diagnosis. This may
intimate question as this may well make the mean that you are not paying careful attention to
patient feel uncomfortable. important clinical information, which the patient
• It is important that the patient understands may give, at the end of their reply. Finally, it is
why you are asking certain questions. important that you don't let your mind wander
Remember that the assessment interview is a on to unrelated thoughts such as what you are
two-way process: besides gathering infor- going to do after the interview. Before you know
16 APPROACHING THE PATIENT
it you have missed a good chunk of what the Table 2.2 Skills ofa good listener
patient has been telling you and have most prob-
ably missed important and relevant information. • Look at the patient when he/she startsto talk
In order to be a good listener you need to set • Use body language such as nodding, leaning forward to
aside your own personal problems and worries demonstrate to the speaker thatyou are interested in
what is being said
and give your full attention to the other person.
• Do not keep looking at the time
It is inevitable that, at times, one's attention does
wander. This may be due to lack of concentra- • Adopt a relaxed posture
tion, tiredness or because the patient has been • Use paraphrasing, reflecting and summarising to show the
patient that you are listening to and understanding what
allowed to wander off the point. In the case of the he/sheis/are saying
former do not be afraid to say to the patient,
'Sorry, could I ask you to go over that again?'. In
the latter case, politely interrupt the patient and
use your questioning skills to bring the conversa-
Non-verbal communication skills
tion back to the subject in hand. This involves all forms of communication apart
During the interview the techniques of para- from the purely spoken (verbal) message. It is
phrasing, reflection and summarising can be through this medium that we create first impres-
used to aid listening and ensure you understand sions of people and, similarly, people make initial
what the patient is trying to convey. judgements about us. Once made, first impres-
Paraphrasing. This technique is used to clarify sions are often difficult to change, yet research
what a person has just said to you in order to get has shown they are not always reliable.
him to confirm its accuracy or to encourage him Therefore, it is particularly important that we
to enlarge. It involves re-stating, using your own consider non-verbal communication here since it
and the patient's words, what the patient has affects not only how we are perceived when we
said. communicate but also how we make judgements
Reflection. This technique is similar to about the patient.
prompting in that it is used to encourage the Non-verbal behaviour includes behaviours
patient to continue talking about a particular such as posture, touch, personal space, physical
issue that may involve feelings or concerns. It appearance, facial expressions, gestures and
may be used when the patient appears to be paralanguage (i.e. the vocalisations associated
reluctant to continue or is 'drying up'. It involves with verbal messages, such as tone, pitch,
the practitioner repeating in the patient's own volume, speed of speech). It is said that we pri-
words what the patient has just said. marily communicate non-verbally. Remember
Summarising. This technique is used to iden- the old adage 'a picture says a thousand words'.
tify what you consider to be the main points of Your body language and paralanguage will send
what the patient is trying to tell you. It can also an array of messages to your patient prior to you
be a useful means of controlling the interview saying anything. Non-verbal communication
when a patient continues to talk at length about serves many useful purposes. It can be used to:
an issue. To summarise, the practitioner draws
• replace, support or complement speech
together the salient points from the whole con-
• regulate the flow of verbal communication
versation. At the end of the summary the patient
• provide feedback to the person who is
may agree with, add to or make corrections to
transmitting the message, e.g. looking
what the practitioner has said. Summarising
interested
serves a useful purpose in checking the validity,
• communicate attitudes and emotions (Argyle
clarity and understanding of old information; it
1972, Hargie et aI1994).
does not aim to develop new information.
The basic skills of a good listener are high- The average person only speaks for a total of
lighted in Table 2.2. 10-11 minutes daily, with the average spoken sen-
THE ASSESSMENT INTERVIEW 17
tence lasting only around 2.5 seconds fessional judgement of the practitioner
(Birdwhistell 1970). Therefore, non-verbal com- (Davidhizar 1992). Certainly eye-to-eye contact is
munication is the main mode of conveying our recommended at the beginning of the interview,
emotional state in most types of human interac- to gain rapport and trust, and at the end of the
tions. In fact, in a typical conversation only one- interview by way of closing the interview.
third of the social meaning will be conveyed However, you should always be aware of poten-
verbally - a full two-thirds is communicated tial cultural and gender differences in appropriate
through non-verbal channels! (Birdwhistell1970). level of eye contact. For example, Hall (1984) has
Due to the broad literature in this area the fol- reported that on average women tend to make
lowing section will focus on selected aspects of more eye-to-eye contact compared with men, so
non-verbal behaviour and how they may adjust your non-verbal behaviour accordingly.
influence the success of the assessment inter- Facial expression. Facial expression is argu-
view. For the interested reader, there is a wide ably the most important form of human com-
range of books available which look at the topic munication next to speech itself (Hargie et al
of non-verbal communication, many specialis- 1994). It is via our facial expression we commu-
ing in the clinical interaction: see Davis (1994), nicate most about our emotional state, and the
Dickson et al (1997), Hargie (1997), or the winter meaning of a wide range of facial expressions
1995 edition of the Journal of Nonverbal Behavior (e.g. happy or sad) are recognised universally
for further information on this topic. (Ekman & Fresen 1975). Smiling, together with
Eye contact. Eye-to-eye contact is frequently judicious eye-to-eye contact, signifies a recep-
the first stage of interpersonal communication. It tive and friendly persona and inspires a feeling
is the way we attract the other person's attention. of confidence and friendliness. Facial expres-
Direct eye-to-eye contact creates trust between sions often carry even more weight in a social
two people; hence, the innate distrust felt of interaction than the spoken word. For example,
someone who avoids eye contact. However, we if a practitioner is giving a very positive verbal
do not keep constant eye-to-eye contact through- message to the patient but, at the same time, the
out a conversation. The receiver looks at the practitioner's facial expression communicates
speaker for approximately 25-50% of the time, anxiety and doubt, then it is likely that the
whereas the speaker looks at the other person for patient will pay more attention to the facial
approximately half as long. So in other words, message. This is because verbal behaviour is
people tend to look more at the other person much easier to control than non-verbal and, as a
when they are listening compared with when result, non-verbal communication is likely to be
they are speaking. more honest! Therefore, it is important that
Too much eye contact is interpreted as staring practitioners are always aware of the message
and is seen as a hostile gesture. Too little is inter- they are communicating using their facial
preted as a lack of interest, attention or trustwor- expressions.
thiness. Interviewers cannot afford to look Posture and gestures. The manner in which
inattentive because the patient may interpret this we hold ourselves and the way in which we
as meaning that he has said enough and as a move says a lot about us as individuals. This area
result may stop talking. Conversely, withdraw- of non-verbal behaviour is often referred to as
ing eye contact may be used as a legitimate way kinesics and includes all those movements of the
of getting the patient to stop talking. body which complement the spoken word (e.g.
Health care practitioners should be aware of gestures, limb movements, head nods, etc.), One
the frequency and duration of eye contact they particularly important aspect is posture. Four
have with their patients. The use of eye contact is types of posture have been identified:
important for assessing a range of patient needs
and providing feedback and support, and its use • approaching posture, which conveys interest,
during the interview should be based on the pro- curiosity and attention, e.g. sitting upright
18 APPROACHING THE PATIENT
and slightly forward in a chair facing towards 'touchers'. During the assessment it may be nec-
the person you are communicating with essary to touch the patient in order to examine a
• withdrawal posture, which conveys negation, part of his body. This type of touching, known
refusal and disgust, e.g. distance between the as functional touching, is generally acceptable
receiver and the communicator, shuffling, to most patients as part of the role of the practi-
gestures indicating agitation tioner and as such does not carry any connota-
• expansion, which conveys a sense of pride, tion of a social relationship. However, people
conceit, mastery, self-esteem, e.g. expanded from certain cultures may find it difficult to
chest, hands behind head with shoulders in accept, even in medical settings. Prior to func-
air, erect head and trunk tional touching of a patient, it is important that
• contraction, which conveys depression, you inform the patient what you intend to do
dejection, e.g. sitting in a chair with head and the reasons for doing it.
drooped, arms and legs crossed or head held During the interview you may wish to use
in hands, avoiding eye contact. touch as a means of reassuring the patient, to
indicate warmth, show empathy or as a sign of
Clearly, the posture adopted by the health care care and concern (McCann & McKenna 1993). A
practitioner is important in developing a rapport hand lightly placed upon a shoulder or holding a
and a working therapeutic relationship with the patient's hand are means of showing concern and
patient. giving reassurance. It is difficult to produce
When we speak we also tend to use our arms guidelines for when this type of touching should
and hands to reinforce and complement the or should not be used. Practitioners must feel
verbal message. In fact, when people are con- confident and happy in its use, and must also take
strained from using their arms and hands, they into account a multitude of communication cues
experience greater difficulty in communicating from the patient before deciding whether it is or is
(Riseborough 1981). Self-directed gestures such not appropriate (Davidhizar & Newman 1997).
as ring twisting, self-stroking and nail biting may Proxemics. All of us have a sense of our own
indicate anxiety. Be aware of self-participation in personal territory. When someone invades that
these types of activities as you may convey a territory, depending upon the situation, we can
non-verbal message of anxiety to your patient be fearful, disturbed or pleased and happy. As
while verbally you are trying to convey a with touch, our sense of personal space is
confident approach. The health care profession affected by culture. In some cultures individuals
should be sensitive to the non-verbal gestures have a large personal space, whereas in others
used by the patient as these may reveal more they have a very small personal space.
about the patient's thoughts and feelings than Encroaching on someone else's personal space
they are able to communicate verbally (Harrigan can be perceived as intimidation and, in the case
& Taing 1997). of the assessment interview, may put patients on
Touch. The extent to which touching is per- their guard. As a result the patient may become
missible or encouraged is related to culture reluctant to disclose relevant information. Hall
(McDaniel & Andersen 1998). In general, the (1969) defined the four zones of personal space
British people are not known as a nation of (Table 2.3).
The zone in which people interact is highly at which you conduct the assessment interview
influenced by social status and people who have may have a significant effect on the success of the
an equal status tend to interact at closer distances interaction. There are four main ways in which
(Zahn 1991). The assessment interview usually you can position yourself in order to interact
takes place in the social/consultative and the with the patient (Fig. 2.1): (i) conversation;
personal zone. During the interview it may be (ii) cooperation; (iii) competition; and (iv) coac-
necessary to enter the intimate zone. Prior to tion. Research indicates that the conversation
doing this, notify the patient in order to justify position is most appropriate for an assessment
any actions requiring closer contact. interview. In fact, research has shown that
Social interactions are not only influenced by when CPs sat at a 90Q angle to their patients
distance, but also by bodily orientation. The angle during a clinical interview, the amount of
A B
C o
Figure 2.1 Body orientation may influence the success of the interview. The figures show four positions commonly
encountered when two people interact. Which of the following orientations do you think would be most appropriate for the
assessment interview? A. Conversation B. Cooperation C. Competition D. Coaction.
20 APPROACHING THE PATIENT
Dialect conveys which part of the country we gender, diagnosis, social class, personality and
originate from. It may also cause us to use vocab- family structure. However, the impact on actual
ularya person from another part of the country is patient care was harder to classify. What does
not familiar with. Avoid using colloquial terms. seem to be the case is that patients were less
Dialect, on the other hand, is not so easy to alter. likely to be seen as having unique concerns,
The only time it should be considered is when health problems and social circumstances.
patients cannot understand what the practitioner Consequently, in addition to practising inter-
is saying. Finally, volume should not be changed viewing skills, it is important for health care
too regularly. Shouting at the patient should be practitioners to reflect on any belief systems they
avoided. In the clinical setting, as in life in may hold regarding particular patient groups,
general, it certainly does not guarantee that the and consider how such views may impair the
other person will listen more to what you say! overall success of the assessment interview.
From this section it should be clear that health
care professionals need to be sensitive to the kind
Documenting the assessment
of atmosphere they are creating through their
interview
non-verbal communication, and the role this may
have in the subsequent interaction with the It is essential either during or at the end of the
patient. The extent to which you establish a satis- assessment to make a permanent record of the
factory rapport will depend heavily on your non- findings of the interview. This record is essential
verbal skills and how you develop them in your as an aide-memoire for future reference when
clinical work (Grahe & Bernieri 1999). monitoring and evaluating the treatment plan
and as a means of communicating your findings
to another practitioner who may collaborate in
Stereotyping treating the patient.
Health care practitioners should be aware of their Despite recent discussions within the field of
own underlying psychological characteristics, podiatry regarding changing to electronic data
which may have a profound effect on the interac- management systems, the majority of patient
tion - i.e. stereotypes. A stereotype is a belief that records are still stored on paper. However, the
all members of a particular social group share use of computerised records is on the increase,
certain traits or characteristics (Baron & Byrne particularly in private practice. It may well be in
2000). For example, you might hold particular the future that paper records are discarded com-
ideas about the characteristics of a patient who is pletely, and replaced by computerised tech-
an alcoholic, elderly, from an upper social class niques. Whatever the future may hold, the
group, from a minority ethnic group or female. In need for clear, accurate recording of information
fact, you probably already hold a range of stereo- will still be the same. The recording of assess-
types about a wide group of patients whom you ment findings, together with the recording of
have never actually treated! While stereotypes treatment provided, forms a legal document.
are not always negative, they do share a common Patient records would certainly be used if action
characteristic in that they reduce the ability of the was taken by a patient against a practitioner, or
health care worker to see the patient as an indi- if certain agencies required detailed evidence
vidual. Consequently, any information gathered of management and progress in the case of
from the patient during the assessment interview disability awards.
is likely to be interpreted in the light of such Patient records may take a variety of forms: at
stereotypes (Price 1987). Ganong et al (1987) con- the simplest level a plain piece of paper may be
ducted a review of 38 research studies, which used. If using plain paper it is essential to adopt
examined stereotyping by nurses and nursing an order to the presentation of your assessment
students. Results indicated that nurses held findings: e.g. name, address, doctor, age, sex,
stereotypes about patients on the basis of age, weight, height, main complaint, medical history,
22 APPROACHING THE PATIENT
etc. This is considered further in Chapter 5. A ment interview may be aimed at undertaking a
variety of patient record cards exist in the NHS full assessment of the patient, with treatment
and private practice. Many practitioners and provided at the end of the interview.
health authorities produce their own tailor-made Letter of application. Was the patient referred
record card. The Association of Chief Chiropody or self-referred? If the patient was referred by
Officers produced a standard record in 1986 for another health care practitioner there should be
charting foot conditions, diagnoses and treat- an accompanying letter of referral. Read this
ment progress. carefully so you are fully informed of the reasons
Handwritten recording of information requires for referral. This information should be used as a
the following: starting point for the assessment. If patients have
referred themselves directly (self-referred) they
• The writing is legible and in permanent ink,
should complete any appropriate documentation
not pencil. If another practitioner cannot read
prior to the interview. Information on application
your writing the information is of no use.
forms can be used to prioritise patients and
• The information is set in a clear and logical
ensure the most suitable practitioner sees them. If
order. It is essential to use an accepted
no application form or letter of referral is avail-
method.
able the practitioner has very little information
• Accurate recording of location and size of
prior to the interview, possibly only the patient's
lesions or deformities. The use of prepared
name.
outlines of the feet are very good for
You may wish to give the patient a short health
indicating anatomical sites and save
questionnaire to complete prior to the assess-
additional writing.
ment (pp. 77-78). This questionnaire may be sent
• Abbreviations are avoided where possible.
to the patient prior to the interview or the patient
What is obvious to you may not be so
may be asked to fill it in on arrival. These ques-
obvious to another practitioner.
tionnaires provide the practitioner with impor-
• Entries are dated. Recording the medication a
tant information before the start of the interview.
patient is taking is useless unless it is dated.
The patient should be allowed time to complete
Once dated the information can be updated
the questionnaire in order that he can think about
as and when there is a change.
his responses. The advantage of such a question-
• Each entry should be signed and dated by the
naire is that the practitioner does not have to ask
practitioner.
the patient a series of routine questions during
the interview. However, some patients may be
STRUCTURING THE ASSESSMENT reluctant to fill in a form without having met the
INTERVIEW practitioner or reluctant to disclose information
in writing.
Preparation
Prior to the interview try to read all the infor-
In order to achieve a good assessment interview mation you have about the patient. You can then
it is essential you prepare yourself for the inter- come across to the patient as well informed and
view. The following should be taken into consid- as someone who has taken an interest in him.
eration. Patient expectations. Does the patient know
Purpose. It is essential that the practitioner is what to expect from the assessment interview?
clear as to the purpose of interview. In some Some new patients, prior to attending their
instances the assessment interview may be used assessment appointment, are sent an information
as a screening mechanism to identify patients for sheet or booklet explaining the purpose of the
further assessment. It may be used to gain infor- assessment interview and what will happen
mation from patients in order that their needs during it. Such an initiative is helpful. The cause
can be prioritised and those judged to be urgent of a poor interview may be that the patient's
can be seen first. On the other hand, the assess- expectations of what will happen are very differ-
THE ASSESSMENT INTERVIEW 23
ent from what actually happens. For example, a treatment is not normally provided at the end of
patient who expected immediate treatment and the assessment. On the other hand, using a clinic
had not envisaged any need for history taking ensures that clinical equipment is readily to hand
may well say, 'Why are you asking me all these and the patient can be moved into different posi-
questions?'. Table 2.4 highlights what should be tions if there are controls on the couch.
contained in a patient information booklet. During the interview you should ensure that
Waiting room. Patients can spend a lot of time you are not disturbed. If there is a phone in the
in the waiting room, especially if they arrive too room, redirect calls. Ensure the receptionist does
early or are kept waiting due to unavoidable cir- not interrupt. While the patient is in the room
cumstances. Try sitting in the waiting room in you should be giving him your undivided atten-
your clinic. Look around you: how welcoming is tion. Constant disturbances not only makes the
it? The waiting room sets the scene for the rest of assessment interview a protracted occasion but
the interview. Where possible, ensure that it is in also can prompt the patient into feeling that his
good decorative order, clean, with magazines to problem is not worthy of your attention.
read and informative, eye-catching posters or
pictures on the wall. Make the most of a captive
The interview
audience to put over important health education
information. TV monitors showing health pro- When the patient enters the room, welcome him
motion videos may be used. to the clinic, preferably by name. This person-
The name of the practitioner displayed outside alises the occasion for the patient and at the same
the clinic may be useful. Some clinics, like a time ensures that you have the correct patient. If
number of high street banks, have a display of you have difficulty with the patient's name, ask
photographs with the names and titles of those politely how to pronounce it rather than doing so
within the department or centre. incorrectly. Introduce yourself. As part of the
Interview room. The assessment interview may Patient's Charter you should be wearing a name
be carried out in an office or in a clinic. Both have badge but a personal introduction is usually
advantages and disadvantages. Using an office preferable, especially if the patient's eyesight is
prevents the patient being put off by surround- poor. It is useful to shake the patient by the hand
ing clinical equipment. It facilitates eye-to-eye since touch is an important aspect of non-verbal
contact by sitting in chairs, and provides a non- behaviour (as discussed earlier), although this
clinical environment. This is especially useful if may be influenced by personal preference.
At this stage you may find it helpful to make
Table 2.4 Information booklet for patients to read prior to one or two general conversation points about
the interview the weather, the time of year or some news item.
The booklet should contain the following information:
This enables patients to see you as a fellow
human. Remember that during the interview
The purpose of the assessment interview
they are going to give a lot of themselves to you.
How long the interview should take
It is important that patients feel you are
What will happen during the interview someone they wish to disclose information to.
Specific information the patient may be asked to provide, Use the introduction as an opportunity to
e.g. list of current medication
explain the purpose of the interview and what
Specific items the patient may be asked to bring, e.g. will happen.
footwear
The positioning of patient and practitioner can
• Examples of questions he/she is likely to be asked
influence the success of the assessment interview.
• The possible outcomes of the assessment interview, e.g. Ideally, you and the patient should be at the same
whether the patient will receive treatment at the end of it.
level in order to facilitate eye-to-eye contact.
The booklet may also contain a health questionnaire for the
patient to complete and bring to the assessment interview.
Barriers such as desks are often used in medical
interviews. They can be considered as means of
24 APPROACHING THE PATIENT
making the interview formal. Standing over a As a general rule of thumb the interview should
patient who is sitting down or lying on a couch be brought to a close when the practitioner feels
may be intimidating. the patient has been given an opportunity to talk
Data gathering. It is essential that the practi- about the problem. Body language can be used to
tioner is clear as to what areas should be covered convey the closing of the interview. Standing up
in the interview. A logical and ordered approach from a sitting position, shuffling of papers, with-
should be adopted. However, it is not always drawing eye-to-eye contact are all ways by which
possible or desirable to stick to an ordered the end of the interview can be conveyed to the
approach. Patients tend to talk around issues or patient, together with a verbal message.
elect to give information about a question that The patient should not leave the interview
you asked earlier at the end of the interview. You without fully understanding what is to happen
must make allowances for this. next and without an opportunity to ask ques-
Effective and efficient use of time is para- tions. A range of outcomes may result from the
mount. Experienced practitioners combine the assessment interview (Table 2.5). Patients should
interview with the examination. This is know which outcome applies to them. They
achieved by, for example, feeling pulses and should always be given the opportunity to raise
skin temperature while simultaneously asking any queries or concerns they may have prior to
questions about medical history. This technique leaving the assessment. This is one of the most
is a matter of preference; some prefer to com- important parts of the assessment and should not
plete the interview before commencing the be hurried. The patient must leave the assess-
examination. ment fully understanding the findings of the
After each assessment interview reflect upon assessment interview and what action, if any, is
it. Ask yourself how you could improve your to be taken, and it is the responsibility of the
performance and how you could make better use health care professional to ensure that they have
of the time. This will help you to make the best communicated such information clearly (Calkins
use of the data-gathering stage of the interview. et al 1997).
Peer appraisal is another mechanism that you It is helpful to provide written instructions as a
may find helpful in aiding you to develop good follow-up to the interview. For example, if the
data-gathering skills. patient is to be offered a course of treatment what
will the treatment involve, when will it be given,
who will give it, what problems may the patient
Closure experience?
Bringing the assessment interview to a close is a
difficult task. When do you know you have
enough information? This is a difficult question Table 2.5 Outcomes from the assessment interview
to answer. Some presenting problems, together • Treatment is not required; the patient requires advice and
with information from the patient, can be easily reassurance
diagnosed. Other problems are not so easy to • The patient can look after the problem once appropriate
resolve and may require further questioning and self-help advice has been given
investigations. • A course of treatment is required; the patient should be
General medical practitioners have been informed as to whether treatment will commence straight
after the assessment interview or at a later date
shown to give their patients, on average, 6
• The patient needs to be referred to another practitioner for
minutes of their time. Psychotherapists, on the treatment
other hand, spend 1 hour or more on each • Further examination and investigations are required
assessment. Unfortunately the demands on before a definitive diagnosis can be made
practitioners' time means they are often not in a • A second opinion is required
position to give the patient as much time as they
• The urgency for treatment should be prioritised
would like.
THE ASSESSMENT INTERVIEW 25
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THE ASSESSMENT INTERVIEW 27
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CHAPTER CONTENTS
Introduction 29
The problem 30
Encouraging the patient to tell you about concerns
The presenting problem
and problems 30
Patients with special needs 31 1. Merriman
Why did the patient seek your help? 31
Summary 36
INTRODUCTION
Most patients consult a practitioner because
they have concerns about or problems with their
lower limbs. Problems are usually quite specific
and focused. Patients may have problems with
painful feet, an ingrowing toe nail or difficulty
accommodating a bunion in footwear. Concerns
are where the patient is worried or anxious
about something. Patients may have concerns
related to a problem, e.g. they are worried about
an ulcer that is taking a long time to heal.
Conversely, a patient may have concerns but no
specific problems, e.g. a patient may be con-
cerned that an asymptomatic mole on their leg
may be a malignant melanoma.
The role of the practitioner is to discover what
are the patient's concernis) and problemts) in
order that an effective management plan can be
drawn up and implemented. This may involve
anything from giving reassurance, e.g. that the
mole is not a melanoma, to implementing a
treatment plan aimed at resolving or reducing
the effects of a specific problem, e.g. pain in the
foot.
During the assessment interview the patient
should be given ample opportunity to express
their concerns and talk about any problems they
may have. The remainder of this chapter con-
centrates on acquiring information about the
patient's presenting problemts). However, the
practitioner should always remember it is also
important to identify any concerns the patient
may have.
29
30 APPROACHING THE PATIENT
patient's own words what she is concerned about Table 3.2 Reasons for a patient choosing a practitioner
and what she sees as a problem. Avoid medical Applied for treatment at their local health service
jargon wherever possible.
Found your name in the yellow pages
Having obtained an idea of the patient's con-
• Saw an advertisement
cerns, it may help to find out if she has any
thoughts as to the cause. Ask the reason for such • Noticed your plate outside the practice
conclusions. The answers to these questions may • Were advised by a friend or relative to seek your help
reveal whether patient and practitioner share the • Were referred by another health practitioner, e.g. GP
same view. Are seeking a second opinion because they were
When patients do reveal what is worrying unhappy with the response of the first practitioner
them, avoid being judgemental and making
comments such as 'Oh, that's nothing!' or 'I
don't know why you are so worried!'. Remem- may want you to give a different diagnosis from
ber it is a problem to the patient even if it is rel- the one given by the previous practitioner. As a
atively innocuous to you. Patients may not result she may not disclose all the salient features
reveal their real reason for coming to see you of the problem. It is important to remember that
until they are just about to leave. This can be a outstanding legal claims for lower limb injuries
source of annoyance to the busy practitioner. Do may affect the patient's perspective.
try and give the patient time even if it is at the
end of the consultation.
ASSESSMENT OF THE PROBLEM
Patients with special needs Assessment of the problem involves acquiring
information about the history of the problem.
Some patients may experience other difficulties The history must be taken logically and system-
in telling you about their concerns and problems atically. An assessment of the current level of pain
than simply having poor powers of description. and discomfort should also be undertaken.
The patient may be deaf and dumb, have suf-
fered a stroke, have a speech impediment or have
learning or language difficulties. It is important History of the problem
you give these patients extra time. Avoid History taking involves finding answers to a
jumping to too many assumptions. If the patient range of questions (Table 3.3). Many diseases can
can write, ask her to write down the nature of the be identified by the pattern of symptoms they
complaint. Friends or relatives may be able to display. Research has shown that history taking
provide valuable details and information or act
as interpreters.
Table 3.3 The history of the problem: questions to ask the
patient
Why did the patient seek your help?
• Where is the problem?
A variety of factors can influence why a patient
How did it start?
has chosen to visit your practice. Table 3.2 gives
How long have you had the problem?
the usual reasons for a patient choosing a partic-
ular practitioner. It is important to find out what • Where is the problem?
made the patient choose you. For example, a • When does it trouble you?
patient who has been referred by a friend or rela- • What makes it worse?
tive may find it very easy to disclose her concerns • What makes it better?
to you. The friend/relative may have been very • What treatments have you tried?
complimentary about your abilities. On the other • Are you treating it at the moment?
hand, a patient who is seeking a second opinion
32 APPROACHING THE PATIENT
can be more effective in diagnosing a problem patient initially experienced. For example, was
than clinical tests alone (Sandler 1979). there anything visible at the start, such as a rash,
Where is the problem? Locating the problem is swelling or erythema? Were there any symptoms,
very important. Getting the patient to show you e.g. the throbbing associated with acute
by pointing is the best way. If the patient has inflammation? Initial symptoms may be different
difficulty reaching the area, you may find it from the patient's current symptoms, especially
helpful to present an outline of the lower limb if the condition had an acute onset but is now
and ask her to mark the area affected. For chronic.
example, pain may start in one area but then How long have you had the problem? It may be
radiate to other areas. Some problems may have necessary to jog the patient's memory, especially
a precise location; others may be far more diffuse if the problem started some time ago. Using
or have multiple sites. These variations may family occasions such as weddings or births,
yield helpful clues to diagnosis. Isolating a national events or the season of the year may
localised area in the case of pain can be very help the patient to pinpoint which time of the
helpful in differentiating enthesopathy from the year it started.
more general discomfort associated with conges- When does it trouble you? Some conditions
tion of the heel pad. During the physical exami- may give rise to constant symptoms. Others may
nation you may touch the area and attempt to occur especially at night or during the day. For
elicit the symptoms in order to make sure you example, one of the distinguishing features of
have isolated the area. Do not forget to tell the gout is nocturnal pain. Chronic ischaemia is asso-
patient that this is what you are going to do. ciated with pain in the calf muscle (intermittent
Palpation should use no more pressure than nec- claudication) after a period of walking and the
essary to elicit symptoms and isolate the particu- maximum distance the patient can walk prior to
lar anatomy affected. It is essential that you experiencing pain gives an indication of the
record, either on a diagram or in words, the loca- severity of the problem.
tion of the problem and give an indication in the What makes it worse and what makes it better?
records as to whether it is well localised or Some conditions may improve on rest, others can
diffuse. For example, a patient with plantar digital deteriorate. Patients may discover all sorts of
neuritis (Morton's neuroma) may complain of ways to alleviate their symptoms, e.g. wearing
acute pain at one particular site, but may also particular shoes, adopting a different walking
describe a paraesthesia which radiates towards pattern. Such information can provide valuable
the apex of the toes. Diagrams may be preferable clues. In instances where patients alter their gait
to written descriptions. Another practitioner because of a problem affecting one part of their
treating the patient on a different occasion can foot or leg they may develop secondary problems
see exactly where the problem lies. It is essential elsewhere. It is essential that the practitioner
that dimensions of skin lesions are recorded. This identifies the original problem, as treatment for
approach allows progress to be monitored for the secondary problem will not be successful
improvement or deterioration. until the initial problem is identified.
How did it start? It is important to identify how What treatments have you tried? Are you treat·
the problem started. The problem may have had a ing it at the moment? It is important to find out if
sudden or an insidious onset. For example, the patient has or is presently using any medica-
rheumatoid arthritis may have an acute sudden tions. Sometimes treatments can mask or alter
onset accompanied by raised temperature and the clinical features of a problem and make diag-
severe joint pains, or more commonly a slow nosis difficult. For example, using 1 % hydrocor-
insidious onset with general aches and pains, tisone cream on a fungal infection of the skin
which gradually get worse and more regular. may mask the inflammatory response and blur
Besides trying to locate the start of the condition, the distinctive border between infected and non-
it is also important to record the symptoms the infected areas.
THE PRESENTING PROBLEM 33
It is important that you record the information pain but as it becomes chronic and the disease
the patient gives you in response to all these process spreads it can affect a wider area.
questions. All critical events should be dated. Radiating pain can result from the extent of the
disease or from pain being referred from one site
to another; for example, a trapped spinal nerve
Dimensions of pain can lead to pains in the leg. Usually, referred pain
Pain is a subjective, multidimensional phenom- does not get worse when direct pressure is
enon that can be affected by social and psycho- applied to the site affected. However, if the pain
logical factors. In the same way as individuals has a localised cause it usually worsens when
differ over what they perceive as a problem, indi- direct pressure is applied.
viduals also differ when it comes to the assess-
ment of their pain. Pain caused by apparently
Severity
similar conditions affects individuals in very dif-
ferent ways. Practitioners should avoid making Certain conditions give rise to severe pain, e.g.
assumptions about the severity of pain an indi- myocardial infarction. However, a patient's ability
vidual is experiencing. Patients vary in their abil- to tolerate and cope with pain differs so much
ities to cope with pain. Some are more than that a description of the severity of the pain must
willing to complain about mild discomfort, be assessed alongside the other features.
whereas others make no complaint despite being
in considerable pain.
Duration
Tolerance and coping are subjective concepts
that are difficult to quantify. A patient's state of Pain may be fleeting or may be persistent.
mind and personal circumstances may make Ascertaining the duration of the pain can provide
their pain worse or demand that they ignore it. valuable information. For example, pain due to
For example, it is well known that runners may intermittent claudication may last a few minutes
continue to run in a race despite having sustained to half an hour. The pain associated with a deep
an injury. vein thrombosis is persistent. These differences
The assessment of pain requires information can be helpful in differential diagnosis.
about its character, distribution, severity, dura-
tion, frequency and periodicity. This information,
Frequency and periodicity
coupled with the history of the problem and
details of the patient's concerns, helps the practi- Some conditions lead to pain occurring in a
tioner to arrive at the correct diagnosis and draw regular pattern; others result in a less pre-
up an effective treatment plan. dictable pain pattern. It may be that the pain
recurs infrequently or regularly.
Character
Pain can be superficial or deep. Pain arising in
the skin often gives rise to a pricking sensation if Table 3.4 Descriptors used to describe pain
brief or burning if protracted. Deep pain is more
Vice-like Deep
nebulous and is often associated with a dull ache.
Patients may use a variety of adjectives to Tooth ache On touching
describe their pain (Table 3.4). Throbbing On weightbearing
Sharp Intermittent
Stabbing
Distribution
Shooting
Pain may be localised, diffuse or radiating. Bursting
Initially, a problem may give rise to localised
34 APPROACHING THE PATIENT
different symbols, the type of pain that occurs low back pain (Ransford et al 1976). This
(Fig. 3.2). Pain charts have been used as an aid method should be used with great caution
to the psychological evaluation of patients with and with the assistance of a suitably qualified
psychologist in order to prevent incorrect
conclusions being reached.
Pain diaries. It may be helpful, especially if a
patient is rather vague about the duration and
frequency of the pain, to get the patient to com-
plete a diary of the pain over a specific period of
time. Figure 3.3 illustrates a pain chart. The cate-
gories used in the chart were devised by the Pain
Research Institute, Liverpool. While pain diaries
can be helpful, they may lead patients to focus on
their problem and could even exacerbate it.
The information gained from a patient present-
ing with a painful first metatarsophalangeal joint
is shown in Table 3.5. The data used for this
example suggest a diagnosis of gout. Laboratory
tests and further assessments, i.e. medical and
social history, may confirm this diagnosis.
REFERENCES
Boeckstyns M E H 1987 Development and construct validity Melzack R 1975 The McGill Pain Questionnaire: major
of a knee pain questionnaire. Pain 31: 47-52 properties and scoring methods. Pain 1(3): 277-299
Bowsher D 1994 Acute and chronic pain and assessment. In: Ransford A 0, Cairns D, Mooney V 1976 The pain drawing
Wells P E, Frampton V, Bowsher D (eds) Pain as an aid to the psychologic evaluation of patients with
management by physiotherapy, 2nd edn. Butterworth- low-back pain. Spine 1(2:6): 127-134
Heinemann, Oxford, pp 39-42 Sandler G 1979 Costs of unnecessary tests. British Medical
Budiman-Mak E, Conrad K J, Roach K E 1991 The Foot Journal 2: 21-24
Function Index: a measure of foot pain and disability. Townsend P, Davidson N 1982 Inequalities in health: the
Journal of Clinical Epidemiology 44: 561-570 Black Report. Penguin, Harmondsworth, pp 76-89
Hayes R 1995 Pain assessment in the elderly. British Journal Weir E C, Burrow J G, Bell F 1998 Podiatrists and pain
of Nursing 4: 1199-1204 assessment - a cross sectional study. The British Journal
Herr K A, Mobily P R 1991 Complexities of pain assessment of Podiatry 1(4): 128-133
in the elderly. Journal of Gerontological Nursing 17: 12-19
CHAPTER CONTENTS
Introduction 37
Types of measurement 38
Quantitative measurement 38
Clinical measurement
Qualitative measurement 38
Semi-quantitative measurement 39 c. Griffith
Integration of the three types of measurement 40
Error in measurement 44
The clinical environment 45
Procedure 45
The equipment 45
The practitioner 47 INTRODUCTION
The patient 50
Clinical measurement is closely intertwined with
Measurement evaluation exercise 51 assessment and evaluation of the lower limb. The
Conclusion 52 term 'measurement' refers to the discovery of the
Summary 52 extent of an observation and to the result
obtained. 'Assessment' and 'evaluation' are terms
that refer to the process of interpreting the
meaning of a measurement. Measurements are
used for a number of reasons. They are funda-
mental to the processes of diagnosis, prognosis,
prescription of treatment, case management and
assessment of outcomes.
The lower limb consists of a number of inter-
related complex body systems. Bones, joints,
muscles, nerves, blood vessels and other soft
tissues all contribute to the health and function
of the lower limb. With so many diverse struc-
tures and physiological functions in each of
these body systems, it is not surprising that a
wide variety of techniques have evolved to
measure their performance.
Some clinical observations are amenable to
objective scientific measurement and others are
not. To gain as much clinically useful informa-
tion as possible about patients and their
responses to treatment, both objective and sub-
jective measurement methods can be employed.
It is a matter of selecting the most appropriate
technique for the particular circumstances.
37
38 APPROACHING THE PATIENT
Quantitative measurement
Qualitative measurement
Quantitative measurements measure quantity in
the true scientific sense, being objective and typi- Qualitative measurements, as the name sug-
cally consisting of two parts: a numerical value gests, measure quality. They are subjective and
and a unit of measurement. The numerical value essentially descriptive measures dependent
denotes the magnitude of an observation, defined upon human perceptions. This type of measure-
against certain norms or standards called units ment results in an observation expressed in
of measurement. Units of measurement give a words. There is some debate as to whether qual-
dimension to the numerical value. The language itative observations are measurements in the
of scientific measurement is the Systeme Interna- true sense. Qualitative researchers argue a
tional (51), also known as the metric system. strong case for the legitimacy of these measures,
Examples of 51 units of measurement appropriate pointing out the reductionist nature of quantita-
to the clinical setting are kilograms (mass), metres tive results. They can provide extremely valu-
(length), pascals (pressure), newtons (force), hertz able clinical information where clinical features
(frequency), degrees (angle) and degrees Celsius cannot be quantified. Returning to the ulcer
(temperature). Because quantitative measure- example, qualitative measurement would
ments have both magnitude and dimension they include descriptions about the appearance of
can be recorded and communicated exactly and the ulcer. Qualitative descriptions of size could
concisely. include 'large', 'small', 'deep' and 'shallow'.
All results obtained from quantitative Comparison of size before and after a period of
measurements are classed as either interval or treatment can be indicated by using phrases
ratio levels of data. It is useful to know which cat- such as 'larger than', 'smaller than', 'shallower
egory data falls into because it affects its inter- than' and so on. Qualitative descriptions are
pretation. The numeric points or graduations on clearly less exact in terms of magnitude than are
any quantitative measurement scale have equal quantitative measures. It would not be possible
intervals between them. This is an important to say by how much the ulcer had decreased or
feature because the results can be compared enlarged over time. Quantitative measurement
arithmetically. They can also be used in the most is clearly superior in the context of magnitude.
powerful inferential statistical tests. A clinical On the other hand qualitative measures can
example will make the concept clear. If a plantar make a major contribution to the understand-
ulcer had a diameter of 1.5 em and a depth of ing, description and communication of clinical
0.5 em this would convey the size of the lesion observations. Considerable credence would be
exactly. With treatment it would be hoped that given to the colour of the ulcer's base and dis-
the ulcer would resolve. The progress of the ulcer charge, the shape of the lesion's edges and
could be monitored over time. If on a subsequent walls, and perhaps any odour noticed. Changes
occasion the ulcer was found to have a diameter in these characteristics are clinically useful indi-
CLINICAL MEASUREMENT 39
hallux valgus condition is denoted simply as and excessive flexion of the hip and knee, so that
present or absent with no indication as to the the toes can clear the ground.
severity of the condition. Only the simplest of Semi-quantitative measurement. A score of
arithmetic calculations can be carried out, and 3 on the MRC muscle strength grading scale. This
the data can only be used in the weakest types of indicates the level of impairment of the anterior
statistical test. muscle group. There is a deficit of motor power.
The patient can dorsiflex the foot against gravity
but not against resistance of the practitioner's
Integration of the three types of hand.
measurement
Quantitative measurement. Active dorsiflexion
In practice, techniques selected from the three can be quantified with a goniometer, e.g. _10°
types of measurement may be used together to dorsiflexion. The measurement of _10° dorsi-
obtain a comprehensive clinical picture. This is flexion indicates that with maximum contraction
illustrated in Table 4.2 by discussion of the of the anterior muscle group the foot still remains
results of measurements obtained for a patient 10° plantarflexed at the ankle. With assistance
presenting with walking difficulties. The rele- from the practitioner the maximum range of
vant case history concerns a fall 1 year previ- dorsiflexion can be obtained (_5°). Although an
ously when a fractured pelvis was sustained. additional 5° of dorsiflexion was obtained with
Following healing and discharge from hospital, the practitioner's help the foot remained
the left leg and foot have become progressively plantarflexed at the ankle. Comparison with the
weaker. unaffected ankle and known normal values will
Qualitative measurement. There appears to be a enable the practitioner to determine the extent of
motor deficit in the anterior compartment of the the reduction in ankle dorsiflexion and identify
leg. This may be due to impingement of a periph- the probable cause. The calf may have shortened
eral nerve related to the pelvic fracture. The lack of if there is a loss of power in the anterior antago-
ankle dorsiflexion during the swing phase is being nist muscle group. Future measurements can be
compensated proximally, by elevation of the trunk used to quantify improvement or deterioration of
ankle dorsiflexion.
The example above demonstrates the value of
Table 4.2 Assessment results
integrating quantitative, semi-quantitative and
Type of Method Results qualitative types of measurement. A complete
measurement picture of the case can be constructed where evi-
Qualitative Visual Stance phase: The dence from one type of measurement comple-
observation left foot slaps noisily ments another. Evaluation of the evidence then
of gait against the ground enables the practitioner to infer the cause of the
at each step
Swing phase: The left changes in gait pattern with more than a reason-
foot is plantarflexed, able degree of confidence. A thorough under-
the hip and knee are standing of the problem gained in this manner
flexed excessively
and there is upper enables an appropriate diagnosis and manage-
body sway to the ment plan to be decided.
right It could be argued that all measurements for
Semi-quantitative MRC muscle The anterior muscle the patient could have been quantitative. Gait
strength compartment score
grading scale of 3 (i.e. movement
analysis could have been recorded with video
against gravity) and the movements of the limb segments digi-
Quantitative Goniometric Active ankle tised to allow quantification. Muscle power
measurement dorsiflexion -10° could have been quantified with a dynanometer.
Passive ankle Nevertheless, the example represents the most
dorsiflexion _5°
usual clinical situation where the practitioner
CLINICAL MEASUREMENT 41
may only have access to a goniometer. An impor- • it may be clear that one particular technique
tant issue for consideration has now been raised. is preferred.
If a number of different measurement options are
available, how does the practitioner select the
The patient
most appropriate method?
Each patient is unique. Although there may be
similarities between patients, no two cases are
SELECTION OF AN APPROPRIATE
identical. An individual patient's characteristics
MEASUREMENT TECHNIQUE
will affect his suitability for different measure-
Selection of an appropriate measurement tech- ment techniques. Age, mental state, build,
nique can be difficult, particularly for students current medical status and medication, dietary
with relatively little experience. Many factors and social habits are characteristics that should
influence the choice of a measurement technique. influence decisions about the choice of measure-
The three main factors are: ment. This may result in a modification to the
measurement procedure, selection of an alterna-
• practitioner tive technique, or even a decision not to perform
• patient the measurement at all.
• resources.
use of a digital camera for two-dimensional mea- surement technique is not repeatable, and conse-
surement of ulcer size with a more traditional quently of limited clinical value.
approach with OpSite Flexigrid film. It was Many articles involving measurement ques-
shown that digital imaging was easier, faster and tion the repeatability of the techniques they have
subject to less variation. employed. Authors often make suggestions of
how their work may be refined to improve
repeatability, demonstrating that clinical mea-
TERMS USED IN CLINICAL surement techniques are continually evolving. A
MEASUREMENT novel procedure described by Prud'homme &
The notion of an ideal measurement is one that is Curran (1999) is one such example. A prelimi-
accurate, precise, repeatable, reliable and valid. To nary study of pain relief following treatment of
gain an awareness of both the value and limita- corns was conducted. They found that the direct
tions of contemporary measurement methods, an force that could be applied to the lesion with a
understanding of the terms associated with mea- hand-held algometer was greater after enucle-
surement is needed. ation of the corn. This indicated that symptoms
improved after podiatry treatment. The authors
identified several potential sources of error. The
Accuracy
rate of application and the uniformity of the
Accuracy concerns a result that reflects the true applied force, the linearity of the instrument and
value of the observation or phenomenon being variability in compliance of superficial tissues
measured. were all considered.
Precision Reliability
Precision is the degree of refinement in a mea- Reliability refers to consistency. It is the extent
surement and relates to the size of the intervals to which a measurement procedure produces
on the measurement scale. A rule with gradua- similar results under constant conditions on all
tions of 1mm would allow greater precision than occasions. Repeatability is a measure of reliabil-
one with graduations every Smm. The intervals ity. Clinical measures which quantify or semi-
between the graduations on the measurement quantify the extent of a problem can also be
scale should always be appropriate for the obser- used to detect change. In this context the mea-
vation of interest. If they are unnecessarily large surements are used both repeatedly and often
and the measurement indicator falls between by different people. Consequently, it is impor-
graduations the practitioner is forced to make an tant to know how much any difference is due to
estimate of the reading, increasing the potential real change and how much is caused by error
for error. (Wade 1992). In this way real improvements or
deterioration in a patient's condition can be
Repeatability determined. Where the repeatability of a tech-
nique is known and variation in measurement
Repeatability is determined by measuring the falls within clinically acceptable limits, the prac-
same patient with the same technique on two or titioner can interpret the results and make clini-
more occasions and comparing the results. cal decisions with confidence. Reliability can be
Inevitably there will be differences. An experi- reduced by many factors.
mental research design can be used to determine There are four main sources of uncertainty
statistically if any differences in repeated mea- when comparing two or more results of the same
surement results are large enough to be measure:
significant. A statistically significant difference
between the results would indicate that the mea- • variation in the patient's state
CLINICAL MEASUREMENT 43
• different instruments may vary, and one one's own measurement capabilities, and evalua-
instrument may vary with time tion should be made at periodic intervals.
• the same observer may differ when measuring Interobserver reliability. This factor concerns
(intraobserver reliability) the variation between results of repeated mea-
• different observers may differ when surements between two or more observers. The
measuring (interobserver reliability). more observers are involved, the greater is the
opportunity for differences to occur between
Patient's state. Differences in the patient's state them. There is evidence to show that intra-
between measurements may adversely affect the observer reliability is greater than interobserver
results. There may be changes in physical and reliability for many measurement techniques. For
mental states, motivation and fatigue levels. example, one study of repeated goniometric mea-
Ingestion of certain drugs and foods can surements concluded that reliability is increased
influence the results of some tests. Some observa- if only one observer takes the measurements
tions, e.g. blood pressure, can be affected by the (Boone et aI1978). Simple, well-defined measure-
time of day that they are taken. ment techniques have been shown to be more
Instrument variation. Different examples of the reliable, presumably because observers can
same instrument may differ in performance. follow the procedures more closely. It is generally
Booth & Young (2000) tested four types of com- agreed that reliability of measurement improves
mercially available 10-G monofilaments with a with training, education and experience (Bovens
I-kg load cell using a standardised technique. et al 1990, Diamond et al 1989, Freeman 1990),
Important adverse characteristics of the but Payne & Richardson (2000) found that relia-
monofilaments were discovered that have impli- bility of neutral and relaxed calcaneal stance
cations for clinical use. Accuracy varied between position measurements did not improve with
the different products (8.1 ± 0.3 to 10.1 ± 0.4), training in a group of undergraduate podiatry
where accuracy was defined as 10 g < 10%. The students. Where the same patient may be mea-
two most accurate types of monofilament were sured by different practitioners over time, the
tested further. The longevity and recovery time interobserver reliability between the individuals
were assessed. in the group should be known. This facilitates
Only 50% of the monofilaments were accurate interpretation of the differences in results to
after 200 compressions, and recovery could take interobserver error or to real change so that
up to 24 hours with none regaining their original useful clinical judgements can be made.
buckling force. Instrumentation may be affected However, reliability should not be considered
by environmental changes such as variation in exclusively but in context with other measure-
temperature and humidity. ment characteristics.
Intraobserver reliability. This factor concerns
the variation between the results of repeated
Validity
measurements obtained by the same observer.
Statistical techniques are used to determine Validity is concerned with whether the mea-
whether the differences in results are significant. surement actually does measure what it is sup-
Intraobserver variation can be attributed to many posed to measure (Bowling 1991). The idea of
human characteristics. Variation in results may using footprints to link foot types to foot pathol-
be due to differences in fatigue, motivation, ogy has appealed to numerous researchers. The
stress levels and dexterity as well as to inconsis- validity of footprint parameters used as indirect
tencies in technique. measures of the height of the mediallongitudi-
Intraobserver reliability differs from one indi- nal arch has been questioned. The arch angle,
vidual to another; some practitioners demon- footprint index and arch index described by
strate greater proficiency by obtaining more various authors were compared with a direct
consistent results. Ideally one should be aware of measure of arch height (Hawes et al 1992). It
44 APPROACHING THE PATIENT
was concluded that these footprint parameters from the tabulated data show that the sensitivity
were no more than indices and angles of the is high, at 95%, indicating that most patients with
plantar surface of the foot itself, and were hallux valgus were identified by the practitioners.
invalid measures of arch height. All of the foot- The specificity is the percentage of patients
print parameters had previously been found to without hallux valgus who were identified as not
be reliable. Presumably this means that the foot- having hallux valgus. The specificity is low at
print pattern and data measured from it are 45%. This means that 55% of patients without
repeatable, but the indices derived cannot be hallux valgus were falsely diagnosed as having
assumed to be valid indicators of arch height. In hallux valgus. The practitioners identified nearly
a more recent study, Mathieson et al (1999) com- half as many false positives (61) as true positives
pared electronic static and dynamic footprint (129). With so many false positives identified the
data using three different indices. Even though new clinical measurement technique would not
there were good correlations between the static be considered a useful screening test for hallux
and dynamic footprints, they concluded that the valgus.
parameters calculated differed considerably. Acceptable values for sensitivity and specificity
The concepts of sensitivity and specificity can be depend to some extent on the particular situa-
used to test validity. tion. Sensitivity of good tests is likely to be
Sensitivity. Ability of a measurement or test between 80% and 100%. Specificity should be in
to identify positive cases of the observation of excess of 95%, particularly for screening tests
interest. where most of the population is likely to be neg-
Specificity. Ability of the measurement or test ative; otherwise, more false positives than true
to exclude negative cases of the observation of positives may occur.
interest.
A hypothetical example will illustrate the prin-
ERROR IN MEASUREMENT
ciples of sensitivity and specificity. If we suppose
that the traditional approach to screening for A significant problem with taking measurements
hallux valgus is to X-ray each patient's feet, it is error. All results from measurements have two
might be thought beneficial to devise a method components: the true value of the observation of
that does not depend on X-rays. Practitioners interest and an error component. The error com-
could be trained to use a new clinical measure- ponent can be further divided into two parts.
ment technique to determine whether patients Random errors. These errors occur by chance
have hallux valgus or not. If X-rays are assumed and, because of their random nature, cannot be
to give the true result, the practitioners' results identified, controlled or eliminated. In research
could be compared with the X-rays. Two groups studies an appropriate research design and use of
of symptomatic patients, one group with and the inferential statistical tests take random errors
other without hallux valgus, would be selected into account. This type of error will not be con-
from the X-ray results. If the practitioners' mea- sidered further.
surements were completely valid, then all the
patients with a positive X-ray for hallux valgus
Table 4.3 Sensitivity and specificity
and those with a negative X-ray would be appro-
priately identified. This never occurs in practice. Practitioners' measurements X-ray results
There are always some false positives, i.e. those
Hallux valgus Hallux valgus
identified as having the condition when they do present not present
not, or false negatives, i.e. those identified as not Hallux valgus present 129 61
having the condition when they do. Table 4.3 Hallux valgus not present 7 49
Total 136 110
illustrates the main principles.
Sensitivity = 129/136 x 100 = 95%
Sensitivity is the percentage of patients correctly Specificity = 49/110 x 100 = 45%
identified as having hallux valgus. Calculations
CLINICAL MEASUREMENT 45
----------------------
Systematic errors. These errors relate to poten- ability and accuracy and, in most circumstances,
tial sources of measurement error that can validity. Standardised techniques have clearly
usually be postulated or identified. Once a source specified procedures which must be followed
of error has been identified, action should be closely. Unfortunately, standardisation cannot
taken to try and reduce its occurrence. In all mea- remove error completely. The extent of mea-
surements conducted on patients there are five surement error that is clinically acceptable is
main potential sources of systematic error: determined by the type of observation, research
and statistical methods. Where different tech-
• clinical environment
niques measure the same type of observation,
• procedure the one that produces the least error should be
• equipment selected. An understanding of the size of the
• practitioner error enables practitioners to understand the
• patient. limitations of the techniques they use so that
they can interpret their clinical measurements
The clinical environment realistically.
Research reports should be read with care.
Lighting must enable the practitioner to see Special attention should be paid to the quality
clearly so that information can be gathered and of the procedure before adopting a new or alter-
recorded with ease. Careful planning of the light- native technique. It is important to balance
ing arrangements is essential. Assessment areas gains in accuracy, precision, reliability and
should be well lit so that vital clinical features are validity claimed, particularly if they are mar-
not obscured. Special lighting facilities are some- ginal, with clinical costs and benefits to
times necessary. For example, a light box is essen- patients.
tial for clear interpretation and measurement
from radiographs.
Clinical space is often at a premium. It is essen- The equipment
tial that there is sufficient space for a selected Equipment indirectly involved with measurement
measurement procedure to be undertaken. Gait can affect results. The examination couch should
analysis requires a walkway of at least 6 m, but permit a variety of positions to suit the many
preferably 10 m, so that a representative walking types of examination that may be performed.
style can be seen. The ambient clinic temperature Practitioner fatigue will be reduced if the appro-
should be controlled at 21°C ± 2°C. This is not priate height of couch is used or if the height can
only important for the comfort of the practitioner be adjusted. Instrumentation used directly on the
and patient but is also essential for vascular and patient should be comfortable to handle and easy
neurological measurements. Significant adverse to use.
effects on vascular measurements are caused by Calibration of instrumentation is a fundamental
factors that change peripheral arterial resistance but essential process of measurement. The
(Johnson & Kassam 1985). purpose of calibration is to minimise the error
Background noise, interruptions and distrac- caused by the measurement equipment. It is a
tions during consultations should be kept to process of setting up the instrument so that its
minimum levels as they impair concentration, readings are as accurate as possible throughout its
communication and patient relaxation. range of measurement. The instrumentation is
tested against known standards. Calibration
curves are plotted so that the accuracy can be
Procedure
determined and the error quantified. An example
Standardisation of measurement techniques will make things clear. To calibrate weighing
reduces the potential for error in measurement. scales they must be placed on a horizontal surface.
Consequently, it can improve repeatability, reli- The measurement indicator is aligned to zero.
46 APPROACHING THE PATIENT
Known loads are applied at intervals throughout studied and where the equipment will be used
the measurement range. A comparison is made (West & Barnett 1999). As there is no perfect
between the output reading on the measurement system, practitioners must weigh the advantages
scale and the known load (kgf). By plotting the and disadvantages of each and choose the one
two variables a calibration curve can be produced. that most closely matches their requirements.
Ideally, the curve would be linear throughout the Platform systems. Platforms measure the
measurement range. If not, errors are identified unshod foot. The patient is unencumbered by
and the measurement tolerances calculated and the attachment of wires but they must target the
specified. platform accurately. Only data from one foot
Where instruments are precalibrated, errors (with a one-platform system) can be gathered
may be specified as a percentage error within the from each walk.
measurement range. For example, most manu- In-shoe systems. These systems seem attrac-
facturers of equipment for measuring foot pres- tive as they measure pressure at the foot-shoe
sure claim an accuracy within 10%. It is therefore interface and many sequential measures of right
not possible to know whether marginal differ- and left feet can be obtained from one walk.
ences are real or due to error. Recalibration of Attachment of wires to the patient, whether it is
equipment should be carried out periodically, to a data pack worn by the patient or by an
following manufacturers' guidelines. umbilical arrangement to a computer, may
Some instruments are designed to measure a affect the patient's gait. The in-shoe environ-
series of values during cyclic activities. Pressure ment is hostile to transducers: humidity, tem-
transducers measure pressure under discrete perature and bending effects may lead to the
areas of the foot. A transducer located under the production of artifact pressure readings or pre-
second metatarsal head would measure pro- mature failure.
gressive loading and unloading pressures
applied during one gait cycle. Static calibration
of the transducer is carried out by applying a 200
series of known loads and then progressively
removing them. A graph is produced in the C'O
~ (a)
form of a loop. This phenomenon is known as
.~ 160
hysteresis. Figure 4.1 shows that the output '"0
are therefore more prone to bias errors in practi- regarded as of little significance. By remaining
tioners than are quantitative measures. An as objective as possible and adopting a system-
awareness of the problems associated with sub- atic problem-solving approach this tendency
jectivity is important, because different individu- will be reduced.
als may perceive the same observation in The brain may interpret the same observation
different ways. in different ways, as shown in Figure 4.2B.
Often, preconceived ideas lead to mistakes, as The same observation may not only differ
illustrated in Figure 4.2A. When first seen most between individuals but differ in the same indi-
people read the legends incorrectly as 'Paris in vidual on different occasions or as they make a
the spring', 'Once in a lifetime', and 'Bird in the closer study.
hand'. We have a tendency to see what we Some quantitative measurement procedures
expect to see and ignore what we consider depend on some subjective decisions by the prac-
unimportant. This may happen in diagnosis, titioner. The location of pulses, anatomical land-
when a feature associated with a particular con- marks and alignment of instrumentation all rely
dition is given greater importance than it should on subjectivity, thus increasing the potential for
receive and assumptions lead to a rapid, poorly bias error. It is important to be aware of the sub-
considered diagnosis. It may be that other clini- jective qualitative factors which may impair
cal features indicate a different pathology but objective measurement so that attempts can be
these may go unnoticed, be ignored or be made to control them.
Vision
Vision plays a major part in measurement.
During clinical training a student practitioner
develops a 'trained eye'. Recognition of pathol-
ogy develops with time and practice into a fine
skill, where even subtle signs may alert the prac-
A
titioner to a problem.
Visual information may be impaired if lighting
is inadequate. Apart from the more obvious
difficulties caused where lighting levels are low,
shadows cast on to a part of the limb may
adversely affect subjective aspects during biome-
chanical examination. Eyeballing describes a
subjective visual technique that can be used to
align joints before measurement, or to identify
midpoints across skin surfaces as goniometric
reference points. Passive examination of the sub-
talar joint range of motion and neutral position is
considered to be an important element in under-
standing abnormal function of the foot.
Inappropriate placement of reference lines, par-
B
ticularly on the curved surface of the back of the
Figure 4.2 A. The three triangles. Failure to see the leg, is more likely to occur if one side of the leg is
duplicated words is common. We see only what we want to adequately lit and the other is not. A true vertical
see B. Howald is she? Some observers see a young bisection of the leg may not be obtained.
woman, others an old woman. The chin and neck of the
former become the nose and mouth of the latter and vice Consequently, the proportions of inversion and
versa (Munro & Edwards 1990). eversion contributing to the total range of motion,
CLINICALMEASUREMENT 49
and determination of the neutral position, would when reading analogue measurement scales.
be incorrect. Parallax error up to 3° was noted in one study
Parallax error. A potential source of measure- (Griffith 1988).
ment error, parallax error is particularly associ- The patient must be advised on the need for
ated with joint position and movement. appropriate clothing if normal indoor dress
Parallax is an apparent difference in position or inhibits a particular observation. Body parts
direction of an object caused by a change or rel- must be clearly exposed where feasible. Shorts
ative change of observation point, as shown in and a T-shirt, for example, allow a relatively
Figure 4.3. Viewing an object or patient at right uninhibited view of posture and movement.
angles will eliminate parallax error. Measure-
ment error will increase if the measurement
Touch
instrument is not aligned with the plane of
motion. A 90° alignment must also be ensured Touch involves many forms of direct and indirect
(using instrumentation) physical contact with
,
I
I
I
,
I
I
I I
,
I
patients. During clinical examinations various
components of the lower limb may be pushed,
pulled, pressed, squeezed and twisted. The
amount of force used is determined by feedback
I I I through the practitioner's proprioceptive path-
I I I
I I I ways, the patient's response, sound and visual
I I I information. It is very subjective. The force used
I
tpJctfJC F
to test joint ranges of motion will need adjust-
ment for different patients and different joints.
Fluidity of the joints, muscle tone and the weight
A B C
of the limb will all influence the force required to
examine a joint effectively.
Instruments used in neurological and vascular
assessments must be applied to the appropriate
area and with an appropriate amount of force.
Using neurotips, tuning forks and cotton wool
requires a systematic approach and correct tech-
nique. For instance, inadvertently tickling the
patient with cotton wool when testing for light
touch will be interpreted through pain pathways
rather than light touch receptors, invalidating the
result.
Measurement of lower limb temperature can be
obtained quantitatively with a digital thermome-
o ter, but most practitioners rely on touch. The prac-
ABC
titioner's hand temperature will influence his
appreciation of the patient's limb temperature.
Figure 4.3 The effect of parallax on observation of the This can be demonstrated with a simple experi-
midpoint of the posterior aspect of the leg and heel ment. If both hands are inserted into a bowl of
A. Inappropriate positioning of the patient's leg leads to
parallax error B. With the patient's leg and the tepid water, having previously had one in cold
practitioner's eyes correctly aligned parallax error is and the other in hot, a clear difference in appreci-
eliminated C. Inappropriate positioning of the practitioner's ation of temperature of the tepid water by each
eyes leads to parallax error D. The actual and apparent
midpoints obtained from the relative eye and leg positions hand is noted. The subjective appreciation of tem-
adopted in diagrams A, Band C. perature is therefore a relative phenomenon and a
50 APPROACHING THE PATIENT
patient's limb will feel warmer to a practitioner Vowden (1999), Grasty (1999) and Baker &
with cold hands than one who has warm hands. Rayman (1999).
===t>
Forward bloodflow
<;::===
Reverse bloodflow
TIme
Figure 4.4 Diagrammatic representations of Doppler output showing normal and abnormal waveforms (adapted from Baker
& Rayman 1999).
CLINICAL MEASUREMENT 51
sensation felt, which relies greatly on patient sub- index. Digital vessels are less likely to calcify and
jectivity. Vibration sensation may be tested with a toe pressures could be taken instead.
variety of instruments. Higher vibration percep-
tion thresholds (VPTs) are associated with large
MEASUREMENT EVALUATION
peripheral nerve dysfunction. A 128 Hz tuning
EXERCISE
fork is quick and simple to use but is unsatisfac-
tory for measuring the threshold at which vibra- Many commonly used measurement techniques
tion becomes perceptible. The Rydel Seiffer have been shown to be prone to substantial error.
tuning fork is a cost-effective alternative, allow- Problems with kinetic, goniometric, vascular and
ing semi-quantification. The biothesiometer and neurological measurement techniques applied to
neurothesiometer allow quantification but take the lower limb have been regularly reported. A
more time. Cassella et al (2000) used a neurothe- paper about vascular assessment has been
siometer to demonstrate that enhanced VPT selected from the literature so that the measure-
readings were obtained (i.e. the ability to per- ment issues raised in this chapter can be applied.
ceive vibration was improved) at the medial The paper simply looked at whether or not four
malleolus, first metatarsophalangeal joint and observers could agree on the presence of two
thumb in a mixed group of normal subjects pedal pulses. Following a summary of the
1 hour after caffeine consumption. It is therefore research findings the potential sources of error
important to enquire whether caffeine-contain- and possible solutions to minimise errors will be
ing drinks have been consumed before com- considered under the five main headings: clinical
mencing neurological testing. The psychological environment, procedure, equipment, practitioner
state of the patient may influence measurement and patient. The reader may also be interested in
results. Painful diabetic neuropathy is associated trying this exercise on papers of their own choice.
with significant depression (Tesfaye & Price Dorsalis pedis and posterior tibial pulses are
1997). These patients may, or may not, have traditionally palpated to evaluate the blood
normal peripheral nerve function. It is important supply to the foot. An investigation of observer
to consider the effect that depression might have variation in assessment of dorsalis pedis and
on any sensory test results obtained. posterior tibial pulses by palpation and Doppler
If the patient is embarrassed, poorly moti- ultrasound was conducted (Magee et al 1992).
vated, self-conscious or in pain, his walking The study concluded that palpation of pedal
pattern and speed may be altered. If patients are pulses in patients with arterial disease is subject
required to visualise and step on a specific target to substantial error.
such as a force or pressure platform, they may A consultant, registrar, senior house officer and
adjust walking speed or step length before acti- a nurse measured 33 claudicants and five con-
vating the transducer mechanism, giving an trols. Following palpation of the claudicants'
atypical result. Controlling walking speed is a pulses all observers agreed on the presence of a
major factor in foot pressure measurement. Step dorsalis pedis pulse in 67% of limbs, and the
length, cadence, stance phase gait and peak pres- presence of the posterior tibial pulse in 53% of
sure have all been shown to vary with walking limbs. In contrast, with Doppler ultrasound, all
speed (Hughes et aI1991). observers agreed on the presence of a dorsalis
Some underlying pathological conditions can pedis pulse in 58% of limbs, and the presence of
influence the measurement results. Doppler a posterior tibial pulse in 78% of limbs. The poor
ultrasound waves are attenuated when they pass reliability of these measurement procedures has
through fat, haematoma or scar tissue, resulting obvious clinical implications and warrants
in a weak signal. Calcification of arterial walls further consideration.
prevents collapse of the artery when a blood press- The clinical environment. Temperature and back-
ure cuff is applied. The abnormally high reading ground noise levels must be controlled to reduce
obtained would invalidate the ankle-brachial the potential for error. High and low temperatures
52 APPROACHING THE PATIENT
alter peripheral resistance and may have had an Some suggestions of changes to the measurement
influence on the ease of detection of the pulses if techniques have been made which hopefully
the ambient temperature was not controlled. would reduce the margins of error.
The procedure. Standardised procedures for Measurement of clinical observations is an
each measurement should be followed. The essential part of clinical practice, but it is not a
subject's acclimatisation time before measure- simple step-by-step process. The knowledge pro-
ments are taken is particularly important: at least vided by research leads to continual improve-
10 minutes' rest is required. The patients should ments in standardisation of techniques and
be placed in the same position for each measure- advancements in instrumentation. It is important
ment. The Doppler probe must be applied at the that practitioners develop a scientific and system-
correct angle (60°) against the direction of blood atic approach to clinical measurements and appre-
flow to obtain a clear signal. It is possible to ciate the value and limitations of their
occlude superficial vessels with the Doppler measurements. It is only by the diligent applica-
probe if too much pressure is applied. This may tion of measurement techniques that the body of
explain why there was lower agreement between scientific knowledge will increase and further
practitioners over the presence of the dorsalis improvements in the standards of clinical practice
pedis pulse when the Doppler probe was used. will occur.
The equipment. If different Doppler units were
used, even of the same make and model, there SUMMARY
could be differences in the results they produce. If
a Doppler unit's battery charge is low, weaker Measurement may be conceptualised as being
sounds may not be heard. Systems that can quantitative or qualitative in nature or a mixture of
provide a permanent visual record of the vascu- both. Data may be considered to have ordinal,
lar flow waveform would help confirm the pres- nominal or graded (scores) properties which
ence of a pulse, and also allow identification of provide variable conclusions about the data col-
artifacts, and venous sounds. lected from measurement. This chapter has
The practitioner(s). The ability of different attempted to highlight a number of the many pit-
observers to detect pulses could be due to a falls for the unwary that may lead to significant
variety of factors. More experienced observers error. Ongoing research has identified many of the
may be more skilful and better able to locate causes of error in measurement, particularly those
weak pulses. There may be differences in sensi- associated with the subjective application of tech-
tivity in the fingertips between observers. When niques to simple as well as sophisticated tech-
searching for the dorsalis pedis artery with the niques. Error in measurement is affected by many
Doppler probe it may lose contact with the skin influencing factors. Compensation for error is pos-
and coupling gel so that ultrasound waves are sible up to a point.
not transmitted. Sufficient quantities of an ultra- When using any sophisticated equipment it is
sound gel must be used. Noise and artifacts essential that it is applicable to the purpose
caused by movement of the Doppler probe could required, is calibrated and has known tolerances
lead to error because of distortion of the audio of error that can be accounted for. The terms
spectrum. 'validity', 'reliability' and 'repeatability' con-
The patient. Anatomical variations, blood tribute to a better understanding from any type of
vessel abnormalities and oedema could cause equipment used. Different observers can affect
variation in results between examiners. results and therefore strict protocols in practice are
essential to obtain the most helpful information.
The practitioner must therefore attempt, using
Conclusion
the type of knowledge highlighted in this
The exercise above has identified problems asso- chapter, to minimise the potential for poor data
ciated with clinical observations that are mea- collection and erroneous interpretation that
sured by many practitioners on a daily basis. could lead to false results.
CLINICALMEASUREMENT 53
-----------------------------------
REFERENCES
Baker N, Rayman G 1999 Clinical evaluation of Doppler and solutions. In: Bernstein E F (ed) Non invasive
signals. The Diabetic Foot 2: 22-25 diagnostic techniques in vascular disease, 3rd edn.
Boone D C, Stanley P A, Lin C M, Spence C, Baron C, Lee L C V Mosby, St Louis, ch 7, P 55
1978 Reliability of goniometric measurements. Physical Lord M, Reynolds D P, Hughes J R 1992 Foot pressure
Therapy 58: 1355-1360 measurement: a review of clinical findings. Biomedical
Booth J, Young M J 2000 Differences in the performance of Engineering 8: 283-293
commercially available lO-G monofilaments. Diabetes Magee T R, Stanley P R, al Mufti R, Simpson L, Campell
Care 23: 984-988 W B 1992 Should we palpate foot pulses? Annals of the
Bovens AMP M, van Baak M A, Vrencken J G PM, Wijnen Royal College of Surgeons of England 74: 166-168
JAG, Verstappen F T J 1990 Variability and reliability of Mathieson I, Upton D, Birchenough A 1999 Comparison of
joint measurements. American Orthopaedic Society for footprint parameters from static and dynamic footprints.
Sports Medicine 18: 58-63 The Foot 9: 145-149
Bowling A 1991 Measuring health: a review of quality life Munro J S, Edwards C R W 1990 Macleod's initial
measurement scales. Open University Press, Buckingham examination. Churchill Livingstone, Edinburgh
Calnan J S 1989 Handling the original idea. In: Mathie R T, Payne C, Richardson M 2000 Change in the measurement of
Taylor K M, Calnan J S (eds) Standardizing biomechanical neutral and relaxed calcaneal stance positions with
testing in sport. Human Kinetics Publishers, Champaign, experience. The Foot 10: 81-83
Illinois, p 87 Prudhomme P J, Curran M J 1999 A preliminary study of
Cassella J P, Ashford R L, Meakin J 2000 The effect of caffeine the use of an algometer to investigate whether or not
on neurothesiometer readings. The Diabetic Foot 3: 18-20 patients benefit when podiatrists enucleate corns. The
Dainty D, Gagon M, Lagasse P, Orman R, Robertson G, Foot 9: 65-67
Sprigins 1987 Recommended procedures. In: Dainty D, Rajbhandari S M, Harris N D, Sutton M et al1999 Digital
Norman R (eds) Standardizing biomechanical testing in imaging: an accurate and easy method of measuring foot
sport. Human Kinetics Publishers, Champaign, Illinois, ulcers. Diabetic Medicine 16: 234-243
p 87 Tesfaye S, Price D E 1997 Therapeutic approaches in
Diamond J E, Mueller M J, Delitto A, Sinacore D R 1989 diabetic neuropathy and neuropathic pain. In: Boulton
Reliability of a diabetic foot examination. Physical A J M (ed) Diabetic neuropathy. Marius Press, Carnforth,
Therapy 69: 797-802 pp 159-181
Freeman A C 1990 A study of the intertester and intratester Tollafield D R 1990 A reusable transducer system for
reliability in the measurement of resting calcaneal stance measuring foot pressures. A study of the reliability
position and neutral stance position. Australian Podiatrist in a commercial pressure pad. Department of Health
June: 10-13 and Life Sciences, Coventry Polytechnic, Coventry,
Grasty M S 1999 Use of the hand-held Doppler to detect pp 31-48
peripheral vascular disease. The Diabetic Foot 2: 18-21 Urry 1999 Plantar pressure measurement sensors.
Griffith C J 1988 An investigation of the repeatability, Measurement Science Technology 10: R16-R32
reliability and validity of clinical biomechanical van Schie C H M, Abbott C A, Vileikyte L, Shaw J E, Hollis
measurements in the region of the foot and ankle. S, Boulton A J M 1999 A comparative study of the
Project report No. 88/25. University of Westminster, Podotrack, a simple semiquantitative plantar pressure
London measuring device, and the optical pedobarograph in the
Hawes M R, Nachbauer W, Sovak D, Nigg B M 1992 assessment of pressures under the diabetic foot. Diabetic
Footprint parameters as a measure of arch height. Foot Medicine 16: 5-10
and Ankle 13: 22-26 Vowden P 1999 Doppler ultrasound in the management of
Hughes J, Pratt L, Linge K, Clark P, Klenerman L 1991 the diabetic foot. The Diabetic Foot 2: 16-17
Reliability of pressure measurements: the EMED F Wade D T 1992 Measurement in neurological rehabilitation.
system. Clinical Biomechanics 6: 14-18 Oxford Medical Publications, New York, p 20
Johnson K W, Kassam M S 1985 Processing Doppler signals West S, Barnett S 1999 Plantar pressure measurement: which
and analysis of peripheral arterial waveforms problems system? The Diabetic Foot 2: 3, 108-110
FURTHER READING
Introduction 57
The purpose of the medical and social history 57
57
58 SYSTEMS EXAMINATION
can then be employed to confirm the diagnosis lant therapy requires special consideration
and stage the severity of the condition. because of the likelihood of very slow blood
An example of a provisional diagnosis that clotting and haemorrhage. If drugs are pre-
can be obtained through history taking is scribed (or recommended) in the absence of a
Morton's neuroma, which describes a painful detailed medical history an existing condition
condition of the forefoot caused by a benign may be exacerbated. For example, aspirin or
enlargement of (usually) the third common nonsteroidal anti-inflammatory drugs (NSAIDs)
digital branch of the medial plantar nerve, may precipitate asthma attacks. Inadequate
located between and often distal to, the third knowledge of the patient's existing medication
and fourth metatarsal heads. The syndrome is a could lead to adverse reactions with newly pre-
mechanical entrapment neuropathy, with scribed drugs.
degenerative changes resulting from stretch and 2. The practitioner is placed at risk. Inadequate
compression forces. Initially, the patient may history taking may place the practitioner at risk
experience paraesthesia (pins and needles) or when handling tissue products. A history of jaun-
numbness in the ball of the foot. In more dice should alert the practitioner to the possibil-
advanced cases, the pain may be sharp or throb- ity of hepatitis, whereas a history of haemophilia,
bing, and classically radiates distally into adja- blood transfusion, foreign travel or intravenous
cent toes. The pain is worse on exercise and is drug use may place the patient and thus the prac-
relieved by rest and massage. By the time the titioner at risk from the human immuno-
patient attends for consultation the symptoms deficiency virus (HIV) and hepatitis B.
will often have been present for 4-6 months, 3. Poor treatment outcomes. Treatment may
and be gradually worsening such that symp- fail or cause the patient's presenting condition
toms come on more quickly with exercise and to worsen because inadequate history taking
take longer to subside with rest. Such a history has prevented accurate diagnosis of the pre-
points to a diagnosis before the practitioner senting foot complaint. Swelling on the top of
even needs to examine the patient and will indi- the foot in a 39-year-old woman, which devel-
cate what confirmatory tests need to be ops after an ankle sprain, may be nothing more
employed. Diagnosis can then be confirmed by than inflammation-related oedema. If the prac-
point tenderness between the metatarsal heads titioner finds there is also a history of cigarette
followed by the use of diagnostic nerve blocks. smoking, use of the contraceptive pill and
A comprehensive history taking therefore recent immobilisation, the differential diagno-
helps the practitioner to formulate a diagnosis sis would include deep vein thrombosis, a
and develop and implement an effective man- potentially life-threatening condition that
agement plan. An inadequate history of the requires quite different management to an
patient's health status may have the following ankle sprain.
consequences. 4. An increased risk of clinical emergencies.
1. The patient is placed at risk. Inappropriate Individuals may be placed at risk by certain
or unsafe treatment may be provided because of treatments, drugs or procedures that are nor-
inadequate knowledge of the patient's medical mally considered routine. Adequate history
history. Performing nail surgery on a patient taking will identify those patients who have
with a prosthetic joint may produce a bacter- previously developed adverse reactions.
aemia, which could infect and then loosen the Requesting an inappropriate antibiotic prescrip-
joint replacement. Bacteraemia in patients with tion from a GP for a penicillin-sensitive patient
a history of infective endocarditis or rheumatic may result from poor history taking. Hyper-
valvular disease may lead to bacterial growth sensitivity reactions to dressings, for example
on the previously damaged heart valves or zinc oxide strapping, or medicaments, for
endocardium. Invasive or operative treatment example iodine, may be known to the patient
on haemophiliacs or patients taking anticoagu- and should be noted.
THE MEDICALAND SOCIAL HISTORY 59
range of systemic conditions or they could be prescribed by their doctor. It is not uncommon
poorly nourished due to alcoholism, drug abuse for a patient to have used prescribed drugs for
or anorexia nervosa. Fatigue and weight changes many years with no clear understanding as to
are symptoms of many systemic illnesses and are why he has taken them. The practitioner should
always worthy of note, especially if weight refer to the British National Formulary (BNF) or
change appears to be rapid. The following ques- another pharmacological text if unfamiliar with
tions will reveal important information about the any drugs that the patient is taking.
patient's general health: Large doses or prolonged use of certain med-
ications can be associated with significant
• Are you feeling well?
ad verse drug reactions with relevance to the
• Are you under the doctor or consultant for
lower limb. Most drugs produce several effects,
any treatment currently?
but the prescriber usually wants a patient to
• Do you sleep well at night?
experience only one (or a few) of them; the other
• Do you feel tired during the day?
effects may be regarded as undesired. Although
• Is your weight stable?
most people use the term 'side effect', the term
• For women, could you be pregnant?
'adverse drug reaction' is more appropriate for
In general, patients who are unwell are not effects that are undesired, unpleasant, noxious or
good candidates for involved procedures or potentially harmful. Prednisolone, commonly
treatments that are likely to demand close com- used in the treatment of rheumatoid arthritis, can
pliance on their behalf. reduce skin thickness and impair wound healing.
Bendrofluazide, a useful diuretic for the treat-
ment of cardiac failure or hypertension, can
Past and current medication
cause hyperuricaemia, which may result in gout-
Information about the patient's previous and like symptoms. Warfarin, an oral anticoagulant
current drug therapy can provide useful infor- used for the treatment and prophylaxis of venous
mation about the patient's health. Patients thrombosis and pulmonary embolism, increases
should be asked if they are currently taking, or clotting time and has obvious implications if sur-
have taken in the past, any tablets or medicine or gical treatment is planned. Other examples of
used any ointments or creams that have been adverse drug reaction can be found in Table 5.2.
Patients should also be asked if they are cur- which can lead to convulsions as a result of
rently taking or have taken in the past any tablets central nervous system stimulation. This may be
or medicine or used any ointments or creams followed by a profound drop in blood pressure
which they have purchased from the chemist. and life-threatening cardiovascular system
Self-prescribed medication is of interest to the depression. In such circumstances oxygen must
practitioner not least because the quantities used be administered to support the patient. The risk
may be quite variable, with the possibility of of such a clinical emergency can be minimised by
chronic overdosing. For example, repeatedly adhering to the maximum safe dose values for
exceeding the recommended daily dosage of vit- the various local anaesthetic agents and always
amins A and D supplements may give rise to having oxygen available. A local type I hypersen-
ectopic calcification in tendon, muscle and peri- sitivity reaction may be caused by local anaes-
articular tissue. thetic agents. The skin around the area of the
The practitioner should be alert to the possi- injection shows an immediate, localised inflam-
bility of a patient developing an allergy or matory reaction.
adverse reaction to medications used during Use of all recreational drugs should be
treatment. In particular, details of any adverse recorded. Amphetamines, like many mood stimu-
reactions, either by the patient or any member lants, will have a vasoconstrictive effect. The use
of the patient's family, to previous local anaes- of injectable drugs places the patient at risk of
thetic injections and other drugs (e.g. penicillin) hepatitis and HIV. Long-term or heavy use of
should be sought and explored. A type I hyper- tobacco can affect wound healing due to the
sensitivity reaction, which leads to anaphylactic immediate vasoconstrictive effect of nicotine as
shock, is of most concern. It is not known why well as the long-term effect of increased plate-
some individuals are predisposed to anaphy- let adhesiveness and atherosclerosis. Tobacco
laxis, though genetic mechanisms are certainly smokers are also at greater risk of bronchitis,
involved since there is a strong familial disposi- asthma and lung cancer. Heavy alcohol consump-
tion. In some individuals, contact with certain tion can affect the peripheral sensation, immune
allergens will stimulate the production of an response, postoperative wound healing and the
antibody of the immunoglobulin E (lgE) class, metabolism of local anaesthetics, as well as having
which has the ability to adhere to mast cells in implications for treatment compliance. Alcohol
tissues and basophils in the circulation. When consumption is generally measured in units. One
an individual sensitised in this way is exposed unit of alcohol is equivalent to one glass of wine, a
on a second occasion to the allergen, the aller- single measure of spirits or half a pint of beer.
gen combines with the IgE antibodies on the More than four units of alcohol per day is note-
surface of the mast cells. This causes immediate worthy. Unfortunately, it is likely that those
destruction of the mast cell, which releases its patients abusing alcohol are least likely to be
contents, specifically histamine, serotonin, forthcoming about their alcoholism. Where
platelet-activating factor and slow-reacting sub- alcohol abuse is suspected, questions should be
stance. If the exposure to the allergen is sys- asked in a permissive manner:
temic, hypotension, bronchiole constriction,
• Although you may not be drinking a lot now,
laryngeal oedema, swelling of the tongue,
what about in the past?
urticaria, vomiting and diarrhoea may follow.
• Was there ever a time when you were
Fatal anaphylaxis is rare. When it does occur it
drinking more heavily?
usually follows entrance of an antigenic drug
such as penicillin to the circulation of a sensi- The patient should also be asked about dry
tised individual. Insect stings are also an impor- retching in the morning, as this is a symptom of
tant cause of anaphylactic fatality. alcohol withdrawal. Drinking before 10 a.m. is an
Of particular concern to the podiatric practi- important finding, as it is associated with chronic
tioner is the overdosage of local anaesthetics, alcoholism.
62 SYSTEMS EXAMINATION
the presence of any impairment of the venous with weakness, vertigo, headaches, tiredness,
system, toxic metabolites will accumulate, gastrointestinal complaints and CHF.
increasing carbon dioxide tension while lowering Sickle cell disease is an inherited condition that
oxygen levels. Muscle ischaemia follows, mani- can affect persons of African or West Indian
festing as a painful tautness of muscle fibre. descent. Those who inherit the gene from both
Also enquire further about any peripheral vas- patients have more than a 75% chance of devel-
cular symptoms. Ask the patient if they: oping the condition. Sickle cell individuals are
prone to ulceration around the malleoli, a com-
• get cramp at night
plaint more characteristic of older people with
• get muscle cramps while walking
venous insufficiency. In most cases, patients will
• suffer from chilblains
know whether they have sickle cell anaemia, as
• notice their feet change colour if it is
from early childhood the digits of the hands and
particularly cold.
feet tend to swell and are very painful. The use of
All the above factors are signs and symptoms tourniquets carries an increased risk of complica-
of peripheral vascular disease. Assessment of the tion. A tourniquet causes relative anoxia and this
vascular status of the lower limb is covered in in turn causes occlusion in small vessels due to
detail in Chapter 6. changes in the haemodynamic qualities of red
To determine the presence of haematological blood cells, which may lead to small vessel
disease patients should be asked if they have: infarction and possibly digital gangrene.
• anaemia
• haemophilia The respiratory system
• any other blood disorder.
To determine the presence of known systemic
Haematological disorders should be consid- respiratory disease the patient should be asked if
ered. Anaemia occurs when red blood cells or they have ever had (Table 5.3):
haemoglobin content decreases because of blood
loss, impaired production or excessive destruc- • asthma
• chronic bronchitis
tion of red blood cells. Tissue hypoxia results
from anaemia and this in turn leads to cardiovas- • emphysema
• pulmonary embolism.
cular and pulmonary compensations. Clinical
symptoms depend upon the severity and dura- Asthma presents as a dry, wheezing cough
tion of the anaemia. Severe anaemia is associated accompanied by dyspnoea. Exercise, infection or
to the toilet
• have had any sexually transmitted infections.
The practitioner should use the systems
enquiry and medical and social history to deter-
mine whether the patient is in a high-risk group
for blood-borne infections, such as hepatitis B or
AIDS.
Renal pain is a symptom of gross structural
disease of the kidney, such as kidney stones or a
blood clot passing down the ureter. Infection or
malignancy may also cause pain in the area of the Figure 5.2 The renal angle.
renal angle (Fig. 5.2) as well as more anteriorly in
the abdomen. Leg and ankle swelling is an
important finding, which may be related to that renal dysfunction is not the only cause of
kidney disease and indeed could be the first clin- ankle oedema. Breathlessness on exertion,
ical sign of a renal problem. Renal dysfunction weight loss, nausea and vomiting also occur in
that leads to a massive loss of protein into the renal failure and may further confuse the clinical
urine will disrupt normal capillary haemodynam- picture. A symptom that is renal-specific is dis-
ics, causing reduced transudation of fluid. Fluid turbed micturition (Table 5.4). Frequency of uri-
will pool in the tissues rather than returning back nation is dependent upon fluid intake and
into the capillary circulation. Oedema of the specific drugs within food and drink. Most
dependent limb will result, particularly around people urinate 4-6 times every 24 hours, mostly
the ankles. However, it should be remembered in the daytime.
Polyuria Frequent micturition Diabetes mellitus, diminution in bladder's effective filling capacity
due to infection, foreign bodies, stones or tumour
Dysuria Painful urination Irritation and inflammation of bladder or urethra usually due to
bacterial infection
Nocturia Urination during the night May reflect early renal disease. Decrease in concentrating
capacity may be associated with cardiac or hepatic failure
Oliguria Straining, decrease in force Obstruction distal to the bladder. In men most commonly due to
and calibre of urinary stream prostatic obstruction
Haematuria Blood in urine Haematuria without pain: renal or prostatic disease, bladder or
kidney tumour. With pain: ureteral stone or bladder infection
70 SYSTEMS EXAMINATION
The patient should be asked if he experiences Table 5.5 Lower limb signs and symptoms associated with
sexually transmitted diseases
any pain or problems passing water and whether
his sleep is disturbed by the need to pass water. Disease Lower limb signs and symptoms
A positive response to these questions requires
Reiter's Asymmetric arthralgia of hip, knee,
further investigation as the kidneys may affect ankle and metatarsophalangeal
bone metabolism as well as blood pressure and joint. 'Sausage toe'. Keratoderma
water regulation. blenhorragica
HIV Kaposi's sarcoma - a Widespread
skin or mucous membrane lesion
Sexually transmitted infections appearing as a pink or red macule
or violaceous plaques and nodules
Reiter's disease, gonorrhoea, HIV and syphilis on the face, trunk and limbs. May
are all sexually transmitted infections (Case appear wart-like
history 5.7). Practitioners investigating a lower Gonococcal arthritis Acute joint pain, swelling and
stiffness. Usually accompanied by
limb complaint may find it difficult to enquire urethritis, dysuria and haemorrhagic
about sexually related problems (Table 5.5). vesicular skin lesions. Serious joint
However, as these conditions can lead to an damage may result if the condition
is not properly treated
array of lower limb symptoms, questions about
them must be included in the systems enquiry.
After enquiring about the urinary system, the
patient should be asked if he has ever had any symptoms may be significant. The patient should
sexually transmitted infections, skin problems be asked if he suffers from frequent headaches.
or discharge. While stress-related headaches, migraine and
extracranial causes such as cervical spondylosis
The central nervous system account for the majority of headaches, cranial
arteritis is an important cause in the elderly.
Diseases of the nervous system may cause pain Brain tumours (slow onset) and subarachnoid
in the lower limb, deformity or gait abnormali- bleeding (sudden onset) must be considered in
ties. Comprehensive history taking is essential severe headaches.
(Case history 5.8). To determine the presence of Fainting, dizziness and visual disturbance may
CNS disease the patient should be asked if they occur in association with headaches. The basis
have had: for most fainting episodes is inadequate blood
• any neuromuscular disorder supply to the brain and is commonly cardiac or
• a head injury cerebrovascular in origin. Anaemia, hypogly-
• a stroke caemia and emotional stress can also explain a
• epilepsy. temporary loss of consciousness.
will continue to need a source of energy, home- metabolism, the most obvious being to stimulate
ostasis provokes breakdown of body fat and the basal metabolic rate. In thyroid disease there
muscle tissue. This process of 'accelerated starva- is either inadequate or excessive production of
tion' can be quite abrupt in children, causing thyroid hormones. The clinical features of hyper-
anorexia, nausea, coma and, if untreated, death. thyroidism are listed in Table 5.8.
In older patients it is more gradual and indeed the Clinical features of hyperthyroidism such as
first presenting symptom may be one of the com- muscle weakness, tachycardia, weight loss and
plications of the disease. sleep disturbance may have already been picked
Thirst, polyuria and weight loss are the three up from the systems enquiry. Other features
most common symptoms of diabetes. These three associated with the condition may not have been
features may also occur with other conditions highlighted, e.g. heat intolerance, hand tremor
such as diabetes insipidus, hypercalcaemia and and irritability. If hyperthyroidism is suspected
renal failure (Table 5.7). The thirst associated the patient, should be asked:
with diabetes is a result of the osmotic diuretic
• Do you find that you cannot tolerate hot
effect of glucose - although it is difficult to be
rooms or buildings?
precise as to what is excessive thirst. Increased
• Have you noticed a change in your
volume and frequency of urination will lead to a
handwlriting?
corresponding increase in fluid intake. The
• Do your hands shake?
patient is often aware that sleep is regularly dis-
• Do your hands and feet get excessively sweaty?
turbed by the need to urinate and a history of
polyuria should always be followed up by Hyperthyroidism is an important systemic
glucose testing of the urine. Although diabetics cause of hyperhydrosis of the feet and hands.
often believe that their decreasing weight is due Other lower limb signs and symptoms include
to polyuria, it is in fact a result of accelerated fat infiltration of non-pitting mucinous ground sub-
and protein catabolism. stance on the anterior surface of the tibia, which
The thyroid hormones tri- and tetra-iodothyro- causes intense itching and erythema. This so-
nine (T3 and T4) are essential for normal growth called pretibial myxoedema (a confusing term
and development and have many effects on body since myxoedema suggests hypothyroidism) is
more accurately described as an infiltrative der-
mopathy. Hyperthyroidism can cause tarsal
Table 5.7 Causes of thirst and polyuria tunnel syndrome and must be considered as a
differential diagnosis for this condition, especially
Cause Physiological reason as the dermopathy will remain even after thyroid
Diabetes mellitus Osmotic diuretic effect of glucose function is stabilised.
Diabetes insipidus Kidney disease prevents normal
concentrating of urine or pituitary
gland disorders cause a Table 5.8 Clinical features of hyperthyroidism
deficiency of antidiuretic hormone
Weight loss (with a normal appetite)
Hypercalcaemia Result of hyperparathyroidism
Heat intolerance
where hypercalcaemia causes
reversible impairment of renal Fatigue
concentrating mechanism Cardiac palpitations
Hypocalcaemia Often a side effect of diuretic Irritability
therapy it leads to impaired Hand tremors
concentrating ability in the kidney Sleep disturbance
Excess salt intake Osmotic diuretic effect of Bulging eyes
increased sodium level Goitre
Renal failure Normal concentrating function of Diarrhoea
kidney lost Generalised muscle weakness
THE MEDICAL AND SOCIAL HISTORY 73
it reduces his ability to deal with stress. Cardiac Disorder Clinical features
arrhythmias or metabolic imbalance may occur
in stressful situations. Screening for thyroid Adrenal undersecretion Common features:
(e.g. Addison's disease) Tiredness
disease is therefore essential and the above Generalised weakness
enquiry should be included in any presurgery Lethargy
assessment. Anorexia
Weight loss
Disorders of the adrenal gland should also be Dizziness and postural hypotension
considered. The adrenal gland has two function- Pigmentation
ally distinct parts, the cortex and the medulla. The Less common features:
more important of the two, the adrenal cortex, is Hypoglycaemia
Loss of body hair
essential for life as it produces glucocorticoids Depression
and mineralocorticoids, which are essential for Adrenal oversecretion Truncal obesity (moon face,
maintaining blood volume during stress. The (Cushing's syndrome) buffalo hump, protuberant abdomen)
Thinning of skin
patient should be asked: Purple striae
Excessive bruising
• Do you ever feel faint or dizzy when Hirsutism
standing up after sitting for some time? Hypertension
Glucose intolerance
• Have you noticed any coloured patches or Muscle weakness and wasting,
streaks developing on your skin? especially of proximal muscles
• Have you had any problems with increased Back pain (osteoporosis and
vertebral collapse)
facial hair? Psychiatric disturbances
• Do you bruise easily?
74 SYSTEMS EXAMINATION
l<-e-5u.lcJ ~0 ~
anr.kv
Figure 5.3 Specimen medical and social history and functional enquiry.
FURTHER READING
British National Formulary (BNF), updated twice yearly. Seymour p, Siklos C 1994 Clinical clerking: a short
British Medical Association (BMA) and Royal introduction to clinical skills, 2nd edn. Press Syndicate of
Pharmaceutical Society of Great Britain (RPSGB), London the University of Cambridge
Greenberger N, Hinthorn D 1993 History taking and Tally N, O'Connor S 1989 Clinical examination. Blackwell
physical examination; essentials and clinical correlates. Scientific, Oxford
Mosby Year Book, St Louis Turner R, Blackwood R 1991 Lecture notes on history taking
Munro J F, Campbell I W 2000 Mcl.eod's clinical and examination, 2nd edn. Blackwell Science, Oxford
examination, LOth edn. Harcourt Brace, Edinburgh Zier B 1990 Essential of internal medicine in clinical
Seidel H M et al1995 Guide to physical examination, 3rd podiatry. W B Saunders, Philadelphia
edn. Mosby, St Louis
CHAPTER CONTENTS
Introduction 79
Summary 111
THE PURPOSE OF A VASCULAR
ASSESSMENT
Information gained from a vascular assess- • Identify those patients in whom vascular
ment can be used to achieve the following: conditions require further investigation by
referral to a specialist.
• Identify whether the blood supply to and
from the lower limb is adequate for normal
function and tissue vitality.
• Identify vascular problems which could OVERVIEW OF THE
compromise the state of the tissues. It is CARDIOVASCULAR SYSTEM
important to detect not only the presence of
such abnormalities but also the functional
ANATOMY OF THE
site, e.g. is it an arterial or venous
CARDIOVASCULAR SYSTEM
insufficiency or a combination of both? These
patients require monitoring so that The cardiovascular system (CVS) consists of a
complications - e.g. necrosis, ulceration and closed system of vessels through which blood
infection - can be prevented or their effects and lymph are pumped around the body by
reduced. means of the heart (Fig. 6.1).
• Identify whether there are any vascular
abnormalities which could affect healing or
The heart
the choice of treatment. These should be
borne in mind when drawing up a treatment The heart is constructed as a double pump in
plan. series: one pump comprising the left side of the
carotid
artery
superior
vena cava
dorsal
aorta
inferior
vena cava
hepatic vein hepatic artery
heart and the other the right side (Fig. 6.2). Each blood from the body flows through the superior
pump has two chambers. Each upper chamber and inferior vena cavae into the right atrium.
or atrium is a receiving vessel with a thin muscle
wall or myocardium, whereas the lower cham-
Peripheral circulation
bers or ventricles are the dispersing vessels and
therefore have much thicker muscle walls to The blood flows through the two circulations via a
generate strong propulsive forces (Fig. 6.3). The system of vessels of varying diameters (Table 6.1).
heart is lined by endocardium and surrounded
by a tough, non-extensible pericardium. The
Arterial tree
endocardium forms the cusps of one-way
valves, called the tricuspid and bicuspid valves, The vessels which transport blood to the tissues
which control the flow of blood through the are called arteries. These branch into consecu-
heart. It also forms semilunar valves, which tively smaller vessels called arterioles. The walls
control the entry of blood into the vessels of arteries consist of three layers - the tunica
leaving the heart. Closure of these valves is intima, tunica media and tunica adventitia - all of
responsible for the two heart sounds, 'Iub-dup', which are lined with vascular endothelium,
which can be heard through a stethoscope whose cells secrete a variety of substances essen-
applied to the chest wall. tial for maintenance of vessel wall and circulatory
The heart serves two circulations. The right function (Fig. 6.4A). All the vessels have some
ventricle serves the pulmonary or minor circula- smooth muscle in the tunica media to enable
tion and sends deoxygenated blood via the pul- them to change diameter, but arterioles have the
monary arteries to the lungs, whereas the left greater proportion. The arteries leaving the heart
ventricle supplies the systemic or major circula- have a high proportion of elastic tissue in their
tion with oxygenated blood through the aorta to walls, which enables them to act as secondary
the body (Fig. 6.2). Oxygenated blood is returned pumps, whereas the rest of the arterial tree con-
from the lungs via the right and left pulmonary sists of muscular distributing vessels. The small-
veins into the left atrium and deoxygenated est arterioles deliver blood to capillary beds.
Venous tree
Blood is drained from the tissue beds by small
vessels called venules, which join to form larger
vessels called veins. The three layers seen in the
arterial walls are again present but the propor-
tions differ, as can be seen in Figure 6.4A. The
vascular endothelium forms semilunar valves in
the veins and venules to prevent backflow of
Aorta 25 cm 2 mm
Artery 4 mm 1 mm
Arteriole 30 urn 20 urn
Capillary 6 urn 1 urn
Venule 20 urn 2 urn
Figure 6.2 The heart is a double pump in series. It serves Vein 5 mm 500 urn
two circulations, the low-pressure pulmonary and the high- Vena cava 30 mm 1.5mm
pressure systemic circulation.
82 SYSTEMS EXAMINATION
Aorta
Right
pulmonary vein
\ - - - - - - Left pulmonary vein
."lll!rllJrt---- Thick-walled
myocardium
Inferior
vena cava
Right ventricle
Endocardium
Figure 6.3 Vertical section through the heart showing the valves, chorda tendinae, main vessels attached and the varying
thickness of the myocardium. The direction of flow of oxygenated (non-shaded arrows) and deoxygenated (shaded arrows)
blood is also shown.
blood. Veins are found either in the superficial numerous vessel, having only a thin-walled
fascia or deep in the muscle. Communicating endothelium (Fig. 6.4B). It permeates all the
veins link the two types so that blood can drain tissue beds so that no tissue cell is far from a cap-
from the superficial veins to the deep ones. illary. Flow of blood into individual capillaries is
regulated by smooth muscle sphincters in vessels
called metarterioles, which are situated at the
Capillary
entrances to the capillaries. Capillaries can be
A third type of vessel, the capillary, links arteri- bypassed by arteriovenous (A-V) anastomoses:
oles and venules. This is the smallest and most these are vessels which form a direct link
VASCULAR ASSESSMENT 83
-tI-+F""---- AVA
Metarteriole
Aorta---f"--.
Figure 6.6 A. Small side vessels normally carry an insignificant fraction of blood into the peripheral tissues. Damage or
occlusion of the major arteries alters pressure relationships to divert blood through the side vessels (collateral circulation).
B. Anterior view of heart showing lack of anastomoses between arterial vessels supplying the myocardium. Left coronary
artery supplies hatched area, right coronary artery supplies unhatched area. The lack of anastomoses between left and right
coronary arteries explains why an occlusion of the left coronary artery can be so catastrophic.
VASCULAR ASSESSMENT 85
wave of contraction which pushes the blood that this is achieved is via the autonomic system
in the desired direction. Apart from these (ANS) (Ch. 7). The two branches of the ANS send
specialised pathways, the septa that divide fibres to the SA node. The sympathetic nerve acts
the four chambers of the heart consist of on the heart via specific receptors called beta 1-
fibrous, non-conducting tissue. receptors, the action of which is to increase
While the heart can contract without nervous cardiac output by increasing both stroke volume
stimulation, it is essential that it can alter its (positive inotropy) and heart rate (positive
activity according to the differing demands chronotropy). The parasympathetic nerve to the
placed upon it as mentioned earlier. One way heart is called the vagus and causes slowing of
Arterial end
respiring cells
Venous end
Blood Tissue Result
fluid
HPb > HPt < HPt Fluid in
Figure 6.8 The process of formation and reabsorption of tissue fluid in an ideal capillary. Movement of fluid in and out of the
capillary will vary according to the precise balance of pressures along the capillary at anyone time.
VASCULAR ASSESSMENT 87
the heart rate (negative chronotropy), acting the sympathetic nerves, which act on the smooth
through cholinergic receptors. muscle of the tunica media. Despite being very
At rest the parasympathetic nerve predomi- sensitive to changes in blood pressure, barorecep-
nates, producing the average resting heart rate of tors show a rapid adaptation to a sustained
72 beats per minute. The rate is less in trained change, so that in hypertension they are triggered
athletes and higher in children and is also by a higher than normal 'operating' range.
affected by posture, increasing on a change from All vessels except capillaries are subject to
a supine to an upright position by approximately some sympathetic influence or 'tone'. The greater
10 beats per minute. The latter is due to compen- the sympathetic tone, the more vasoconstriction
sation for the effects of gravity on blood in the is achieved, with vasodilation being produced by
peripheral vessels and is mediated through the a reduction in this tone. This in turn produces a
baroreceptor reflex (Fig. 6.10). Baroreceptors are change in resistance to flow, or peripheral resis-
situated in both the arterial and venous compo- tance, a change in the pressure exerted on the
nents of the systemic circulation, but the arterial blood and a change in the work the heart has to
baroreceptors in the aortic arch and carotid body do (afterload), The greatest effect is produced in
are the more important for regulation of blood the arterioles, called the resistance vessels, which
pressure. They continuously monitor the level as mentioned previously have the largest propor-
and feed this information to the cardiovascular tion of smooth muscle in their walls. They allow
control centre in the part of the brain stem called the CVS to control distribution of blood and,
the medulla oblongata. As a result of this infor- together with the heart, are the effector organs
mation being integrated in the medulla, compen- for the homeostatic control of blood pressure. A
satory adjustments are made to the action of the similar reflex exists to regulate blood volume,
heart and the diameter of the arterial tree through which in addition involves, to a greater extent,
the low-pressure baroreceptors in the right superficial papillary loops and the specialised
atrium and where the effector organs include the glomus bodies which can re-route blood
kidney as well as the CVS. towards or away from the skin surface. The
The aorta and pulmonary arteries are the purpose of such redirection is either to control
elastic arteries, having a large proportion of heat loss or to ensure that superficial tissues do
elastic tissue in their walls. This distends as the not suffer from ischaemia caused by cold-
bolus of blood is received from the ventricles induced vasoconstriction.
and acts as a secondary pump during diastole The function of the capillaries is the exchange
when the elastic recoil propels the blood of the substances transported to the tissues by
forward. The rebound causes a shock wave to the blood. It is here that tissue fluid plays its
travel rapidly through the blood in the arterial essential role of intermediary between blood
tree and it can be felt as a pulse wave at certain and tissues mentioned earlier, being the ideal
points called pressure points. candidate since it bathes every cell. There is a
The overall purpose then of all the vessels large pressure drop across the capillary beds so
within the systemic circulation, with the excep- that blood flowing in the venules and veins is at
tion of the capillaries, is to deliver blood with its low pressure and needs help to get back to the
dissolved nutrients, oxygen and hormones to the heart, in the form of semilunar valves, venocon-
tissues and to remove metabolic waste such as striction and the pumping action of surround-
carbon dioxide and urea. This transportation ing skeletal muscle on the deep veins. In
must meet the demands of the different tissues, addition, the fluctuating negative pressures in
which will vary in need according to their nature the abdomen and thorax, due to respiratory
and level of activity. Heat is also distributed movements and the action of the heart itself, all
from areas such as active muscles and the liver act as suction pumps, drawing blood back into
to the rest of the body. The skin is an important the atrial chambers. The volume of blood
organ for controlling heat loss, involving the returning to the heart is termed the venous
return or preload. It is essential that ventricular
output exactly matches this venous return to
t ARTERIAL PRESSURE avoid a transfer of blood from one circulation to
the other.
This matching of venous return and cardiac
output is an intrinsic property of the myocardium,
Arterial baroreceptors independent of nervous control, which is often
referred to as Starling's law of the heart. The con-
tFIRING sequences of unmatched venous return to cardiac
output is seen in a person with congestive heart
Reflex via medullary
cardiovascular failure, the congestion being due to a build up of
centre blood throughout the venous tree because of a
weak or damaged myocardium. In addition to
returning blood to the heart, veins, because of
their distensibility, act as capacitance vessels, nor-
mally holding three-fifths of the total volume of
... SYMPATHETIC blood in the body. This can boost the circulation
OUTFLOW TO
HEART, ARTERIOLES, when necessary.
VEINS The purpose of the pulmonary circulation is to
deliver blood containing carbon dioxide to the
lungs and exchange it via the alveolar capillaries
Figure 6.10 Flow chart showing the arterial baroreceptor
reflex. If arterial pressure decreases the arrows in the boxes for oxygen. Having two separate circulations also
would be reversed. allows each to operate at a different pressure.
VASCULAR ASSESSMENT 89
Red blood cells contain the pigment haemoglo- diagnoses made by practitioners using observa-
bin, which picks up oxygen in the lungs in a step- tion with diagnoses arrived at with the aid of
wise manner and releases it in the tissues. hospital tests found that the former method was
Presence or absence of oxygen causes a change in almost as reliable as the latter.
shape of the haemoglobin molecule and with it a
change in colour, so that oxygenated blood is GENERAL OVERVIEW OF THE
bright red and deoxygenated blood is bluish-red. CARDIOVASCULAR SYSTEM
Red blood cells or erythrocytes are formed
from stem cells in the red bone marrow and Central problems such as congestive heart
mature under the influence of kidney hormones failure, angina of effort and myocardial infarc-
or erythropoietins. Various factors are needed, tion as well as systemic problems such as the
such as iron, folic acid and vitamin BI 2 , for for- anaemias can all have a bearing on the diagnosis
mation of the mature erythrocyte. The red blood and management of lower limb problems and so
cell circulates for 120 days before being broken must be taken into consideration (Table 6.2),
down in the liver by phagocytic von Kupffer although full investigation of such problems are
cells. Anaemias, reduction in the oxygen-carry- beyond the scope of this textbook.
ing capacity of blood, can result from a defect in
any part of this process. For example, damage to Past history and current medication
the bone marrow by radiation can damage the History taking is discussed in detail in Chapter 5.
stem cells or the young red blood cells, resulting Any factors which reduce or prevent tissue per-
in aplastic anaemia. An autoimmune disease fusion will not only deprive the tissue of oxygen
can destroy the parietal cells in the stomach, but also of nutrients, and prevent removal of
leading to lack of Castle's intrinsic factor, and waste products, causing a condition referred to
this causes an inability to absorb vitamin BI 2 , as ischaemia. The most common cause of
which is required for erythropoiesis and normal ischaemic heart disease (IHD) is atherosclerosis
nerve function. After some delay, pernicious of coronary vessels; therefore, IHD is often
anaemia develops. termed coronary arterial disease (CAD).
The presence of CAD should alert the clinician
to possible atherosclerosis in the lower limb. The
THE VASCULAR ASSESSMENT
An assessment of the vascular status of a patient Table 6.2 Cardiac conditions which may affect lower limb
consists of a general overview of the cardiovas- perfusion
cular system and a detailed assessment of the
Heart failure: left- and/or right-sided
peripheral vascular system, with particular ref-
Ischaemic heart disease: angina or myocardial infarction
erence to the lower limb. As mentioned previ-
ously, the peripheral vascular system consists of Rheumatic fever
A male Caucasian first presented to the clinic when Transcutaneous oxygen tension (Tcp02) values of right
74 years old, complaining of hard skin on the balls of his and left dorsum of the feet were 41 and 47 mmHg,
feet and on the ends of his toes. He was finding it difficult respectively. He had suffered a myocardial infarction and
to focus and so had sought treatment. His medical and a stroke when 76 and his medication had been changed
social history revealed that he was a smoker and that he to digoxin and furosemide (frusemide).
had had an aortic aneurysm resected when aged 73. When the patient first presented to the clinic, the
He was taking bendroflumethiazide (bendrofluazide). A condition of skin, nails and general tissue viability were
preliminary vascular assessment showed telangiectases unremarkable for someone of his age. Three years later
and haemosiderosis superimposed on a normal skin he had suffered a myocardial infarction and a stroke,
colour in both lower limbs. Varicose veins were present in which suggests possible atherosclerosis in coronary
the right leg, hair was absent from legs and feet and the and cerebral arteries. The likelihood of lower limb
skin was dry. Nails were long but otherwise unremarkable. arteries also being involved is considerable and would
The feet felt cold. All four pulses were palpable and account for the low oxygen tension in the skin and the
demonstrated arrhythmia. Brachial BP was 110/60 mmHg. barely palpable pedal pulses. Smoking is a risk factor
The patient failed to attend further appointments until 3 for atherosclerosis and for strokes. The peripheral
years later, when examination revealed cyanotic feet with oedema and cyanosis were likely to be consequences
the right foot being worse than the left. His toenails were of cardiac insufficiency following the myocardial
thickened and crumbly and oedema was present in both infarction, although asymmetry also suggests some
ankles. Pedal pulses were barely palpable. peripheral factors at play, i.e, venous incompetency.
medical history should reveal conditions which muscle contraction, reducing peripheral resis-
indicate coronary artery disease, such as angina tance and so reducing blood pressure.
of effort or previous myocardial infarctions. The
presence of risk factors for atherosclerosis
should also be noted, such as smoking or the Symptoms
presence of diabetes mellitus, hypertension or Angina and myocardial infarction
hyperlipidaemia (Case history 6.1).
Anti-hypertensive medicaments such as Pain in the chest on exercise or other stress indi-
diuretics, beta-blockers, ACE inhibitors and cates inadequate blood supply to the myocar-
calcium antagonists all indicate a vascular dium. Angina may occur as the result of a
problem which often has a central component. previous myocardial infarction (M!) or may be
Diuretics act on various parts of the kidney the precursor to an MI. The pain of angina can
nephron to reduce water and salt reabsorption, vary from a mild discomfort to an intense crush-
reducing preload and cardiac output and, as a ing sensation, or a feeling as if the chest is being
consequence, blood pressure. Beta-blockers gripped by a steel band. It may radiate into the
prevent the stimulatory action of endogenous left arm, to the back and the throat or even down
catecholamines on the heart, again reducing the right arm. It may settle into a predictable
cardiac output and blood pressure. ACE pattern so that the patient will be able to
(angiotensin-converting enzyme) inhibitors describe the trigger factors and the intensity,
interfere with the production of angiotensin 2, duration and frequency of the attacks. More
which is both a powerful vasoconstrictor and seriously, the attacks may increase in frequency
triggers release of the hormone aldosterone from or intensity, when it is termed unstable angina
the adrenal cortex. As aldosterone promotes and may be prodromal to an acute heart attack.
water and salt reabsorption from the kidney, Unless vigorously treated, a large proportion of
drugs that inhibit its release will again reduce patients with unstable angina will go on to
preload and cardiac output, so that ACE develop MI within weeks (Kumar & Clark
inhibitors promote a two-pronged attack on 1990a). It is important to recognise such situa-
blood pressure. Calcium antagonists act by inter- tions should they develop, as prompt action is
fering with the process of vascular smooth essential.
VASCULAR ASSESSMENT 91
is called the systolic blood pressure. The lowest • The patient should be seated comfortably
point is when the heart is relaxed, just before it with one arm flexed at the elbow and resting
begins its next contraction. This is called the dias- at heart level on a flat surface.
tolic pressure. The blood pressure is always • The brachial pulse should be palpated.
written as systolic pressure/diastolic pressure. • The cuff should be wrapped around the
The value for a healthy adult is 120/80 mmHg selected arm of the patient, well clear of the
(17/11 kPa). Pulse pressure is the difference brachial pulse point.
between the systolic and diastolic pressures and • The pressure cuff should be inflated until the
will widen or reduce as either or both pressures brachial pulse can no longer be palpated. The
change. The value of the systolic and the pulse value of this pressure should be noted and
pressures rises with age due to loss of compli- the pressure released rapidly.
ance in the arterial tunica media. • The diaphragm of the stethoscope should be
The taking of blood pressures by the ausculta- placed on the pulse point and the pressure
tory method is a simple technique but requires cuff re-inflated to the same value as
practice and attention to detail in the procedure previously obtained. Nothing will be heard at
(Fig. 6.11). Other methods such as the palpatory this stage. All vessels will be occluded so that
method are not considered to be as sensitive. The no blood can flow through the artery.
method was developed using mercury manome- • The pressure should be released slowly and
ters, but increasing awareness of health and steadily, watching the needle on the
safety is seeing the gradual replacement of these manometer face (or the column of mercury
by aneuroid manometers, which are not only fall). As the pressure falls to the level of the
safer but more user-friendly. Even easier to use patient's systolic blood pressure a knocking
are automatic manometers which display the sound will be heard in the stethoscope. At
blood pressure and heart rate on a liquid crystal this stage the pressure in the cuff is sufficient
display (LCD) panel although accuracy varies to prevent flow of blood during diastole, but
according to the model used. not during systole, so that the systolic flow
In the manual versions the manometer is con- can be heard. The reading of the manometer
nected to a rubber hand pump with a valve and when the sound is first heard should be
an inflatable cuff and the following procedure noted; this corresponds to the value of
should be adopted: systolic blood pressure.
Figure 6.11 Diagram showing correct position of patient for measuring brachial blood pressure using the auscultatory method.
94 SYSTEMS EXAMINATION
HDLC <35 mg/ dl (0.9 mmol/D are considered Table 6.3 Causes of arterial insufficiency in the foot
in the United States to have subclinical CAD
Acute Extrinsic:
(Hecht & Superko 2001). light clothing
Coronary angiography. This involves intro- tourniquet
duction of a diagnostic catheter through the plaster cast
trauma
femoral artery into the left ventricle and associ- frostbite
ated vessels (Kumar & Clark 1990c). Pressures immersion foot
in various of the heart chambers and main Intrinsic:
thrombosis
vessels can be measured directly. Blood samples embolus
can be taken to measure oxygen content and ruptured aneurysm
ischaemic metabolites such as lactate and oedema
contrast cine-angiograms can be taken by injec- Transient (usually lead to acute problems but may
tion of a radio-opaque dye at the site to be progress to chronic)
Raynaud's phenomenon
investigated. Digital subtraction angiography Chilblains
produces better-quality angiograms. Hereditary cold fingers
Myocardial perfusion scintigraphy (radionuclide Chronic Atherosclerosis
perfusion imaging). This is a very sensitive test Vasculitis
using exercise thallium-201 or technetium-99m Thromboangiitis obliterans (Buerger's disease)
Arteriolosclerosis?
imaging to detect coronary artery disease (Kapoor
& Singh 1993b, Kumar & Clark 1990d).
• dermatomyositis
Case history 6.2
• systemic sclerosis
• polyarteritis nodosa A 35-year-old female Caucasian first presented to
• giant-cell arteritis the clinic when aged 24, complaining of broken skin
on the toes. The patient presently lived alone as she
• erythema nodosum had recently separated from her partner and she
• Henoch-Schonlein syndrome. had a history of poor circulation to both hands and
feet. Footwear was inadequate for winter, and foot
Thromboangiitis obliterans is characterised hygiene was poor. Examination of the lower limbs
by inflammatory changes in small and medium- revealed pale skin and cold feet. The lesser toes
were held in flexion deformities. No hairs were
sized arteries and veins. It mainly affects young present. The nail on the left fifth toe was black. The
males and there is a very strong association with skin was tight, shiny and smooth. There were small,
smoking. All signs and symptoms of arterial painful ulcers on the apices of toes and fingers. All
ulcers showed signs of infection. Pedal pulses were
ischaemia and superficial phlebitis of the hands palpable but feeble. Popliteal pulses were stronger.
and feet may be present. Eventually, distal Ankle-brachial pressure indices at the dorsalis pedis
necrosis occurs. artery for right and left foot were 1.0 and 0.97,
respectively. There was no evidence of underlying
Arterial emboli can be composed of any systemic disease.
obstructive body that lodges in the smaller A diagnosis of idiopathic Raynaud's disease was
vessels of the arterial tree, causing ischaemia dis- made. The condition was exacerbated by personal
and social factors. The repeated breakdown of
tally. The most common embolus is formed by lesions, as detailed in the patient's record over the
fragmentation of a thrombus, such as a mural past 4 years, was due to the underlying vasospastic
thrombus found on the endocardium, especially disorder, which was worsened by cold weather, self-
neglect and emotional upsets. Current treatment was
around the heart valves, or in the arteries, successful in healing the lesions but without continued
mostly at sites of bifurcation, where turbulence patient compliance the overall prognosis is poor.
is most likely. Emboli may occlude arterioles and
capillaries, causing isolated patches of digital
necrosis. The source of such emboli may be
septic thrombus from infection or deformed • pallor
red blood cells as seen in sickle cell anaemia. Any • pulselessness
history of previous MI, stroke or transient • paraesthesia
ischaemic attacks suggests the presence of • paralysis
atherosclerosis which, in addition to affecting • perishing cold.
the coronary and cerebral arteries, may also be
Pain is usually associated with arterial
affecting the arterial supply to the lower limb. A
insufficiency. It is important that the site, nature,
past history of vascular surgery such as coronary
duration and aggravating factors of the pain are
or femoropopliteal bypass grafting is also a good
recorded. This information can be very helpful
indicator that atherosclerosis may be present. A
when assessing the prognosis of diseases that
history of cryovascular disorders (e.g. chilblains,
affect the arterial supply. Inadequate blood
Raynaud's disease/phenomenon) should be
supply to respiring tissues may be an acute situ-
noted as the attacks of vasospasm may become
ation, producing a characteristic range of signs
chronic and cause painful digital ulceration.
and symptoms, including pain, pallor and lack
(Case history 6.2).
of pulses. When the deficiency is prolonged, the
tissues eventually suffer irreversible damage
Symptoms and this stage can be recognised by mottling,
muscle tenderness, motor or sensory deficit and
Inadequate blood supply to the lower limb leads
necrosis. Continuation of the condition will lead
to a range of signs and symptoms that are known
to a chronic state of insufficiency, accompanied
as the six Ps:
by pain on exercise, or even at rest if very severe,
• pain and necrosis and ulceration. The following types
VASCULAR ASSESSMENT 97
Table 6.4 The Fontaine classification of peripheral aid flow and cooling the limb helps to reduce
vascular disease (PVD)
metabolic activity.
Stage Symptoms
Colour Causes
withstand the normal daily stresses on the lower regions being affected first. The tissue will
limb. The characteristics of the lesion can assist in appear hard, black and mummified, with a clear
diagnosis of the circulatory problem, since ulcers demarcation line between dead and living tissue
caused by ischaemia differ in many respects from (Plate 3). Ulceration and infection may cause a
those caused by other deficiencies such as poor septic vasculitis, which again leads to ischaemia
drainage or neuropathy (Ch. 17). Ischaemic ulcers and necrosis, but here the tissue remains moist
are caused by trauma and are usually very and usually has a distinctive smell. This is wet
painful, unless there is neuropathy present, as for gangrene. Pus and infection of surrounding
example in some diabetic patients. There is lack of tissue is present. The presence of proximal arter-
granulation tissue and low amounts of exudate, ial occlusion and poor collateral development
but slough is often present. The borders are well may be contributing factors.
demarcated and they may have a 'punched out'
appearance (Plate 2). They often occur first under
Oedema
the toe nails, on the apices of the toes or around
the borders of the feet, a contributory factor Oedema is not usually associated with poor
usually being tight or ill-fitting footwear. Leg ele- peripheral arterial supply. If present bilaterally,
vation can exacerbate the pain, whereas lowering the cause is likely to be a central one such as
the leg into dependency can improve the blood congestive heart failure. Unilateral or localised
supply and ease the pain. Ischaemic ulcers are oedema may be due to infection, trauma, allergy
unlikely to heal unless there is an improvement in or impaired venous or lymphatic drainage
blood supply. Ulcers of any type are less likely to (Table 6.6).
heal if the patient is on medication which reduces
cardiac output, e.g. beta-blockers.
Clinical tests
Nails The following tests should be repeated for both
lower limbs and require none or very simple
Poor blood supply will affect the nails. These may
apparatus of the type usually found in a practi-
be crumbly, discoloured or thickened. They are
tioner's clinical environment. Again some of
prone to fungal infection and pitting. The latter
these tests are of greater significance than others
should be differentially diagnosed from dermato-
in aiding diagnosis.
logical conditions such as psoriasis (Ch. 9).
Causes
lower limb from the knee to the toes. The proxi- plantar surface of the foot will appear pale as
mal part of the leg should feel warm to the touch, blood will have drained out of all superficial
with a gradual cooling as the feet are vessels due to the effects of gravity. The blood
approached. On a cold day the toes can feel very can be stroked from the raised limb to accelerate
cold; this is quite normal but a sharp temperature the gravitational effects. A mild pallor should
drop on a comfortably warm day will suggest an then be seen within 1 minute. A severe, wide-
inadequate blood supply, with possibly an spread pallor suggests arterial insufficiency. The
obstruction occurring at the level of the sudden limb should be lowered into dependency and
change. Remember too, that the temperature felt the time taken for the plantar surface to return to
is relative to the temperature of the hand of the the colour of the other limb or for the dorsal
practitioner. This problem can be overcome by veins to refill should be noted. If the blood
measuring skin temperature with a simple probe supply is adequate, the plantar surface of the
thermocouple attached to a hand-held digital foot should regain its normal colour within
display unit. Any difference between the two 15 seconds. A delayed time of 20 seconds or
limbs of more than 2°C should be investigated more suggests that blood supply is inadequate,
further. with severe ischaemia being likely if the delay is
40 seconds or more. If the colour on dependency
is a dusky red, this is a serious sign, indicating
Capillary filling time (CFT)
that the blood supply is severely compromised.
CFT is gradually falling into disuse as it has Buerger's test has been shown to be a useful
failed to show a correlation with gold standard adjunct to routine vascular assessment and can
measurements such as transcutaneous oxygen be an indicator of more severe ischaemia with
tension (Tcp02) values, being replaced by more distal limb artery involvement (Ins all et al 1989).
meaningful tests. To be strictly accurate, it is not
the capillaries but the subpapillary venous
plexus which is responsible for colour in the skin Allen's test
and is blanched by digital pressure. The time is
noted in seconds for the blood to return after This can be used to detect occlusion distal to the
blanching. Normal colour should return within ankle. One leg of the patient is elevated and the
2-3 seconds on a warm day and within 5 seconds dorsalis pedis artery is compressed with the
on a cold day. Absence of blanching in a cyanotic practitioner's thumb. Maintaining pressure on
foot indicates that the tissues are devitalised. the artery, the leg is lowered into dependency. If
the tibialis posterior artery is patent, the foot
should return rapidly to its normal colour. The
Buerger's elevation/dependency test patency of the dorsalis pedis artery can be tested
The leg should be elevated until all the veins in in a similar manner, by compressing the tibialis
the dorsal arch of the foot have emptied. The posterior artery.
100 SYSTEMS EXAMINATION
B c
Figure 6.12 Location of pulses in the lower limb A. Dorsalis pedis B. Anterior tibial C. Posterior tibial D. Popliteal
E. Femoral.
VASCULAR ASSESSMENT 101
systole
B
A biphasic trace typical of a lower limb artery
distal to a stenosis. Note dampened wave form
and loss of reverse flow.
D
A trace showing the typical pattern of valvular
incompetence in a vein.
compression release
Figure 6.13 Doppler traces A. Triphasic trace typical of a healthy lower limb artery. Note the reverse flow has started before
the forward flow in the systolic phase has ended B. A biphasic trace typical of a lower limb artery distal to a stenosis. Note
dampened waveform and loss of reverse flow C. A trace typical of a popliteal vein with intact valves during compression and
release of the vein D. A trace showing the typical pattern of valvular incompetence in a vein.
VASCULAR ASSESSMENT 103
waveform indicates disease (Fig. 6.13B), although Ankle-brachial pressure index (ABPI)
a diphasic response can be seen with ageing as the This was first described by Yao in the 1960s. The
vessels lose compliability (Case history 6.3). ankle-brachial index provides a good indication
Forward and reverse flow simultaneously sug- of the presence of ischaemia in the lower limb. It
gests turbulence, as would occur just distal to a can be used quantitatively since it also correlates
site of stenosis. A monophasic response always well with the patient's symptoms, walking dis-
indicates disease, but care must be taken first to tance and angiography. It can be used to deter-
ensure that the technique is not at fault. Patients mine the optimum level of amputation and
with bradycardia will have a weak triphasic prognoses for grafts (Ameli et al 1989, Davies
sound and patients with tachycardia will show 1992).
only a biphasic sound as the heart is beating too The ankle-brachial pressure index is arrived
rapidly for reverse flow to occur. The amplitude of at by recording the systolic pressure at the
the waveform is not significant since it depends brachial artery and at the posterior tibial artery
on the angle of the probe. (ankle). Practitioners may find Doppler easier to
use than a stethoscope when trying to take a
Claudication distance reading of the systolic pressure in lower limb
arteries. The reading obtained for the ankle is
If the patient complains of intermittent claudica- then divided by the brachial systolic reading and
tion or if pedal pulses seem weak or absent, this is expressed as a ratio. The value obtained at the
test can be used to give an indication of the sever- ankle will depend on the position of the patient.
ity of the arterial occlusion. The patient is exer- If the person is supine and the legs are at the
cised, preferably on a treadmill, as the exercise same horizontal level as the heart the ratio
should be standardised, and the distance the should be 1. If the person is sitting or standing,
patient walks before the onset of pain is noted. the pressure in the artery at the ankle will be
The treadmill should be at 0% incline and at a greater than in the arm, because of the vertical
speed of 4 km/h. No patient should be exercised column of blood between heart and ankle. As a
if there is a history of angina and it is recom- rule of thumb the ankle systolic pressure will be
mended that a full resuscitation kit should 2 mmHg higher for every inch below the heart.
always be present for any exercise test. Thus the ratio will be greater than 1. Average
1--····----·-----·- -----.--------------.----
I Case history 6.3
I
------------------------------_._--_._--------_._-------
A ss-year-old female Caucasian presented to the clinic because of the ulceration present. The ischaemic index
with an ulcer of 12 months' duration over the right medial for the left leg was 1.2. The Doppler signal of the popliteal
maleolus. The patient complained that the skin had been vein in the popliteal fossa indicated venous reflux.
itchy prior to the ulcer occurring and had developed The past medical history revealed that the patient had
following a knock to the right ankle. Pain was worsened suffered a deep vein thrombosis while recuperating from
on standing for long periods and relieved by elevation of a major abdominal operation when 20 years old. The
the legs. She had no symptoms of paraesthesia or thrombosis had been treated effectively at the time but
claudication. Examination of the lower limbs was the patient had noticed some 10 years later that her right
remarkable for pitting oedema, varicose veins, leg began to ache and feel heavy after prolonged
haemosiderosis, atrophe blanche and gravitational standing. When she was about 40 years old her ankle
eczema in the distal third of the right limb. The skin was started to swell towards the end of the day and by the
warm, pedal pulses were bounding and regular (70 beats time she was 50 the skin around the area had become
per minute) in the left foot but pedal pulses in the right discoloured and itchy. Despite a range of treatments the
foot could not be palpated because of the oedema. Both ulcer had not healed.
right pedal pulses were located with Doppler and gave a A diagnosis was made of venous ulceration, as a
regular, biphaslc signal. There was no evidence of trophic result of post-thrombotic complications. These ulcers are
changes to skin or soft tissue. An ischaemic (ankle- notoriously difficult to heal and account for the majority of
brachial) index was not undertaken on the right leg lower limb ulceration.
104 SYSTEMS EXAMINATION
values for healthy adults in the sitting position 1992). Again a standardised treadmill exercise
are 0.98-1.31 (Davies 1992). should be used (4 km/h, 0% incline, 4 minutes).
A ratio which is greater than 1 does not In a healthy adult, unless exercise is severe, the
always mean that all is well. Elderly patients may index will show no change or will rise but
show calcification of the tunica media of mus- rapidly returns to resting value once exercise has
cular arteries (Monckeberg's sclerosis) which, stopped. In a person suffering from peripheral
although independent of any atherosclerotic vascular disease, the index will not rise and may
process and clinically insignificant, leads to fall, taking a long time to return to resting values.
incompressibility and a false high systolic pres- Heavy exercise may produce a fall in the index in
sure value. People with diabetes are also prone to healthy subjects due to shunting of blood from
calcification of the artery wall (not to be confused the distal arteries to the exercising muscles.
with Monckeberg's sclerosis), again leading to If the patient cannot be exercised, the hyper-
incompressibility of the artery. Nevertheless, 'the aemic test can be used. A second occlusion cuff is
measurement of ankle pressure using Doppler is placed proximal to the first and inflated to above
the single most valuable adjunct to the assess- the systolic pressure for 2 minutes or as long as
ment of the blood supply to the foot' (Faris 1991). the presence of ischaemic pain will allow. It is
Any value below 1 should be checked again. then deflated and the systolic blood pressure is
Values less than 0.8 suggest some obstruction immediately taken. The second cuff occludes the
in the more proximal part of the artery to the arterial supply. Since venous drainage is also
lower limb, although it is possible to find no temporarily interrupted, metabolites will accu-
associated lesions in such patients. Values of 0.75 mulate in the area. These have a vasodilatory
or less indicate severe problems, and at values effect on the blood vessels, so that in a healthy
below 0.5 healing is unlikely to take place, the leg person, on releasing the second cuff, blood will
being in a pre-necrotic state. Critical limb rush into the area, producing a temporary hyper-
ischaemia is said to be present when the ankle aemia. This will cause a slight rise in systolic
systolic pressure falls below 50 mmHg or the toe blood pressure and so raise the value of the ABPI,
systolic pressure falls below 30 mmHg (Lowe but will quickly return to normal values. In a
1993). Ischaemic ulcers may be present. patient with peripheral vascular disease the nar-
If severe ischaemia is suspected, but a high rowed arteries will be unable to respond to the
ABPI is obtained due to calcification, the Pole test vasodilatory effects of the metabolites, either
can be used to calculate the ABPI (Smith et al because they are unable to dilate or because the
1994). The Pole test is a variation on the Buerger occlusion prevents an increased flow, so that the
test using a mini-Doppler machine. With the ABPI will either stay the same or fall.
patient supine, the suspected pedal artery is If a low ankle-brachial index is recorded, the
located and the affected leg raised until the pulse index should be calculated at progressively higher
can no longer be heard. The vertical distance positions up the leg, to ascertain the site of the
between the heart and this point is noted. Ankle occlusion. When using the ankle-brachial pres-
systolic pressure is calculated using the formula sure index it is also important to remember that
13 cm == 10 mmHg. Values of less than 40 cm the value obtained for the ankle cannot accu-
(31 mmHg) suggest severe occlusion. Calcifi- rately predict the healing of lesions in the fore-
cation will have no effect on this reading, but the foot although pedal arteries are rarely affected by
method is limited to those patients with pres- atherosclerosis. Digital cuffs can be used to assess
sures less than 60 mmHg. It is also worth remem- the systolic reading in toes. A Doppler head of
bering that the peroneal artery is usually spared 10 mHz is preferable although not essential.
from calcification. ABPI of the peroneal nerve, toe pressures and
Since mild to moderate atherosclerotic change analysis of the Doppler waveform will give a reli-
may not affect the resting ABPI the effects of able indication of the presence of significant
exercise on the index are often observed (Davies ischaemia, which will be revealed as reduced
VASCULAR ASSESSMENT 105
ABPI, reduced toe pressure and dampening of Magnetic resonance imaging (MRI) and positron
the Doppler waveform. emission tomography (PET) scanning. These are
The cardinal signs of ischaemia can be sum- expensive, more recent procedures which can be
marised as follows: used to visualise the various parts of the circula-
tion. Initially, doubts were raised as to the value
• diminished or absent pedal pulses
of such procedures in the absence of evidence to
• ABPI <0.9 suggest any improvement in patient outcome
• ischaemic pain. (Kapoor & Singh 1993c) but recent improvements
in resolution using gadolinium enhancement
Hospital tests now enable imaging of digital vessels as small as
1 mm diameter and have led Mercer & Berridge
If an ischaemic limb has been identified, further
(2000) to consider magnetic resonance angiogra-
investigation may be required to assess:
phy as the modality of the future, eventually
• suitability for reconstructive surgery replacing contrast angiography.
• the prognosis for the healing of ulcers
• the level at which amputations should be Microcirculation
performed.
Capillaroscopy. With the patient in a sitting
position, the capillaries of the pedal nail fold can
Macrocirculation
be examined, using an oil immersion microscope
Duplex ultrasound. This xornbines B mode under a strong light. The nutritive capillaries are
ultrasound and Doppler to give both an image of distinct and well filled with blood in a person
the artery under investigation and the flow with no arterial disease but, as ischaemia pro-
within that artery (Banga 1995). It takes time and gresses, the capillaries become hazy and less dis-
requires a level of expertise, but using Doppler tinct. Capillaroscopy can be used to predict those
and pulse-generated run-off (PGR) a complete patients likely to develop critical limb ischaemia
non-invasive assessment of the lower limb can be as well as the likelihood of healing of ischaemic
achieved, which reduces the need for contrast ulcers.
angiography. Transcutaneous oxygen tension (Tcp02)' The
Angiography (arteriography). At present this skin is heated to arterialise the capillaries and the
procedure, especially using intra-arterial digital oxygen which diffuses to the surface of the skin
subtraction angiography, remains the gold stan- equilibrates with an electrolyte solution held in a
dard for imaging the arterial supply of the lower small chamber on the skin. The partial pressure
limb. A needle is inserted into the femoral artery of oxygen in the solution is measured by an elec-
and a radio-opaque dye is injected just proximal trode which screws into the chamber. This value
to the occlusion. It can be used to locate occlu- reflects the difference between oxygen supply
sions and stenotic vessels and to determine and consumption in the local tissues. Severe
whether a collateral circulation has been estab- ischaemia is indicated if the value is below
lished. It is used to help determine the most 40 mmHg, when healing will be unlikely. This is
appropriate revascularisation procedure and, if a not a routine test but can be used as a predictor
bypass procedure is to be performed, the site of of level of amputation and of the success of
the distal anastomosis. It also is used to predict angioplasty.
the prognosis for limb salvage and graft patency. Photoelectric plethysmography. This method is
It can also be used during surgery, to enable the used to measure skin blood pressure. A light-
surgeon to have an accurate picture of distal run- emitting diode is placed on the skin and a photo-
off. Being an invasive procedure, it carries more cell is used to detect the emitted light, which is
risks than non-invasive procedures, which are proportional to the amount of haemoglobin in
likely to replace it as technicalities improve. the tissues. A sphygmomanometer cuff is used to
106 SYSTEMS EXAMINATION
blanch the skin. The cuff is then slowly deflated • inflammation of the vein wall (phlebitis) with
and the pressure point at which a flow signal possible secondary formation of a thrombus
returns is taken to be the skin perfusion pressure. (phlebo-thrombosis).
A similar piece of apparatus is used to measu~e
The first condition affects superficial or com-
oxygen percentage saturation of the blood m
municating veins. The cause may be congenital,
pulse oximetry (Coull 1988). .
where family history is common; be caused by
Isotope clearance. This method IS used to
increased pressure, such as occurs during preg-
measure skin perfusion pressure (SPP) and skin
nancy; or an abdominal tumour or ascites which
vascular resistance (SVR) in the compromised
causes venodilation and renders the valves
foot in order to ascertain the likelihood of the
incompetent. Much less common are congenital
healing of ischaemic ulcers. The SVR can be cal-
conditions causing swelling or dilation of veins.
culated from the graph of clearance values and
The resulting back flow due to gravity leads to
applied pressure. A straight-line ~elations~ip
increased hydrostatic pressure in the lower limb
exists between the two and the SVR IS the reCIp-
veins, giving rise to the knotty appearance of
rocal of the slope. A small volume of the
varicose veins.
radioisotope technetium-99m, together with a
The second and third conditions can affect
vasodilator such as histamine, is injected into
superficial or deep veins, but part of th~ s.equela.e
the skin and the rate of clearance of the isotope
of deep vein pathology is often superficial van-
is recorded. The pressure from a sphygmo-
cosities. Phlebitis with no thrombosis affects
manometer cuff just necessary to prevent the
superficial veins, usually as a result of trauma or
radioisotope from leaving the area is taken as
infection. Causes of venous thrombi are multifac-
the SPP. This value reflects the degree of large
torial, being any factors which contribute to
artery disease. A value of 30 mmHg or more is
Virchow's triad of:
needed to ensure healing. Radionuclide
imaging as performed for investigation of coro- • stasis
nary arteries can also be used to estimate blood • hypercoagulability
flow in the foot and to detect the presence of • injury to the endothelium.
osteomyelitis (Faris 1991).
Patients suffering from recurrent thromboses
Laser-Doppler fluximetry. This measures the
show a familial tendency and an association has
movement of red blood cells in cutaneous
been demonstrated with a mutation for genes
vessels, which changes as ischaemia progresses
and so can be used to determine amputation
level. Table 6.7 Causes of venous insufficiency
Type Cause
VENOUS DRAINAGE Superfical Varicose veins:
primary - idiopathic
Venous problems may arise in the superficial, secondary - backflow from deep to
communicating and/or deep veins (Table 6.7). superficial vein
Superficial veins lie in the superficial fasci~, d~ep Thrombophlebitis
veins lie in skeletal muscle and communicating Phlebangioma (congenital swelling of vein)
veins link the two. There are three main patho- Phlebectasia (congenital dilation of vein)
logical processes affecting veins, which can be
Deep Deep vein thrombosis due to:
interlinked: abnormalities affecting blood flow
abnormalities of clotting
• absent or incompetent valves abnormalities of endothelium
• formation of a thrombus which may trigger Idiopathic
secondary inflammation of the vein wall
Thrombophlebitis
(thrombophlebitis)
VASCULAR ASSESSMENT 107
coding for coagulation factor V, with greater inci- popliteal cyst, as sometimes occurs in patients
dence among Caucasians than other ethnic with rheumatoid arthritis, may cause similar
groups (Khachemoune et al 2001). symptoms. If a DVT is suspected, it is not advis-
The presence of a thrombus in the deep veins, able to use any diagnostic test which increases
whether causing or following an inflammatory pressure on the calf, such as detection of
response, is much more serious than its presence Homans' sign, as this increases the risk of
in a superficial vein as it will lead to chronic embolism. Because of the direction of venous
venous insufficiency and the stasis syndrome flow proximally and centrally, venous emboli
(post-thrombotic syndrome) in approximately a will be swept through increasingly larger
quarter of these cases with the further risk of pul- vessels and emptied into the heart. From
monary embolism. The incidence of deep vein here they will enter the pulmonary circulation
thrombosis (DVT) in the United States is 1:1000 and only here are the vessels small enough
with death from pulmonary embolism being to stop the embolus. Occlusion of the main
1-2% (Khachemoune et al200l). pulmonary vessels (pulmonary embolism) pre-
vents any gaseous exchange, often with fatal
consequences.
Past history
As varicose veins and recurrent deep vein
thromboses tend to have a familial predisposi- Observation
tion, it is important to ask the patient if anyone Hosiery
else in the family suffers from the condition.
Varicose veins may be part of the post-thrombotic The wearing of elastic or support stockings or
syndrome (Case history 6.3) but do not always bandages suggests some problem with venous
indicate previous DVT. Patients should be asked drainage. The extra compression provided by the
if they have previously suffered with any stocking aids venous blood flow and reduces
venous problems, e.g. DVT. Women of child- peripheral oedema.
bearing age may have experienced a DVT
during, or more probably shortly after, child-
Colour
birth. Although this may have occurred some
years ago, it may be the underlying cause of Telangiectases (dilated microvasculature) around
current venous problems. the medial malleolus can indicate poor drainage
(Plate 4). A mottled cyanosis may appear in the
lower third of the lower limb due to stagnation of
Symptoms
blood in the veins as a result of poor drainage.
Uncomplicated varicose veins may be asympto- Atrophie blanche, white patches on the skin
matic but present a cosmetic problem to many around the ankles, occurs due to strangled micro-
women. Where superficial veins are affected by circulation and leads to fibrotic and sclerotic
phlebitis the vein and surrounding area will be changes in the skin (Plate 5).
tender with erythema or cellulitis. If throm- Brown iron complexes of haemosiderin may
bophlebitis is present the vein will be palpable as be deposited in the tissues as a result of
a linear, indurated cord and is usually associated increased hydrostatic pressure (Plate 6).
with tenderness, erythema and warmth. Differential diagnoses from haemosiderosis are
A bursting or aching sensation associated erythema ab igne, common in the elderly, and
with ankle oedema suggests problems with the necrobiosis lipoidica diabeticorum, a condition
deep veins. The pain and oedema are often alle- associated with diabetes, where yellowish
viated by leg elevation. The onset of DVT can be patches are seen on the shins and the skin
asymptomatic or be associated with severe pain, appears very transparent, so that superficial
tenderness and warmth in the calf. A ruptured blood vessels can be seen.
108 SYSTEMS EXAMINATION
proteins, including fibrinogen, and will become pitched sound, like wind sighing down a
organised. Transudate will not become organised chimney, because of the effects of respiration on
unless it is very long-standing. Once the oedema the flow of venous blood in the thorax. On a
is organised it cannot be squeezed by digital pres- chart the venous trace shows as an irregular,
sure and so is called non-pitting. The oedema due continuous wavy line with flow away from the
to DVT usually demonstrates pitting unless it is probe (Fig. 6.13C). However, if there is excessive
very long-standing. There will often be an outline fluid in the lower limbs, as in congestive heart
of the patient's hosiery or footwear impressed on failure, the veins may give a pulsatile sound.
the skin. The Doppler machine can be used to test for
Oedema may result in ischaemia around the valvular incompetence of the calf veins as
ankle. In these instances moist gangrene may follows.
occur if the occlusion of arteries is very severe. With the patient standing and knee slightly
The different types of oedema which can occur in flexed, the Doppler probe should be positioned
the lower limb and their differential diagnosis over the vein in the popliteal fossa (it may be
are shown in Table 6.6. easier to locate the popliteal artery and then
move the probe slightly sideways until the vein
is located). The practitioner should squeeze and
Leg shape release the calf, distal to the probe. Two sharp
Patients with chronic venous ulceration and sounds should be heard. The first sound is
oedema may develop characteristic 'champagne forward flow towards the probe as the vein is
legs', also known as 'inverted bottle legs'. squeezed and the second sound is reverse flow
due to gravity on release of the pressure. If there
is no sound on compression this indicates a
Clinical tests blockage between site of compression and
Pitting/non-pitting oedema probe. If the second sound is not abrupt, but
continues and fades away, it suggests leakage of
Digital pressure is firmly applied to the area for a blood through the valves. This will be seen on a
period of 3-5 seconds. If an imprint of the fingers chart recording as a sharp peak, corresponding
remains, the oedema is described as pitting. to flow towards the probe and a rapidly rising
and much slower descending, irregular trace in
Perthes test the opposite direction as the blood flows
through the valve (Fig. 6.130). This test should
This can be used to test the competency of leg not be performed if a DVT is suspected.
veins. With the leg dependent, an occlusion cuff
is inflated at mid-thigh level. The superficial
veins will become prominent as they fill. The Hospital tests
patient is then asked to walk for 5 minutes. If Plethysmography. A range of methods can be
the veins are healthy, the prominence will used - impedance or air plethysmography, phle-
reduce due to drainage into the deep veins. If borheoplethysmography and mercury strain-
the superficial veins are incompetent, the gauge plethysmography. These instruments can
prominence will remain and if this is accompa- be used to diagnose thrombotic obstruction of
nied by a dusky rubor it suggests that the deep major proximal veins of the extremities. They are
veins are incompetent. not useful for detecting calf vein thrombosis.
Venous angiography. A radio-opaque dye is
injected into the affected vein to show valvular
Doppler
incompetence and the presence of an obstruction.
In contrast to the pulsating sounds of arteries, Duplex ultrasound. Duplex can be used to
veins give a non-pulsatile, continuous, low- ascertain the long saphenous vein suitability for
110 SYSTEMS EXAMINATION
femoral bypass grafting as well as determining system, such as obstruction or damage due to
the presence of a thrombus. r~diotherapy, malignant disease, surgery (Case
history 6.4), pregnancy ('white leg') or certain
tropical infections (filariasis).
LYMPHATIC DRAINAGE
As previously described, the lymphatic vessels
Observation
play an important part in draining tissue fluid
back, via the thoracic duct, to the heart. If Oedema
lymphatic drainage is adversely affected,
In primary lymphoedema the oedema begins as
oedema (lymphoedema) results. Lymphoedema
a soft, pitting form but becomes harder and non-
can be congenital, where it is classified as
pitting with time. The condition can be unilateral
primary, or acquired, where it is classified as
or .t'ilateral. Secondary lymphoedema is usually
secondary lymphoedema. The causes of
umlateral and considerable fibrosis may occur
primary and secondary lymphoedema are out-
(Case history 6.4, Table 6.8).
lined in Table 6.8.
Tissue viability
Medical history and symptoms
The tissue fluid stagnation will interfere with dif-
A history of permanent oedema, usually confined
fusion of gases and nutrients and removal of
to the lower limbs, suggests primary lymph-
waste products and, as a result, impair tissue via-
oedema, especially if there is a family history of
bility. It may be associated with troublesome cel-
the disease as one form is an autosomal dominant
lulitis and usually leads to a thickening and
condition (Milroy's disease).
scaling of the skin, which can lead to an
Onset is either early in life (lymphoedema
'elephantiasis-like' appearance: an oedematous
praecox) or after the age of about 35 years
leg with skin that resembles elephant skin.
(lymphoedema tarda). It affects females more
than males. Unlike venous oedema, once it is
organised, it will not be alleviated by leg eleva-
tion. In contrast, secondary lymphoedema will
arise as a result of some trauma to the lymphatic Case history 6.4
A40-year-old male Caucasian attended clinic
complaining of difficulty in undertaking routine foot
care of the left foot. An assessment of the vascular
Table 6.8 Causes of lymphoedema status revealed ~hat the left leg was considerably
largerthan the nght and the skin was thickened, dry
Type Cause a~d coarse. Th~ nails on the left were very thickened,
distorted and discoloured. Examination of the left leg
Primary (congenital) Milroy's disease showed the presence of non-pitting oedema. The
Idiopathic patientsaid the left leg had become very swollen and
theskin thickened and dry after an operation on his
Secondary (acquired) Intrinsic: groin.
malignant neoplasia The past medical history revealedthat the patient
radiotherapy had ~ad testicular cancer. This had been treated by
surgical excision of surgical removal of the testicles and radiotherapy. His
lymph nodes problems with the left leg had resulted afterthe
filariasis course of radiotherapy.
infection Adiagnosis of secondary lymphoedema was
pregnancy made. It is likely that the radiotherapy damaged the
Extrinsic: left-side inguinal lymph nodes and as a result
trauma lymphatic drainage of the left leg was adversely
plaster cast affected, resulting in lymphoedema.
VASCULAR ASSESSMENT 111
REFERENCES
Ameli F M, Stein M, Provan J L, Aro L, Prosser R, St Louis Blackwell S 2001 Common anemias - What lies behind?
E L 1989 Comparison between transcutaneous oximetry Clinical Reviews 11: 53-62
and ankle-brachial pressure ratio in predicting run off Coull A 1988 Making sense of pulse oximetry. Nursing
and outcome in patients who undergo aortofemoral Times 32: 42--43
bypass. Canadian Journal of Surgery 32: 428--432 Davies C S 1992 A comparative investigation of ankle-
Banga J D 1995 Lower extremity arterial disease in diabetes brachial pressure indices within an age variable
mellitus. Journal of British Podiatric Medicine 50: 68-72 population. British Journal of Podiatric Medicine 48: 21-24
112 SYSTEMS EXAMINATION
Davies A H, Horrocks M 1992 Vascular assessment and the Kumar P L Clark M L 1990b Clinical medicine. A textbook
ischaemic foot. Foot 2: 1-6 for medical students and doctors, 2nd edn. Bailliere
Faris I 1991 The management of the diabetic foot, 2nd edn. Tindall, London, p 516
Churchill Livingstone, Edinburgh, p 150 Kumar P L Clark M L 1990c Clinical medicine. A textbook
Ganong W F 1991 Review of medical physiology, 15th edn. for medical students and doctors, 2nd edn. Bailliere
Lange, London, p 510 Tindall, London, pp 539-540
Hecht H S, Superko H R 2001 Electron beam tomography Kumar P L Clark M L 1990d Clinical medicine. A textbook
(EBT) may improve diagnosis of subclinical CAD in for medical students and doctors, 2nd edn. Bailliere
females. Journal of the American College of Cardiology Tindall, London, p 538
37: 1506-1511 Lainge S P, Greenhalgh R M 1980 Standard exercise test
Howell M A, Colgan M P, Seeger R W, Ramsay D E, Sumner to assess peripheral arterial disease. British Medical
D S 1989 Relationship of severity of lower limb Journal 280: 13-16
peripheral vascular disease to mortality and morbidity: a Lowe G D 0 (ed) 1993 Critical limb ischaemia - a slide
six year follow-up study. Journal of Vascular Surgery 9: lecture kit. Schering Health Care/Professional
691-696, discussion 697 Postgraduate Services Europe Ltd, Worthing
Huntleigh Diagnostics 1999 Library of sounds-support booklet Mercer KG, Berridge D C 2000 Peripheral vascular disease
for audio cassette. Huntleigh Diagnostics, Cardiff, pp 5-21 and vascular reconstruction. In: Boulton A J M, Connor
Insall R L, Davies R L Prout W G 1989 Significance of the H, Cavannagh P R (eds) The foot in diabetes, 3rd edn.
Buerger's test in the assessment of lower limb ischaemia. J Wiley, Chichester, p 220
Journal of the Royal Society of Medicine 82: 729-731 Murphie P 2001a Macrovasular disease aetiology and
Kapoor A S, Singh B N 1993a Prognosis and risk assessment diabetic foot ulceration. Journal of Wound Care 10:
in cardiovascular disease. Churchill Livingstone, New 103-107
York, p 131 Murphie P 200lb Microvascular disease aetiology in
Kapoor A S, Singh B N 1993b Prognosis and risk assessment diabetic foot ulceration. Journal of Wound Care 10:
in cardiovascular disease. Churchill Livingstone, New 159-162
York, pp 130-131, 145 Nicholson M L Byrne R L, Steele G A, Callum K G 1993
Kapoor A S, Singh B N 1993c Prognosis and risk assessment Predictive value of bruits and Doppler pressure
in cardiovascular disease. Churchill Livingstone, New measurements in detecting lower limb arterial stenosis.
York, pp 4, 11,423 European Journal of Vascular Surgery 7: 59-62
Khachemoune A, Sahu M, Phillips T J 2001 Diagnostic Smith F C T, Shearman C P, Simms M H, Gwynn B R 1994
dilemmas. Wounds 13: 2-4 Falsely elevated ankle pressures in severe leg ischaemia:
Kumar P L Clark M L 1990a Clinical medicine. A textbook the pole test - an alternative approach. European Journal
for medical students and doctors, 2nd edn. Bailliere of Vascular Surgery 8: 408-412
Tindall, London, p 571
FURTHER READING
Berkow R (ed) 2000 The Merck manual. Merck, Sharp and edition, 8th edn. McGraw-Hill, Boston
Dohme Research Laboratories, New Jersey Walker W E 1991 A colour atlas of peripheral vascular
Berne R M, Levy M N 1992 Cardiovascular physiology, 6th disease. Wolfe Medical, London
edn. Mosby Year Book, St Louis, MO Yao S T 1970 Haemodynamic studies in peripheral arterial
Vander A, Sherman L Luciano D 2000 Human physiology - disease. British Journal of Surgery 57: 761-766
the mechanisms of body function, international
CHAPTER CONTENTS
Organisation 116
Anatomical classification 116
Functional classification 122
Function 124
The nerve impulse 124
Sensory pathways 126
Motor pathways 129
Cerebellum 130 There are many conditions affecting the nervous
Basal ganglia 130
system which modify lower limb function
Reflexes 130 (Table 7.1). The purpose of this chapter is to
Reflex arcs 131 enable the practitioner to detect the presence of
Coordination and posture 133 these conditions. The chapter begins with an
outline of the histology, organisation and func-
THE NEUROLOGICAL ASSESSMENT 134
tion of the nervous system. Reflexes are dealt
General overview of neurological function 135 with as a separate topic as they form the basis of
History 135 so much neurological behaviour. It is not possible
Observation 136 to discuss the nervous system without also
Assessment of the level of consciousness 136 making some reference to the muscular system:
History 136 since muscles are the effector organs for much
Observation 137
Clinical tests 137
nervous activity, neurological deficits are often
Hospital tests 137 recognised by their characteristic effects on
Laboraory tests 138 muscle. Similarly, muscular disease may show
Assessment of lower limb sensory
similar characteristics to those of nervous dis-
function 138 orders. The second part of this chapter is con-
History 139 cerned with a detailed description of the
Clinical tests 139 assessment of each part of the neuromuscular
Hospital tests 144
system and, for the purposes of this chapter, the
Assessment of lower limb motor function 144 descriptive term 'neurological' is also taken to
Upper motor neurone lesions 145
Lower motor neurone lesions 146
imply 'neuromuscular' wherever appropriate.
Assessment of coordination/proprioception
function 150 Why undertake an assessment of the
Observation 150
Clinical tests 151
patient's neurological status?
It is important to undertake an assessment of the
Assessment of autonomic function 153
Observation 153 neurological status in order to identify whether
Clinical tests 153 the patient has an intact and normally function-
Summary 154
ing neurological system. The purpose of the
assessment is to:
• establish which, if any, part of the nervous
system is functioning abnormally
113
114 SYSTEMS EXAMINATION
Table 7.1 Neurological conditions that may affect the lower limb
Condition Description
Cerebral vascular accident (CVA) (stroke) Due to haemorrhage, embolus or thrombosis of the cerebral arteries
Parkinsonism Degeneration of dopaminergic receptors. Usually idiopathic but can be
drug induced
Friedreich's ataxia One of a group of hereditary syndromes affecting the cerebellum.
Inheritance is autosomal recessive. Onset in childhood, death usual
around 40 years
Multiple sclerosis Patchy demyelination of the CNS. Shows relapses and remissions.
Onset 20+
Poliomyelitis Virus that affects lower motor neurones (LMNs).
Syringomyelia Progressive destruction of the spinal cord due to blockage of central
canal, e.g. tumour
Tabes dorsal Occurs with tertiary stage syphilis
Spina bifida Defective closure of vertebral column. Congenital
Motor neurone disease Degeneration of both upper motor neurones (UMNs) and LMNs. No
sensory loss. Onset usually between 40 and 60 years. Death usually
due to respiratory infection. Idiopathic
Subacute combined degeneration Due to lack of vitamin B12 . Usually seen in pernicious anaemia. Affects
of the spinal cord both sensory and motor tracts in the spinal cord. See UMN signs,
sensory and proprioceptive deficit. Reversible if detected in time
Charcot-Marie-Tooth disease/ Affects peroneal nerve, predominantly motor with variable sensory
peroneal muscle atrophy/hereditary deficit. Commonest inherited neuropathy. Usually autosomal dominant.
motor-sensory neuropathy Onset in teens, slowly worsens
Guillain-Barre syndrome Post-viral autoimmune response, rapid onset, potentially fatal from
respiratory failure. Predominantly motor effects, with muscle weakness
and paralysis, but some sensory loss; 80% of patients show full
recovery. Also chronic relapsing form
Neurofibromatosis Autosomal dominant condition that leads to tumours of nerves and
compression of spinal cord
Peripheral neuropathy Occurs due to a variety of causes, e.g. alcoholism, injury, diabetes
mellitus
Myasthenia gravis Autoimmune disease that affects the neuromuscular junction and leads
to severe fatigue and weakness/paralysis
Myopathies Range of relatively rare diseases affecting muscle only. May be inherited
or acquired. Symptoms similar to LMN diseases but no fasciculation
• identify the extent of dysfunction function, e.g. initial clinical features associated
• where possible, arrive at a specific diagnosis with multiple sclerosis such as double vision,
• draw up a treatment plan which takes falling over, tingling sensations, and loss of func-
account of the above information. tion. If an appropriate treatment plan is to be
drawn up, knowledge of the presence of any con-
It is important to establish which part or parts dition and its specific effects on the lower limb is
of the nervous system are affected. For example, essential. For example, sufferers of Cuillain-Barre
an ataxic (uncoordinated) gait may be due to a syndrome are predisposed to foot ulcers and so
disorder of the cerebellum or a lack of proprio- the treatment plan should include preventative
ceptive information. The practitioner may be in a measures and a monitoring programme, as 10%
position to identify early changes in neurological of patients may show incomplete recovery.
NEUROLOGICAL ASSESSMENT 115
Blood vessel
OVERVIEW OF THE HISTOLOGY, Pedicle
ORGANISATION AND FUNCTION OF
THE NERVOUS SYSTEM
HISTOLOGY
There are two types of cell that make up the tissue
of the nervous system: glial cells and neurones.
A B
Glial cells
There are four types of glial cell (Fig. 7.1):
• ependymal
• oligodendrocytes (brain) and Schwarm cells
(periphery)
• astrocytes
• microglial.
C D
Ependymal cells are involved in the secretion
and absorption of cerebrospinal fluid (CSF), Figure 7.1 Neuroglia A. Fibrous astrocyte B. Ependymal
which acts as an interstitial fluid, bathing the cells cell C. Oligodendrocyte D. Microglial cell.
of the brain and spinal cord. Oligodendrocytes in
the brain and Schwarm cells in the periphery are
responsible for the manufacture of a fatty neurone to the next, or to other excitable tissue
(myelin) sheath around the axons of the neu- such as muscle. Like other highly specialised
rones, which improves the speed of nerve con- cells, neurones lose the ability to mitose soon
duction. They also playa role in the development after birth and so once the cell body is
and repair of nervous tissue, helping to guide the destroyed, it cannot be replaced; damage results
growing axons to their correct destinations. in permanent changes.
Astrocytes have a buffering function, ensuring A neurone consists of four main parts (Fig. 7.2):
that the K+ concentration of the CSF is constant. 1. Cell body. This contains the nucleus and
This is essential for the correct functioning of the other organelles and is the site of synthesis of
neurones. These cells may also have a nutritive chemicals (neurotransmitters) for the transmission
role, they are phagocytic and they take up certain of impulses.
neurotransmitters. Microglial cells are also 2. Dendrites. These fine branches from the cell
phagocytic and remove debris. Since glial cells body are the chief receptive area for impulses
outnumber the neurones by a factor of at least from other neurones or for the reception of other
10 to 1, their sheer bulk means that they provide stimuli.
structural support, there being no connective 3. Axon. This is the conducting portion and
tissue within the nervous tissue. can be up to 1m in length. It conducts electrical
impulses and is also involved in the transport of
various substances to and from the cell body. It
Neurones
may be myelinated as shown but if less than Lpm
Despite being in the minority, a mere 10 12 in the in diameter it will be unmyelinated.
brain, it is these cells which have the very 4. Presynaptic terminals. These are fine
special function of rapid communication, trans- branches of the axon and are responsible for the
mitting signals or nerve impulses from one release of neurotransmitters to enable the
116 SYSTEMS EXAMINATION
'.j'ti===:;:=== Neurofibrils
.~ Nissl bodies
\ \ - - - Dendrites
Node of
Ranvier - - - - ' l o . ",-- Myelin sheath
\\\'ll'r---- Nucleus of Schwann cell
Axon----~\
The nervous system can be divided in a number Presynaptic _::..JL----\.)/ ":;"....,4-""::_- Postsynaptic
of ways to identify its different parts, based on
both anatomical and functional classifications
(Fig. 7.4).
<
BRAIN
CENTRAL
NERVOUS (CNS)
SYSTEM
SPINAL CORD
<
NERVOUS AFFERENT (SENSORY)
SYSTEM
(NS) SOMATIC NS
EFFERENT (MOTOR)
PERIPHERAL
NERVOUS (PNS)
SYSTEM AFFERENT
AUTONOMIC NS <SYMP
< EFFERENT
PARASYMP
The brain can be divided into fore-, mid- and temporal lobes, thalamus and hypothalamus -
hindbrain and is covered by the three meninges form the limbic system, the output of which is
and protected by the cranium (Fig. 7.5). The cere- coordinated by the hypothalamus.
bral cortex (telencephalon) consists of two hemi- The cerebellum consists of two hemispheres
spheres (right and left), each of which is divided which are primarily composed of the anterior
into four lobes by deep grooves or sulci. The four and posterior lobes. These are phylogenetically
lobes are frontal, parietal, temporal and occipi- younger than the flocculonodular lobe and the
tal. The cortex is highly convoluted, which midline structure called the vermis. The
increases its surface area and therefore the brain stem consists of the medulla, pons and mid-
number of neurones it contains. It overshadows brain. It contains a diffuse network of neurones
other structures in the forebrain such as the basal called the reticular formation and discrete clus-
ganglia and thalamus (diencephalon). An inter- ters of neurones called nuclei. The parts of the
connected collection of cortical and subcortical brain and their main functions are listed in
structures - including parts of the frontal and Table 7.2.
Area Function
Forebrain Cerebral cortex Frontal lobe: abstract thought, conscious action, speech
Parietal lobe: general senses, verbal understanding
Temporal lobe: hearing, taste, smell, emotions
Occipital lobe: vision
Diencephalon Thalamus: sensory relay station
Hypothalamus: emotions, endocrine system, ANS
Limbic system: motivation and emotions
Basal ganglia: movement
Midbrain Corpora quadrigemina Superior colliculi: visual orientation
Inferior colliculi: auditory orientation
Hindbrain Pons Modification of respiration
Cerebellum Modification of movement
Medulla oblongata Vital control centres
118 SYSTEMS EXAMINATION
Cerebrum
Diencephalon
-t'rt'W-{-- Cerebellum
Somatosensory cortex
Figure 7.5 The brain A. Anatomy of the brain B. Position of the lobes and cortex (adapted from Vander et al 1998).
The spinal cord is surrounded by the 32 ver- and their axons form the 'white matter' because
tebrae of the spinal column; the cell bodies of of the presence of myelin. Cerebrospinal fluid
the neurones form the so-called 'grey matter' (CSF) circulates through and over the brain and
NEUROLOGICAL ASSESSMENT 119
spinal cord. During development a difference in the subarachnoid space, with eSF, continue to
growth rates between the spinal cord and the the level of the second sacral vertebra, so that
surrounding vertebrae means that the spinal lumbar punctures can be performed at the level
cord ends at the upper border of the second of L3 or L4 to withdraw a sample of eSF
lumbar vertebra (Fig. 7.6). The dura mater and without damaging the spinal cord.
A""l--=---Cl
10 ~L.J 1 C2
D
CJ
02
03 C3
tJ 04 C4
/l 05 C5
~ C6
:R
=-'
06
C)7
C7
l--+H-+---+---- Femoral
t;tS1--t-'r-----'\--- Sacral plexus L4, 5; S1-3
L3
Sciatic - - - ' - - - - + - t f l
L4
1 + - - - - - - Common peroneal
L5
1 + - - - - - - - Superficial peroneal
Tibial - - - - - - - f - - l I H I
I f f i H + - - - - - - - Saphenous
~- Deep peroneal
Figure 7.6 The spinal cord A. Relationship of vertebrae to spinal cord segments (reproduced from Matthews & Arnold
1991, with permission) B. Organisation of the lumbar and sacral plexi and innervation of the lower limb (adapted from
McClintic 1980).
120 SYSTEMS EXAMINATION
Peripheral nervous system (PNS) pairs of spinal nerves. The spinal nerves emerge
The PNS comprises those nerves that lie outside from the spinal cord as two roots, a dorsal (pos-
the spinal cord and brain, which can be sub- terior) and a ventral (anterior) root, which then
divided into: join to form the peripheral mixed spinal nerve
(Fig. 7.7), which emerges between two adjacent
• afferent nerve fibres, which carry impulses vertebrae. The dorsal root contains the cell bodies
towards the CNS from receptors such as of afferent fibres in a swelling called the dorsal
warmth receptors root ganglion. The central process of each affer-
• efferent nerve fibres, which carry impulses ent neurone travels into the area of grey matter of
away from the CNS to effectors such as the the spinal cord called the dorsal horn. The
leg muscles or sweat glands. ventral root contains mainly efferent fibres, the
The nerve processes form 12 pairs of cranial cell bodies of which lie within the ventral and
nerves originating from the brain stem and 31 lateral horns of the spinal grey matter.
Internuncial neurones
Dorsal root
Peripheral receptor
Smooth muscle
or gland
Skeletal muscle
~----,Ht-- Grey ramus
White ramus
Ventral root
VI"e",' orqan
rn/
~ , ....•...
/~
.~.,
!---- Sympathetic ganglion
B Visceral receptor
Figure 7.7 A. Transverse section through the spinal cord showing mixed spinal nerve roots: (1) the paired mixed spinal
nerves; (2) dorsal (posterior) root; (3) ventral (anterior) root (4) central grey matter; (5) dorsal horn; (6) ventral horn; (7)
central canal; (8) surrounding white matter; and (9) dorsal root ganglion B. Connection between sensory and motor neurone
to the spinal cord (adapted from McClintic 1980).
NEUROLOGICAL ASSESSMENT 121
Muscle
Muscle is divided histologically into three main
types (Table 7.3): Front Back
• skeletal Figure 7.8 The lower limb sensory dermatomes and their
• cardiac nerve roots (adapted from Epstein et al 1992).
• smooth.
In general, skeletal muscle is structurally the where in between. All three types of muscle
most highly organised, smooth muscle has the depend on the binding of calcium ions to
simplest structure and cardiac muscle lies some- calcium-binding proteins to initiate contraction.
This shortening involves the formation of cross- as the baroreceptors of the carotid sinus. The
bridges and sliding of actin and myosin efferent branches of the ANS differ from those in
myofilaments over one another. the somatic system in that there are two neurones
in the pathway. The cell body of the first neurone
is in the eNS but those of the second are found in
Functional classification
the autonomic ganglia outside the eNS. This
While it is possible to divide the nervous system divides the efferent neurones into pre- and post-
into areas according to function, it has to be ganglionic neurones. This efferent outflow can be
remembered that the nervous system acts as a further divided into the sympathetic and
coordinated whole, so that many areas of the parasympathetic systems (Fig. 7.9). The effector
somatic and autonomic nervous systems will organs for both systems are composed of smooth
work together. This is best illustrated by the total or cardiac muscle.
response to an intensely painful stimulus, where Parasympathetic nervous system. This is the
the painful stimuli are fed not only into the efferent part of the autonomic nervous system
sensory cortex but also to the hypothalamus and which restores the 'status quo' and allows emp-
limbic system, and the response is a product of tying actions. The cell bodies of the preganglionic
action by the somatic motor, autonomic and neurones are situated in the brain stem and sacral
endocrine systems on a range of muscles and region of the spinal cord (craniosacral outflow).
glands. The postganglionic cell bodies are found in
ganglia close to or within the effector organ being
innervated, so that the majority of the efferent
Somatic nervous system
pathway is preganglionic. The neurotransmitter
This includes all parts of the nervous system that released at both the pre- and postganglionic
deal with the conscious perception of stimuli and endings is called acetylcholine.
conscious action, including the sensorimotor or Sympathetic nervous system. This is the effer-
so-called conscious cortex. The afferent nerves ent branch of the autonomic nervous system
can also be called sensory nerves and the efferent which prepares the body for action: the fight or
nerves can be called motor nerves. The receptors flight response. The cell bodies of the pregan-
detect changes in the external environment glionic neurones are found in the lumbar and
and the effectors bring about movement of the thoracic regions of the spinal cord and the sym-
skeleton. pathetic ganglia form a chain alongside the
spinal cord, so that the majority of the efferent
pathway is postganglionic (see Fig. 7.7B). The
Autonomic nervous system (ANS)
neurotransmitter released at the preganglionic
This is the part of the nervous system that deals endings is again acetylcholine, but the postgan-
with the internal organs. The parts of the brain glionic endings mostly release noradrenaline
primarily involved with the autonomic system (norepinephrine).
are the hypothalamus and the limbic system. The Where an effector organ receives dual innerva-
terms sensory and motor are not used here, as tion, the two branches usually act antagonisti-
these terms imply consciousness, and much cally, in a push-pull or accelerator-brake fashion,
information coming from the viscera, such as to regulate the activity of the effector organ. For
partial pressure of oxygen in arterial blood, does example, the vagus nerve (tenth cranial nerve)
not reach consciousness; likewise, the move- slows the heart rate down and the sympathetic
ments of the viscera are rarely voluntary move- nerve speeds it up. However, the parasympa-
ments. The afferent neurones are similar in thetic nerves do not innervate structures outside
arrangement to those of the somatic system, with the central axis apart from blood vessels of the
cell bodies in the dorsal root ganglia, although pelvic region. All other peripheral structures,
the receptors are situated in internal organs such skin and blood vessels, are innervated by the
NEUROLOGICAL ASSESSMENT 123
Preganglionic fibres
Postganglionic fibres
Eye
Pons
Medulla
~' •
,."
,."
,."
-- .... ---------- Olfactory glands
Salivary glands
Adrenal Spleen
glands
Kidney
Small intestine
Colon
Parasympathetic
Sympathetic
sympathetic system. Sympathetic activity causes therefore fixed for a particular neurone. Provided
peripheral vasoconstriction and a reduction in the threshold is reached, the resulting action
this activity or 'tone' causes vasodilation. potential will always have the same value for
that neurone. This is known as the 'all or nothing
law'. Since the ion channels are operated by a
FUNCTION voltage change, they are described as voltage-
As with all systems within the body, the prime gated channels.
function of the nervous system is to ensure that The depolarisation is reversed when the sodium
the internal environment which bathes the cells is channels close and potassium channels open,
maintained within acceptable limits (homeosta- allowing an efflux of potassium ions. This
sis). The particular role of the nervous system is renders the interior of the neurone more and
to ensure that the collection of cells and tissues more negative, and the membrane is now
that constitute our bodies can act as an organised 'repolarised'. At the same time the sodium
whole. This can only be achieved if the cells can pump, present in all plasma membranes,
communicate with one another. The nervous actively pumps out the sodium which has
system has evolved as the system of rapid com- recently entered and claws back the escaped
munication, usually producing short-term potassium. Due to a time lag in the closing
effects. It evolved with, and works alongside, the of the potassium channels, the inside of the
generally slower endocrine system, which tends neurone actually becomes briefly more negative
to have long-term effects. than when at rest, and this phase is described as
'hyperpolarisation' (Fig. 7.10).
The opening and closing of the ion channels is
The nerve impulse
triggered by the initial voltage change, but
Neurones use two types of signal to achieve because this opening and closing operates at dif-
intercellular communication - graded and action ferent rates, the ions move in the sequence just
potentials. Both types of signals are dependent
upon the movement of ions across the cell mem-
mV
brane and through protein ion channels, but they
2
also show many differences. 40
Action potential 20
described. Finally, the distribution of ions is channels in the plasma membrane. Influx of
restored to their pre-action-potential level and calcium causes the movement and exocytosis of
the membrane is at resting potential once more. vesicles laden with neurotransmitter. The latter is
All this activity is ultimately dependent upon referred to as the first messenger. The conse-
energy being expended by the sodium/potassium quence of combination of the neurotransmitter
ATPase (adenosine triphosphatase) pump: hence with postsynaptic receptors is a conformational
the term 'action potential'. Due to the establish- change in proteins of the plasma membrane,
ment of local current flow, the initial depolarisa- resulting either in a direct effect on proteins to
tion triggers an identical action potential at open or close ion channels or, much more com-
adjacent sites and this is propagated along the monly, in activation of an enzyme such as adenyl
axon without any attenuation of the impulse. If cyclase. This catalyses the production of cyclic
the axon is unmyelinated, this sequence of events AMP (adenosine monophosphate) from ATP
will be repeated at every point along the axon, (adenosine triphosphate). Cyclic AMP acts as a
spreading out in both directions away from the second messenger, triggering a cascade of inter-
initial stimulus. nal events that finally results in the opening of
The presence of myelin speeds up the passage ion channels, allowing depolarisation of the post-
of the impulse, since it enables the local current synaptic membrane, the so-called graded poten-
to spread further, up to 1 mm along the axon, tial. Since the ion channels are opened by chemi-
before another action potential needs to be gen- cals they are called chemically-gated channels.
erated. Hence, the sodium channels need only be In parkinsonism there is a loss of the neuro-
situated at 1 mm intervals, at the so-called 'nodes transmitter dopamine, and with myasthenia
of Ranvier' with a myelin coat in between. Since gravis there is a loss of cholinergic receptors on
local current flow is faster than the generation of the skeletal muscle end-plate; both these condi-
an action potential, the impulse appears to jump tions adversely affect the normal functioning of
or leap from node to node: hence the term 'salta- the graded potential. Graded potentials rapidly
tory conduction' from the Latin word saltare dissipate and so can only travel over very small
meaning 'to leap'. In multiple sclerosis there is a distances. Since they are small, they must
loss of the myelin coat and the nerve impulse is summate to produce an action potential.
adversely affected, leading to the clinical features Summation can be spatial (convergence) or tem-
associated with this condition. poral. This is initiated within a short distance on
the postsynaptic membrane. Provided the sum-
mation is adequate, the summated graded poten-
Graded potential
tials will initiate an action potential at a specific
When the action potential reaches the terminals site on the nerve fibre where there are most
of the neurone there has to be some mechanism sodium channels and the threshold is lowest. On
by which the impulse can cross the synaptic gap, most neurones this area is where the axon leaves
reach the next neurone in the pathway and gen- the cell body, the axon hillock (see Fig. 7.2).
erate an action potential in this neurone. This is Synapses slow down the passage of impulses
achieved by means of release of a chemical or due to the time taken for the neurotransmitter to
'neurotransmitter' from the presynaptic termi- be released, but this disadvantage is more than
nals, which diffuses across the gap and combines outweighed by the variability or plasticity which
with receptors on the postsynaptic membrane synapses confer on the system. They play an
(see Fig. 7.3). The postsynaptic membrane is essential role in memory and learning, since fre-
usually the dendrite of the next neurone, but can quent use of a particular pathway facilitates the
be an axon or the cell body itself. passage of an impulse across the synapses used,
The release of the neurotransmitter from the in preference to others. Initially this is a chemical
presynaptic membrane is triggered by the arrival change, which may involve a facilitator such as
of the action potential, which opens calcium nitric oxide, but later a physical increase occurs
126 SYSTEMS EXAMINATION
Table 7.4 Differences between action and graded pressure, touch, temperature, pain and position
Action potentials Graded potentials
sense, the so-called somatic receptors (Table 7.5).
Again, the use of the word 'sense' implies aware-
Voltage-gated ion channels Chemically/mechanically/light- ness of the stimulus, i.e. it reaches the conscious
gated ion channels
cortex.
Threshold must be No threshold, all triggers will Those receptors situated in the skin can also be
reached before an action generate graded potentials
potential is generated referred to as exteroceptors. There are also
Fixed magnitude (all or Magnitude proportional to size
stimuli which do not usually reach consciousness
nothing) of trigger but go to different areas of the brain; these origi-
Large potentials Small potentials nate within the internal organs and are called
Do not summate Summate
interoceptors. Examples of these are the barore-
ceptors in the aorta, which monitor changes in
Do not attenuate Rapidly attenuate
blood pressure, and the osmoreceptors in the
Used for long-distance Used for local signals
signalling
hypothalamus, which monitor the osmolarity of
the extracellular fluid. Receptors in the muscles,
tendons and joints that register position sense,
tension and degree of stretch are called proprio-
in the surface area and complexity of the synap- ceptors. They send impulses both to the cerebel-
tic membranes. They are also responsible for con- lum, which is part of the unconscious brain, and
verting the pathways into one-way systems, to the part of the conscious brain called the
essential if chaos is not to reign. Synapses are not somatosensory cortex.
the only site for graded potentials. They also The area served by a sensory unit (afferent
occur at receptors where the ion channels may be nerve, its branches and the attached receptors) is
triggered by mechanical or light changes as well called the receptive field. Receptor fields may
as chemicals. overlap and the density of receptors may vary in
The differences between action and graded different regions of the body. The precision with
potentials are summarised in Table 7.4. which a stimulus can be located and differenti-
ated depends on the size of the receptive field
and the density. For example, fingers and thumbs
Sensory pathways
are very good at detecting stimuli from the exter-
The various changes in the internal and external nal environment because the receptive fields are
environments are detected by receptors. small and dense.
Receptors may be found within specialised The peripheral afferent (sensory) pathway is
organs, such as the rods and cones of the eye, or the name given to the pathway from a receptor to
they may be distributed throughout the body, the eNS. As explained earlier the cell body of the
such as the pain receptors of the skin and gut. afferent neurone is usually situated along this
The first type give rise to the special senses of pathway, near to, but not in, the spinal cord. The
sight, hearing, balance, taste and smell, whereas central process then travels into the spinal cord
the second type give rise to the general senses of where it may synapse with one or more neurones
in the dorsal horn or continue on its path up the • the rapid, highly organised oligo- (few)
spinal cord to the brain stern. The grey matter is synaptic pathways
divided into layers or laminae of Rexed and the • the less well organised multisynaptic
neurones in the various layers differ in size and pathways.
functions. Stimuli detected in the periphery will
initially be conveyed by afferent neurones to the Most of the tracts are named according to
spinal cord, but if further integration and inter- their origin and destination: e.g. the lateral
pretation is to occur, the information must reach spinothalamic tract carrying pain information
the appropriate part of the brain. The informa- runs from the lateral region of the spinal cord
tion travels to these higher centres in ascending up to the thalamus, an important sensory relay
tracts or columns of the white matter of the station in the brain. The spinocerebellar tracts
spinal cord (Fig. 7.11). do not reach consciousness but instead carry
All information from a particular receptor type, proprioceptive information to the ipsilateral
such as pressure, travels together in the same lobes of the cerebellum, in the hindbrain.
ascending tract. The ascending tract is joined, The oligosynaptic pathway consists of two
at each spinal segment on its upward journey, tracts:
by neurones which are carrying information • the dorsal (posterior) columns
from pressure receptors in other dermatomes. • the neospinothalamic tracts (part of the
The organisation continues in the brain, so anterolateral tract).
that discrete areas of the cortex receive
the information from the various parts of The multisynaptic pathways also travel via
the body (Fig. 7.12). This is called somatotopic two ascending tracts. One of these tracts, the fas-
organisation. ciculi proprii, runs as a central chain of neurones
There are two main ascending systems (Budd through the spinal cord and ascending reticular
1984): activating system (RAS) of the brain stern to the
fasciculus gracilis
,
fasciculus cuneatus
J
dorsal.
- (posterior)
I
co umns
lateral
corticospinal tract
ventral spinocerebellar tract
anterolateral tract
(neo-paleo-spinothalamic) ?
I I
I
ascending
Figure 7.11 Transverse section of the spinal cord showing ascending and descending pathways (adapted from McClintic 1980).
128 SYSTEMS EXAMINATION
±
·.·' ·
1( :>".
.,
,
L
r)
A B
Figure 7.12 Diagram illustrating the somatotopic organisation of (A) the motor and (B) the sensory cortex. The left half of
the body is represented by the right hemisphere of the brain and the right half of the body by the left hemisphere (reproduced
from Ross & Wilson 1990, with permission).
central areas of the thalamus, before projecting to information differs, as the dorsal column deals
the limbic system and the hypothalamus. These with detailed localisation of the touch sensation
pathways do not cross and can be activated by and the spinothalamic tract with gross tactile
more than one stimulus. The other multisynaptic sensations.
pathway is the palaeospinothalamic tract, which Some of the pathways, the neospinothalamic
follows the same course as the neospinothalamic pain pathways in particular, carry information
tract until it reaches the brain stem, where it about a single type of stimulus. These are
diverges, to make further synaptic connections described as specific pathways, since they are
with the RAS and central thalamus before travel- interpreted as well-localised, precise sensations
ling on to the limbic system. The information is by the somatosensory cortex - e.g. the sharp sen-
interpreted in a less precise manner but with sation of a pinprick.
emotional overtones, such as the sensation of a The majority of these ascending tracts cross
deep, burning abdominal pain. over to the opposite side at some stage, either in
The division into tracts of differing modalities the spinal cord or in the brain stem, synapsing
is not hard and fast, however, since the nervous with contralateral areas of the thalamus before
system demonstrates the phenomenon of redun- continuing to the conscious cortex. This
dancy, which means that if one tract is damaged arrangement explains why a stroke/ cerebrovas-
another is usually able to take over the function, cular accident (eVA) affecting a particular part
albeit in a slightly altered form. For example, of the sensory cortex produces numbness or
impulses conveying information about touch paraesthesia in a specific part of the body on the
travel in both the dorsal column and the ventro- opposite or contralateral side. Neurological
spinothalamic tract though the nature of the damage to the spinal cord may produce numb-
NEUROLOGICAL ASSESSMENT 129
ness on either the contralateral side, if the site of The multineuronal tract. This tract runs to
damage is before the tracts cross, or the ipsilat- lower motor neurones by a slower, more diffuse
eral (same) side, if the site of damage occurs route, since it makes many more synaptic con-
after the tracts have crossed. nections on the way, particularly in the
descending reticular system and the nuclei of
the brain stem. Although influenced by UMNs
Motor pathways the tracts are only recognisable as separate
Just as all conscious stimuli are interpreted in pathways as they emerge from the brain stem to
the cortex, so all conscious actions originate travel through the spinal cord as the vestibu-
there. The whole area is known as the sensori- lospinal, tectospinal and reticulospinal tracts.
motor cortex; one part is called the primary The tracts enter the ventral horn of the grey
motor cortex and initiates conscious action matter to influence the appropriate lower motor
(Fig. 7.12). It too shows somatotopic organisa- neurone.
tion, so that damage to this region produces These tracts do not form part of the pyramids
precise effects on particular actions on the con- in the medulla and so are also called the extra-
tralateral side of the body. Close to this area is (outside) pyramidal pathways. They mainly
the premotor cortex, which is involved in the influence the large, proximal limb muscles and
planning of actions. Since the actions produced the axial muscles of posture, and have a predom-
by these neurones are the conscious movements inately inhibitory effect on the ventral horn cells.
of the body, the muscles involved will be skele- They are responsible for the antigravity reflexes,
tal and the neurones will be part of the somatic which keep our knees extended and head erect in
motor system. order to maintain upright posture.
Neurones in the brain which are responsible for The division of the descending tracts is not
initiating the commands are called upper motor clear cut, as they also demonstrate redundancy,
neurones (UMNs). They do not send impulses there being much overlap and interaction between
directly to the muscles but exert their influence the two. Other areas of the brain also have strong
via neurones in the ventral (anterior) horn of the modifying influences, such as the cerebellum and
spinal cord called lower motor neurones (LMNs). clusters of neurones in the fore- and midbrain
The latter send impulses to the skeletal muscles known collectively as the basal ganglia.
via their axons, which form the peripheral effer- The last stage in the production of a conscious
ent pathways within spinal nerves. action is the excitation of an LMN in the ventral
The descending pathways from brain to spinal (anterior) horn of the spinal cord and the
cord can be divided into two main tracts: the passage of an impulse along its axon in the
corticospinal tract and the multineuronal (brain spinal nerve to the skeletal muscle. The LMN
stem) tract (see Fig. 7.11). will be subject to influences from many neu-
The corticospinal tract. This is a rapid pathway rones, not only from descending tracts but also
and is mainly responsible for the skilled move- from spinal neurones. As many as 10000-15000
ments of small, distal limb muscles such as those synapses, both excitatory and inhibitory, can
used in scalpel work. Most of the fibres cross over occur on one lower motor neurone. If the sum of
in the brain stem and descend in the white matter these influences is excitatory, the LMN will be
of the spinal cord as the lateral corticospinal tract. stimulated to discharge an impulse along its
The uncrossed fibres descend as the ventral (ante- axon and the skeletal muscle will contract. This
rior) corticospinal tract. At the appropriate level in peripheral pathway from LMN to skeletal
the spinal cord they enter the ventral horn of the muscle is called the final common pathway and
grey matter to synapse with a lower motor the entire pathway, including the neuromuscular
neurone. Because the corticospinal tract forms a junction and the 10-600 skeletal muscle fibres
rough pyramid shape as it passes through the innervated by that nerve is called a motor unit
brain stem, it is also called the pyramidal tract. (Fig. 7.13).
130 SYSTEMS EXAMINATION
REFLEXES
Reflex actions are automatic responses to partic-
Cerebellum ular stimuli and form the basis of much of our
The actions of the cerebellum are unconscious behaviour, from the simple knee jerk to driving a
and are very important in postural reflexes. The car. They are also very important in posture,
cerebellum has no direct descending pathways to balance and gait. Reflexes can be inborn (inher-
the spinal cord; instead it has a rich afferent input ited, innate, instinctive) or acquired (learned).
and sends modifying influences to the sensori- Examples of the former are eye blink, pupil dila-
motor cortex, the reticular formation and the tion/ constriction, change in heart rate, knee jerk
brain-stem nuclei. Thus, symptoms of cerebellar (stretch) reflex, pain withdrawal and sweat secre-
defects may be due to lesions in the ascending tion. Examples of the latter are swimming,
spinocerebellar tracts, in the cerebellum itself or in walking, driving, debriding callus. They can
efferent pathways going to other parts of the involve any subdivisions of the nervous system
brain. and any type of effector organ. We may be aware
The cerebellum receives all information about of them or they may never reach consciousness.
position sense. The vestibular apparatus of the It is here that the close association between the
ear projects via the vestibular nuclei of the brain nervous and endocrine systems is best illus-
stem to the flocculonodular lobe. The spinocere- trated, since both can contribute to the same
bellar tracts carry proprioceptive information reflex arc. For example, when the retina of the eye
from muscles, tendons, joints and cutaneous detects a threatening situation, this information
pressure receptors which project to the vermis will be carried by the optic nerve to the brain and
and anterior lobes. The cerebral cortex gives one of the responses will be the release of the
information about the actions decided upon and hormone adrenaline (epinephrine) from the
projects to the posterior lobes via pontine nuclei. adrenal medulla, to prepare the body for action.
The cerebellum integrates the information In all cases, the pathway allows the body to
received from all these areas and compares it respond rapidly to a given stimulus. Generally,
with the information on intended actions inborn reflexes produce stereotypic responses
received from the cerebral cortex. It then sends which are usually protective reflexes or those
modifying influences back to the motor cortex needed for posture and balance. Acquired reflexes
and brain stem, so that descending instructions are more complex, involving the conscious cortex
to the LMNs can be altered where necessary. and many different effectors, so that the response
NEUROLOGICAL ASSESSMENT 131
is more easily modified. Try standing upright Table 7.6 Essential elements of a reflex arc
and leaning backwards as far as you can. What 1. A detector to detect the change (stimulus) in either the
happens to your arms and knees? Can you internal or external environment
prevent their movement? Compare this with the 2. Afferent neurones that send the information into the CNS
ease with which you can change from a walking along the afferent pathways
to a running gait. 3. An integrating centre to match the appropriate response
to the stimulus. This will be in the brain or spinal cord.
Different parts of the CNS communicate with one another
Reflex arcs via ascending and descending pathways
4. Efferent neurones that carry instructions from the CNS
The pathway between detector and effector is via efferent pathways to the effectors (skeletal, smooth or
called a reflex arc and always involves the CNS, cardiac muscle or gland)
though not necessarily the brain (Table 7.6). 5. An effector to carry out the necessary response
There are three reflexes that are of particular
importance to the functioning of the lower limb:
by Melzack & Wall in the 1960s to explain pain
• pain withdrawal reflex
inhibition by such techniques as rubbing the
• crossed extensor reflex
painful area, although the precise nature of the
• stretch reflex.
gating mechanism is still not completely
Pain withdrawal reflex. Injured cells produce known. From here the impulse is transmitted to
local chemical mediators, including prosta- an LMN in the ventral horn of the spinal cord.
glandins, that sensitise the nociceptors to other Excitation of this neurone results in an action
mediators. Graded impulses, proportional to potential reaching the motor end-plate. The
the damage done, are generated and trigger neurotransmitter acetylcholine is released and
action potentials in the afferent pathways. The its combination with receptors in the muscle
action potential travels to the CNS (in this case membrane results in a graded potential that will
the spinal cord) via the afferent neurone and be transmitted to the interior of the muscle as an
synapses within the grey matter of the dorsal action potential and cause contraction of skele-
horn, in either Rexed's laminae II and III (the tal muscle fibres (Fig. 7.14). The number of
substantia gelatinosa) or in laminae V. It is here fibres contracting depends on the number of
that the pain gating mechanism is thought to muscle fibres innervated by that neurone, i.e.
take place. This mechanism was first described the size of the motor unit. Thus the limb suffer-
afferent neurone
----
~ (receptor)
skin
internuncial
neurones ---=~--n+r?::'"
skeletal
muscle
(effector)
Figure 7.14 The reflex arc (reproduced from McClintic 1980, with permission).
132 SYSTEMS EXAMINATION
ing damage is removed from the deleterious inhibited and the extensors contract to provide a
cause. The presence of more than one synapse in rigid support. This reflex occurs not only when a
the reflex arc means that the arc is described as lower limb is injured but at each step in walking,
polysynaptic. In addition to this reflex arc, the when one limb is in the swing phase and the
first-order neurones will synapse in the dorsal other is weightbearing.
horn with neurones which transmit impulses up Stretch reflex. This is a very important reflex
to neurones in the brain, via the ascending for all motor activity, especially when new
anterolateral tracts. However, the cortex is not actions are being learnt. It can be demonstrated
needed for the withdrawal reflex to occur. by the patellar and Achilles tendon reflexes and
Crossed extensor reflex. This is often superim- exists to supply the cerebellum with information
posed on the pain withdrawal reflex and is a pos- about the state of contraction in muscle.
tural reflex, enabling an injured lower limb to be The receptors are stretch receptors in spe-
withdrawn while the remaining limb bears cialised muscle fibres called intrafusal fibres.
weight. In order for this to occur, many LMNs These receptors lie within swellings of the intra-
must be excited and their antagonists inhibited fusal fibres called muscle spindles. Whenever the
(Fig. 7.15). This ensures that the flexors of the ordinary muscle fibres (extrafusal fibres) are
injured limb contract while the extensors relax, stretched, as when the patellar tendon is hit by
whereas in the contralateral limb the flexors are the hammer, the receptors will generate graded
painful
stimulus
from foot
excitation
of extensor
excitation
of flexor
__ contralateral limb
Figure 7.15 The crossed extensor reflex (reproduced from McClintic 1980, w~th permission).
NEUROLOGICAL ASSESSMENT 133
Once the organisation and function of the nervous The effects of any lesion in the nervous
system is understood, it is often possible to diag- system will depend on the area involved. For
nose the site of a lesion by careful history taking, example, occlusion of the posterior cerebral
observation and simple tests. The causes of neu- artery, which feeds the occipital lobe of the brain
rological disorders are many and can be (striate cortex), may result in visual distur-
classified as follows: bances, occlusion of a cerebellar artery may
result in ataxia, and occlusion of the vasa nervo-
• heredity, e.g. Huntington's chorea, peroneal sum of a peripheral nerve may result in a 'glove
muscular atrophy, Friedreich's ataxia, and stocking' paraesthesia.
malignant hyperpyrexia Nerve function deficit is called neuropathy
• developmental defect, e.g. spina bifida, and is classified according to the numbers and
syringomyelia types of nerves involved and the site of the lesion
• trauma, e.g. severing of the spinal cord or a (Table 7.8).
peripheral nerve, concussion The assessment process involves a general
• ischaemia, e.g. stroke, cerebral haemorrhage overview of neurological function followed by
• compression, e.g. tumour of the cerebellum, assessment of:
Morton's neuroma, common peroneal nerve
palsy • levels of consciousness
• infection, e.g. HIV, [akob-Creutzfeldt disease, • sensory function
herpes zoster (shingles), Guillain-Barre • motor function (to include muscles)
syndrome, lepromatous neuropathy • posture and coordination
• autoimmune, e.g. myasthenia gravis, • autonomic function.
polymyositis, possibly multiple sclerosis Many neurological conditions present with
• nutritional! metabolic, e.g. Korsakoff's multiple signs and symptoms because more than
psychosis, sub-acute combined degeneration one part of the nervous system is affected. It is
of the spinal cord, diabetic neuropathy important to bear this in mind when assessing
• iatrogenic, e.g. tight plaster cast causing each of the above parts in order that information
nerve palsy, drug-induced myopathies from all the assessments can be put together to
(lithium, high-dose steroids, etc.) produce a definitive diagnosis. For example,
multiple (disseminating) sclerosis is a progres-
sive disease affecting the CNS where repeated
patchy demyelination of nerve sheaths occurs,
Table 7.8 Classification of neuropathies leading initially to temporary and later to perma-
Type of neuropathy Description nent loss of function. The nerve axons most often
affected are the optic nerves - the optic nerve is
Mononeuropathy Abnormality of a single nerve considered an outgrowth from the CNS rather
Mononeuritis multiplex Asymmetrical abnormality of than a peripheral nerve - the cerebellar nerves
several individual nerves and those of the lower spinal cord, leading to
Radiculopathy Abnormality of a nerve root blurring of vision (diplopia), unsteady gait,
Polyneuropathy Widespread, symmetrical weakness in the lower limbs, lower limb sensory
abnormality of many nerves, loss and/ or disturbances of micturition. Multiple
usually characterised as sclerosis along with Parkinson's disease is the
sensory/motor/autonomic 'glove
and stocking' distribution second most common disease to affect the CNS,
after strokes (Wilkinson 1993a).
NEUROLOGICAL ASSESSMENT 135
betes mellitus or sickle cell anaemia are predis- answer questions and follow instructions can all
posed to earlier onset of CVAs. Coexisting give indications of the level of consciousness.
chronic disease can also be helpful in diagnosing
the cause - for example, atherosclerosis and
History
hypertension are major risk factors for strokes
(McLeod & Lance 1989a). Any history of loss of consciousness should
always be questioned further, to try to establish
whether the cause was:
Observation
• a simple faint
The patient should be observed while walking,
• transient ischaemic attack (TIA) or full-blown
sitting and speaking as well as while performing
stroke
particular tasks. A change in the level of con-
• an epileptic episode
sciousness, inability to follow simple instructions
• a metabolic disorder such as a hypoglycaemic
and deficits in voluntary movement or sensation,
coma.
including the presence of pain, all provide
important clues. Important points to note are: Simple faints (syncope) are always due to a
temporary interruption of blood supply to the
• The affected areas of the body, their
brain, which is rapidly restored by the prostrate
distribution and whether one or more
position of the patient. This may be caused by:
modalities are involved.
• Whether the effect is uni- or bilateral. • benign causes, such as emotional shock,
• If affecting movement, whether it causes causing vasovagal syncope
weakness or complete paralysis. • autonomic neuropathy if the fainting episode is
• Whether it involves particular muscles or associated with a change to an upright posture
particular actions.
• Whether it produces any change in muscle
tone and bulk. Table 7.9 Classification of tremors and their likely causes
• If the deficit is affecting sensation, whether
the sensation is altered (paraesthesia) or lost Type of tremor Condition
(anaesthesia). Physiological Maintenance of posture is
• The presence of a deformity, e.g. a cavoid- accompanied by a tremor (10Hz).
type foot and clawed toes are often seen with This may be exacerbated by anxiety,
fatigue, thyrotoxicosis
spina bifida occulta.
Age (senile) With age the normal physiological
• Presence of tremors. Tremors can have a tremor slows to 6-7 Hz. As a result
physiological cause or be associated with a the tremor becomes more noticeable
neurological deficit. The exact nature of the especially when undertaking a slow
motion such as picking up a cup to
tremor should be noted, when it appears/ drink from
disappears, area of body involved, etc.
Resting Tremor that is present during rest
The causes of tremor are summarised in (4-5 Hz), seen in parkinsonism
Table 7.9. Intention Tremor that increases as the
individual tries to undertake a
coordinated movement, seen with
cerebellar dysfunction
ASSESSMENT OF THE LEVEL OF
CONSCIOUSNESS Essential Postural tremor similar to a
physiological tremor but of much
The cerebral cortex and the reticular formation of greater amplitude, usually hereditary
the brain stem are the two areas of the brain most Drug-induced Tremor similar to an essential tremor
may occur in 40% of patients treated
concerned with maintaining consciousness. The with barbiturates
general level of the patient's awareness, ability to
NEUROLOGICAL ASSESSMENT 137
• serious causes such as haemorrhage or • whether the patient can follow instructions
anaphylactic shock. • the patient's response to stimuli.
Strokes are the result of prolonged/permanent Levels of consciousness can be graded as
interruption of the blood supply to the brain and shown in Table 7.10.
are the most common condition to affect the
CNS. TIAs are a temporary interruption in the
Hospital tests
vascular supply to the brain and like strokes
usually occur in the older person (60+). Both The following is a brief summary of some of the
strokes and TIAs are primarily caused (80% of hospital tests that may be undertaken if a patient
cases) by thrombosis resulting from atheroma- shows an altered level of consciousness.
tous plaques in cerebral vessels, haemorrhage Occuloplethysmography. This is a non-inva-
being the cause of the remainder (McLeod & sive test to detect carotid lesions that cause a
Lance 1989a). TIAs usually last from 1 to 30 reduction in blood flow to the ipsilateral orbit
minutes and always less than 24 hours. compared to the opposite eye.
Epileptic attacks can occur at any age and are Duplex Doppler ultrasound. This technique
due to unusual electrical activity in the cortex, uses sound waves of 4-8 MHz, which are beyond
which could be caused by a lesion or a tumour. the range of human hearing. The transmitted
beams are reflected from their interface with
tissues in amounts proportional to the density of
Observation
the tissues. The difference between transmitted
TIAs may be accompanied by disorders of and reflected beams is proportional to the
speech (dysphasia), vision, movement (dyskine- density of the tissues and is used to create an
sia) or swallowing (dysphagia), depending on acoustic image. In this particular technique, two-
the area of brain involved. However, a full recov- dimensional B-mode scanning is used, which
ery is usual. CVAs can result in neurological gives greater resolution than the M-mode scan-
deficits similar to those seen in TIAs, but are ning of conventional Doppler. Duplex Doppler
often permanent, though partial or total recovery may reveal stenosis or occlusion of the carotid
is possible depending on the extent and site of arteries, a possible cause of a CVA or a TIA, and
damage to the brain. is often used prior to an angiogram.
Epileptic attacks can involve the whole brain
(global) and result in a brief loss of consciousness
(petit mal) which may not show any other symp- Table 7.10 Assessment of the level of consciousness
toms or may last much longer, being accompa- (McLeod & Lance 1989)
nied by tonic-clonic jerks (grand mal). Such an
Level Observable effects
attack is often preceded by an 'aura' and the
patient may cry out. Attacks can also be focal, as Alert wakefulness Patient is fully aware of
in a Jacksonian attack, which affects only the environment and self and responds
to stimuli
primary motor cortex and in which different
parts of the body show jerks as the attack spreads Confusion Patient shows lack of attentiveness,
cannot concentrate and has
over the motor cortex. impaired memory
Delirium Patient is anxious, excited, agitated
and may be hallucinating
Clinical tests
Lethargy Patient is drowsy but responds to
In the clinic the following can be used to establish verbal stimuli
the level of consciousness: Stupor Patient is unconscious but
responds to pain
• the patient's response to a question and answer Coma Patient cannot be roused
schedule
138 SYSTEMS EXAMINATION
(see Fig. 7.12). Any damage to this area, whatever complete anaesthesia (total lack of sensation) or
the cause, will produce a contralateral sensory paraesthesia (an altered sensation). Examples of
deficit in the appropriate part of the body. paraesthesia are pins and needles, burning,
Damage to the occipital lobe (striate cortex) will pricking, shooting pain and dull ache. Patients
produce visual disturbances. The most common should be asked if they experience any abnor-
cause of such neurological deficits is an occlusion mal sensations.
or haemorrhage of one of the cerebral arteries. Phantom limb. An unusual phenomenon that
Damage to the ascending tracts in the spinal arises from amputation of a limb is that of
cord will produce either ipsi- or contralateral 'phantom limb', where the patient has the very
effects, depending on the site of the lesion in rela- real sensation of the amputated limb still being
tion to the point of crossover of the tracts. This is present and behaving just like a normal limb.
well illustrated in the Brown-Sequard syndrome, The most unpleasant effect is the sensation of
where damage to one side of the spinal cord pain which is said to occur in 70% of amputees
results in: (Melzack 1992). The traditional explanation, that
this is due to the growth of neuromas in the
• ipsilateral loss of touch, position sense, two-
nerve stumps which continue to generate
point discrimination and vibration sense
impulses, cannot be the entire explanation since
below the level of the lesion, due to dorsal
cutting the afferent pathways from such nerves
column injury
does not abolish the pain. Melzack has sug-
• contralateral loss of pain and temperature
gested that the phantom sensations are due to
sensation below the level of the lesion, due to
learned circuits in the brain that are capable of
damage to the anterolateral tracts.
generating impulses in the absence of sensory
The exact effect of peripheral nerve damage inputs.
depends on the site and the nature of the Referred pain. Injury to the viscera often pro-
damage, since this dictates the repair process duces pain in a somatic structure some distance
(Table 7.12). away. This is called referred pain. For example, a
myocardial infarction can produce pain in the left
arm as both the heart and the skin of the left arm
History
have developed from the same dermatomal
The nature and distribution of any sensory segment. However, the exact mechanism is still
deficit can be an important aid in diagnosing the not clearly understood although both convergence
underlying cause. This may take the form of and facilitation are thought to playa role (Ganong
1991b). Damage to a spinal nerve may result in
referred pain which is experienced around the
Table 7.12 Classification of nerve damage heel; this occurs if there is damage to S1.
Type Damage
monofilaments and neurothesiometers/biothe- should state the extent of any neuropathy, e.g.
siometers have been evaluated. The tests 'loss of vibration perception from toes to ankles'
examine the integrity of the afferent pathways to aid monitoring of the deficit. If a mononeu-
that involve the ipsilateral dorsal columns ropathy is suspected, e.g. anterior tibial damage
and the contralateral anterolateral columns contributing to foot drop, the dermatomes inner-
(Table 7.13). Each test should be demonstrated to vated by that nerve should be investigated. A
the patient first, usually on the back of the deficit may not always be due to pathological
patient's hand, so that the test is understood and causes: factors such as overlying callus render
the expected sensation experienced. It is then the skin less sensitive and the normal slowing of
possible to ask the patient to compare the same conduction rates associated with ageing results
sensations on hand and foot which will indicate in a reduction in sensation.
the degree, if any, of sensory loss. If the patient
suffers from neuropathy of the upper limbs, the
Testing large-diameter fibres
demonstration test can take place on the fore-
head. For the actual test, where appropriate, the Light touch. Cotton wool, a fine brush or a
patients should have their eyes closed in order 109 monofilament can all be used for this test.
that the results cannot be influenced by observing The nerves being tested are large-diameter A-
the test. Use of forced-answer questions where beta fibres which ascend in the dorsal columns,
possible help to eliminate observer influence, e.g. transmitting light touch perception. The recep-
'Which is sharper, number 1 or number 2?'. tors (Meissner's corpuscles) lie in the superficial
Sham testing, where appropriate, should also dermis. After explaining the test, the patient's
be used to rule out any attempts to guess the eyes should be shut. The patient is asked to state
correct answer by the patient. The test should be when the foot is being stroked and to indicate the
repeated three times on the same site and if 2/3 site. The clinician should make no further
answers are correct, the patient is not considered comment until the test is finished. The skin of the
to have a sensory deficit in that modality. If foot is then stroked lightly with a wisp of cotton
screening is being carried out to detect gener- wool/brush or monofilament. The sense of touch
alised neuropathy it is important that the tests will be reduced in the elderly and in calloused
involve all the dermatomes at that level (see Fig. skin (due to thickened skin). The patient may
7.8), starting distally and working proximally. As incorrectly distinguish between the lesser toes in
most peripheral neuropathies begin at the most this test, but this is normal and is due to the par-
distal site and progress proximally, it is only nec- ticular innervation of the lesser digits.
essary to test more proximal areas if the test has Two-point discrimination. Blunt-ended orange
proved negative distally. The results of each test sticks or the two points of a pair of dividers can
NEUROLOGICAL ASSESSMENT 141
be used for this test, providing the points of the The nerve fibres being tested are once more
dividers have been blunted to avoid accidental those belonging to the A-beta group of fibres.
skin penetration. The nerves being tested are The receptors are encapsulated and lie in the
again the large-diameter A-beta fibres, but here dermis but are slow adaptors and so detect con-
the density of the touch receptor field is being stant pressure rather than vibration. Both touch
assessed. The plantar surface of the foot is and pressure receptors can respond to applied
usually tested. The patient is asked, with eyes pressure, the difference being in the force used
shut, to state how many points can be felt when to apply the pressure. Light touch will stimulate
the tips of a compass lightly press the skin surface a small area of nerve endings and increasing
simultaneously. The distance between the tips of pressure will recruit more and more receptors.
the compass that allows the patient to detect two When the stimulus becomes pressure rather
points rather than one should be noted. Usually than touch and whether a different receptor is
the distance on the foot of a healthy young adult involved with increased pressure is not clear, so
is 2 cm. It will increase with age and if the skin is the stimulus is sometimes referred to as the
calloused. The receptors responsible for identify- touch-pressure sensation.
ing two-point discrimination are also essential The monofilament is applied at right angles
for stereognosis - the ability to recognise objects to the skin surface with just enough pressure to
by touch - and are therefore very important for deform the filament into a 'C' shape. Care
readers of Braille. should be taken not to slide the filament or
Pressure. The 109 monofilament is used for this brush the skin. It should be held in that position
test. The first monofilament for detecting for 2 seconds, the patient having been asked to
neuropathy was the Semmes-Weinstein mono- state when and where pressure from the 109
filament produced by the Hansen's Disease monofilament is felt at various points, with
Center, USA. In theory this monofilament buckles eyes shut. Inability to detect the 109
when a force of 109 is applied. Since then a wide monofilament is taken to indicate neuropathy
variety of monofilaments have been produced, all of large fibres.
said to be buckled by the same force of 109. Vibration. Either a simple 128 Hz tuning fork
However, McGill et al (1998) and Booth & Young or a graduated Rydel-Seiffer version can be used.
(2000) studied 109 monofilaments from a range of The nerve fibres being tested are again large-
manufacturers and found inconsistencies in their diameter A-beta fibres, sensitive to pressure, but
deforming pressures. The clinical relevance of this this time the deeply placed pacinian corpuscles
variation has yet to be determined. Booth & Young are particularly sensitive to rapidly changing
(2000) also showed that all monofilaments decline pressures or vibrations. They are coated with
with use and recommended a 24-hour rest should layers of connective tissue, which has the ability
be allowed between repeated use of a single to absorb low-frequency pressure changes, so
monofilament to allow recovery. A range of that only high-frequency vibrations such as those
monofilaments of different diameters and buck- produced by the tuning fork will reach the
ling forces is also available, but these are more central receptor.
useful for research purposes than for routine The vibrating tuning fork is placed on the
screening. In view of its small size, low cost and skin above a bony prominence such as the apex
ability in detecting large-fibre neuropathy, the of the hallux, malleolus or the first metatar-
monofilament is considered one of the most useful sophalangeal joint (MTPJ). It is important to ask
tools a clinician can possess and is recommended the patients to describe what they feel, without
by the International Diabetes Federation, the any prompting, as most patients will be able to
World Health Organization European St. Vincent feel pressure, but not necessarily any vibratory
Declaration and the International Working Group sensation. Most patients describe the vibratory
on the diabetic foot (International Consensus on sensation as a 'buzzing'. The argument that the
the Diabetic Foot 1999). tuning fork should not be placed over bone, as
142 SYSTEMS EXAMINATION
this augments the sensation, is immaterial, since can no longer detect any sensation. This method
all damaging pressures to which the foot is is not measuring the same index, however, and
likely to be subjected - e.g. tight footwear, the two methods should not be mixed on the
ground forces on bony deformities or foreign same patient. Up to 12 readings can be stored in
objects in footwear - compress soft tissue the memory of the apparatus. Intra-observer
against bone. The Rydel-Seiffer tuning fork is error is small. The disadvantages of the appara-
an attempt to produce a semi-quantitative result tus are its cost and weight. Using data from 392
to enable comparisons to be made with other patients with diabetes mellitus, Coppini et al
patients and on different occasions. It has (2000) found that using a VPT score based on
detachable clamps which can be moved to dif- comparing the patient's value of VPT with an
ferent positions on the prongs, to alter the age-related normal population showed overall
vibrating frequency from 64 to 128 Hz. As the better sensitivity and specificity than raw VPT in
prongs vibrate, the apex of a cone drawn on identifying patients with subclinical neuropa-
the clamps, upright or inverted, will appear to thy; they felt that this measurement would be
move vertically up or down a scale from 1 to 8. more useful in regular monitoring of diabetic
The position of this cone is noted when the patients. A VPT score >10.1 indicates increased
patients say the vibration sensation stops. At risk of developing neuropathy.
128 Hz the apex should reach at least halfway
along the scale, i.e. to the number 4 from 1 or 8,
Testing small-diameter fibres
depending on which cone is being observed. If
vibration sensation is lost before this point is Temperature. Two test tubes filled with warm
reached, the patient is said to have a vibratory and cool water are preferable to immersing saline
perception deficit. sachets in cool and warm water, which quickly
Neurothesiometers provide an alternative lose their temperature differences. Metal rods
method of assessing vibration. The neurothe- cooled or warmed in water can also be used. A
siometer is basically a vibrator that delivers small cylinder made of two metals with dissimi-
vibrations of increasing strength, measured in lar conductivities is even easier to transport and
volts per micrometre. The mains-operated use, but is not so readily available in the UK. For
version, the biothesiometer, has been super- research purposes, quantitative instruments to
seded by the battery-operated neurothesiometer, measure temperature perception thresholds
to meet Health and Safety requirements. using thermode devices (Kalter-Leibovici et al
Cassella et al (2000) recommended that rather 2001) or thermo-aesthesiometers (van Schie et al
than using a pistol grip when using the appara- 1998) have been used. The latter paper concludes
tus, the head of the tool should rest in the palm that a combined method, using two simple clini-
of the operator's hand while being applied to the cal tests and the more sophisticated apparatus,
patient. Only in this way, with no extraneous produced the highest sensitivity (76%).
pressure being applied, could truly reproducible This tests the integrity of the warmth and cold
vibratory perception thresholds (VPTs) be deter- temperature receptors that feed into the anterior
mined. The neurothesiometer is positioned over part of the anterolateral columns. The nerve fibres
a bony prominence and the strength of the vibra- involved are narrow diameter A-delta and C
tions is increased until the patient can detect a fibres. Cutaneous receptors detect absolute values
'buzzing' sensation. This reading is called the rather than the temperature gradient across the
VPT and values of over 25 volts are taken to skin. Warmth receptors operate in the range of
indicate the presence of peripheral neuropathy. 30---43°C and cold receptors operate in the range
The measurement should be repeated three of 35-20°C (Vander et al 1998). Temperatures
times and the average value taken. An alterna- above 43°C or below 20°C will trigger pain recep-
tive method is to begin with the maximum inten- tors. The skin temperature is usually a few
sity of stimulus and reduce it until the patient degrees cooler than that of core temperature, i.e.
NEUROLOGICAL ASSESSMENT 143
between 30 and 35°C, though a greater difference of type 1 diabetic neuropathy patients who suffer
may exist in extremes of environmental tempera- from autonomic symptoms severe enough to
tures. The temperature of the warm water should warrant treatment, such as severe bladder or
be above 35°C and that of the cold water below gastroparesis, orthostatic hypotension and dia-
30°e. Again, with eyes closed, the patient is asked betic diarrhoea associated with a selective small-
to state which they find the cooler/warmer from fibre sensory and autonomic loss with relatively
the first or second tube presented. preserved large-fibre sensory modalities such as
Pain. Disposable Neurotips (Owen Mumford) vibration and touch-pressure sensation. Whether
are best used for this test. The Neurotips have a either or both of the above statements can be
sharp and a blunt end, but the sharp end cannot applied to patients without diabetes is even less
pierce the skin. Spring-loaded devices which are certain. A study by Nakayama et al (1998) on rats
designed to deliver a stimulus at a force of 40g are showed that small-diameter, unmyelinated nerve
thought to be the safest and most reliable way of fibres decrease in number with ageing whereas
testing for pinprick sensitivity (Wareham et al larger-diameter fibres maintain both conduction
1997). The use of the sharp end of a patella ability and numbers. In the absence of solid evi-
hammer is not advisable as it may be sharp dence to the contrary, it would seem advisable to
enough to penetrate the skin and is non-dispos- carry out sensory testing on both small and large
able. A hypodermic syringe should not be used as fibres. However, any testing is better than none.
the danger of skin penetration is high. In research studies, a range of sensory tests have
This tests the integrity of the sharp pain been used to calculate a neuropathy disability
pathway, which begins with free nerve endings score (NDS). For further discussion of peripheral
in the dermis. A-delta fibres travel into the neuropathy assessment in patients with diabetes
spinal cord and synapse in the dorsal horn. The mellitus see Boulton et al 1998, Young &
postsynaptic fibres then cross to the contralat- Matthews 1998 and Chapter 17.
eral anterolateral columns which travel up to Tinel's sign. This helps in the diagnosis of nerve
the brain. compression. Palpating the nerve, or tapping it
Using disposable Neurotips and with eyes with a patellar hammer, at the site of compression
closed the patient is asked to state which is will often elicit an abnormal sensation distally, but
sharper, the first or second sensation. The two it can also follow the proximal distribution of
ends should be presented in random sequence to the nerve. Usually the sensation is paraesthesia
avoid correct guessing by the anxious-to-please (tingling, burning) or is like an electric shock.
patient. Neuropathy does not always mean Tinel's sign can be used to assess for compression
absence of pain, as is witnessed by diabetic of the medial nerve at the wrist or the posterior
patients with neuropathy who can experience a tibial nerve at the ankle (carpal and tarsal tunnel
period of intense pain (Boulton 2000). syndromes). However, no clinical tests for carpal
There are certain perceived wisdoms concern- and tarsal tunnel syndromes are entirely reliable
ing sensory testing on diabetic patients which the (Golding et al 1986), so that the suspicion of such
busy practitioner may use to justify using only a condition needs to be confirmed by nerve con-
one of the above methods: duction tests (see Hospital tests).
Referred pain. Entrapment of a spinal nerve
• vibration sensation is the first modality to
may lead to paraesthesia, pain and weakness of
deteriorate
muscles in the lower limb. Normally when pres-
• the presence of neuropathy as indicated by
sure is applied to a site of pain, the pain becomes
failure to detect the 109 monofilament implies
worse. However, with referred pain the level of
neuropathy of all nerve fibres in that limb.
pain stays about the same. A suspected entrap-
There is no conclusive evidence to support ment of the sciatic nerve usually leads to pain
either of these statements. Indeed Winkler et al when the affected leg is raised while the patient
(2000) have reported the existence of a subgroup lies in a supine position.
144 SYSTEMS EXAMINATION
Upper motor neurone lesions the hip and knee, with plantarflexion and inver-
sion of the foot. If the effect is unilateral, the
Upper motor neurone (UMN) lesions are due to person is described as hemiplegic. The inability
damage occurring anywhere between the cortex to flex the knee and hip leads to a circumductory
and L1 in the spinal cord. Since the spinal cord gait, with the lateral border of the forefoot and
ends at level L1, lesions below this level will not toes often scraping the ground. If both sides are
produce UMN signs. Conditions which can lead affected the person is paraplegic and the gait is
to UMN signs are listed in Table 7.14. described as a scissor gait, with the knees
Although a specific area of the frontal lobes adducted and feet abducted. Walking aids such
(precentral gyrus) is designated the primary as Zimmer frames are essential.
motor cortex (see Fig. 7.12), many neurones
from other areas of the cortex are also involved
in planning and initiating conscious movement Clinical tests
and so can also be called upper motor neurones. Clasp-knife spasticity. The affected limb will
This includes neurones of both descending be initially stiff to passive stretch, but if gentle
tracts. Damage to the descending tracts will stretch is continued, the limb may suddenly
produce the same effects as damage to the neu- relax, rather like the opening of a clasp-knife.
rones themselves. This is due to a length-dependent inhibition of
the stretch reflex (see Fig. 7.16).
Observation Tendon reflexes. Due to the reduced inhibition
by the multineuronal tracts, the alpha LMNs
Damage to the corticospinal neurones and tracts responsible for the contraction of extrafusal
will result in contralateral loss of skilled move- fibres are hyperexcited. This results in exagger-
ments. Lack of movement will in turn eventu- ated patella and ankle tendon reflexes and clonus
ally lead to a form of muscle atrophy known as - increased rhythmic contractions elicited at the
disuse atrophy. Damage to the multineuronal ankle or patella by causing brisk stretch of the
pathway causes release of inhibition on the muscles. More than three contractions as a result
LMNs in the spinal cord, especially those which of testing the patella or Achilles reflex is indica-
innervate the antigravity muscles, producing tive of UMN damage (Fuller 1993b).
the effect most commonly associated with UMN Plantar reflex. Damage to the corticospinal
lesions, that of spasticity or stiffness in the neurones or their axons has another effect that is
limbs. clinically detectable, the so-called plantar reflex
Gait. Observation of the patient's gait is an or Babinski sign. It has been suggested that the
important part of the assessment for UMN abnormal reflex, a dorsiflexing big toe, is due to
lesions. In the lower limb the effect is extension at release of a spinal inhibitory reflex (Van Gijn
1975). The plantar surface of the foot is stroked
Table 7.14 Conditions associated with UMN signs firmly and briskly from the posterolateral border
of the heel to the hallux as shown in Figure 7.17.
• Cerebral palsy due to anoxia at birth
The normal response is a slight plantarflexion of
• Cerebral vascular accidents
the hallux and lesser toes, although no response
Brain injury
is also often seen, especially in the elderly where
• Friedreich's ataxia
the sensory pathway may be affected. In patients
Spinal injury
with corticospinal tract dysfunction, the hallux
Brain or spinal tumours
will extend (dorsiflexion of the hallux) and the
Amyotrophic lateral sclerosis (motor neurone disease)
lesser toes may fan out. This is the extensor
• Vitamin B12 deficiency
response, sometimes referred to as a positive
• Multiple (disseminated) sclerosis
Babinski response. However, the normal
• Later stages of syringomyelia
response does not become established until the
146 SYSTEMS EXAMINATION
l Hospital tests
The use of tests to diagnose UMN lesions will
vary according to the suspected cause. For
example, brain scans are indicated if a CVA is
suspected, whereas a spinal radiograph would
be used if a tumour of the spine was suspected.
Classification Descriptor
Biochemical defect McArdle's syndrome. Abnormality of glycogen metabolism due to deficiency of muscle
phosphorylase. Patient suffers from fatigue, cramps and muscle spasm.
Malignant hyperpyrexia. No muscle wastage or weakness. Symptoms occur during or
immediately after administration of a general anaesthetic, especially if halothane or the
muscle relaxant suxamethonium chloride is given. Defect in calcium metabolism gives rise
to prolonged muscle contraction, in turn raising body temperature. Fatal in 50% of cases
Acquired inflammatory Polymyositis-autoimmune disease. Infiltration of monocytes and muscle necrosis. Weakness
of proximal limb, trunk and neck muscles. Patient has difficulty raising hands above head,
getting up out of low chairs and bath. May be associated pain on muscular exertion
Dermatomyositis. As above, with additional involvement of skin of face and hands, with
erythematous rash
Non-inflammatory Secondary to high-dose steroids and thyrotoxicosis. These are the most usual causes, but
can also be associated with alcoholism, Cushing's disease, Addison's disease, acromegaly,
osteomalacia and malignancy. See weakness of proximal limb muscles and shoulder girdle.
Trunk may also be involved
C1 to 55. However, due to the anatomy of the Table 7.16 Conditions associated with lower motor
neurone lesions
spinal cord any damage to the cord from L2 will
only result in an LMN lesion. It is possible to see • Poliomyelitis
a combination of UMN and LMN symptoms if the • Injury to lower motor neurone and/or peripheral nerve
lesion is between C1 and LI, e.g. syringomyelia. • Motor neurone disease
The conditions that can lead to lower motor
Syringomyelia
neurone lesions are listed in Table 7.16.
Vitamin B12 deficiency
Cord compression/lesion (Brown-Sequard syndrome)
Observation
Spina bifida
If the pathway is interrupted or damaged in any
• Charcot-Marie-Tooth disease
way, either at the level of the cell body or along
148 SYSTEMS EXAMINATION
A 54-year-old male Caucasian first presented to the A 52-year-old Caucasian female presented to the
clinic complaining of corns and callus under the clinic with plantar callus and fissuring, which had
metatarsal heads of both feet. He was unable to bend arisen following plantar fasciotomy to correct 'clubbed
down to cut his toe nails. feet'. The patient stated that she had been born with
A vascular assessment revealed weak pulses in normal feet, but by the time she was 6 years old she
both feet, with the right foot being cold. A neurological could not run or jump properly and by the time she
assessment revealed dimished reflexes in the right was an adolescent her feet had become high-arched
leg and absence of vibration sense in the right foot. and inverted.
Two-point discrimination was 2 ern in the left foot and She had noticed a gradual weakness in her arms
10 cm in the right foot. Orthopaedic examination and legs and on one accasion, when 41 years old, she
showed a leg length discrepancy of 2.5 ern, the right had almost dropped a baby while working as a nursing
leg being the shorter and having developed a auxiliary. This incident had caused her to be sent for a
functional equinus at the ankle. Muscle wastage was neurological examination which revealed slowed motor
apparent in the lower limb of the right side. The nerve conduction velocities. She had a recent history
patient walked with a limp. of several falls, with her ankle 'going over'. She also
Diagnosis: The signs and symptoms are all complained of aching joints in the feet, knees and hips.
consistent with poliomyelitis. The patient had Her 27-year-old son was similarly affected.
contracted the virus when a child. The lower motor Neurological examination showed all sensory
neurones of the right side of the spinal cord at the perception except vibration to be normal, but reflexes
level of the lumbar plexi had been affected. were absent. Muscle power was reduced in all limbs
and muscle wasting of hands, feet and calf muscles
was noted. Orthopaedic examination showed reduced
dorsiflexion and eversion, with a pes-cavus-typa foot
its axon, then the impulse cannot reach the and high-stepping gait.
Diagnosis: The patient suffered from
muscle. The result will be weakness (paresis) or Charcot-Marie-Tooth disease, also known as
flaccid paralysis, depending on the site and peroneal muscle atrophy. It is an inherited peripheral
extent of the damage. The sites of damage may neuropathy and exists in more than one form, the two
most common forms being autosomal dominant.
involve:
• lower motor neurone, e.g. poliomyelitis virus
(Case history 7.2) very small amounts of neurotransmitter (acetyl-
• peripheral axon, e.g. diabetes mellitus choline), possibly due to upregulation of recep-
• neuromuscular junction, e.g. destruction of tors. This results in a quivering of the muscle
cholinergic receptors of the skeletal muscle as (fasciculation), seen on an electromyogram as
in myasthenia gravis. fibrillation. This effect will not be seen if the
lesion is in the muscle itself.
Myopathies will also produce weakness or
paralysis, even if the lower motor neurone is intact.
Clinical tests
In contrast to UMN lesions, which affect par-
ticular movements, LMN lesions and myopathies Muscle power: Muscle power can be graded
affect particular muscles (Case history 7.3). For according to the Medical Research Council scale
example, if the tibialis anterior nerve is affected (Fuller 1993c) as follows:
the anterior tibial muscle is unable to control 5 = normal power
deceleration of dorsiflexion at the ankle in gait, 4+ = submaximal movement against resistance
producing a characteristic slapping gait (Root 4 = moderate movement against resistance
et al1977). 4- = slight movement against resistance
Nerve impulses are essential to the health of 3 = moves against gravity but not resistance
the muscle, so that lack of impulses leads to 2 = moves with gravity eliminated
much more rapid atrophy of muscle, skin and 1 = flicker
other soft tissue than seen in UMN lesions. This a = no movement.
is known as denervation atrophy. In addition, the A reduced strength of contraction suggests
denervated muscle becomes highly sensitive to paresis or paralysis.
NEUROLOGICAL ASSESSMENT 149
Fatiguability. If the site of the lesion is the neu- as in diagnosing tarsal tunnel syndrome (Galardi
romuscular junction, the muscle will show a et al 1994) or by distinguishing between axonal
sliding decrease in response or fatiguability as degeneration and segmental demyelination, the
seen in myasthenia gravis. The acetylcholine two chief pathological processes occurring in
receptors are destroyed in an autoimmune peripheral nerve diseases. The distinguishing
attack and although the first quanta of neuro- characteristics are shown below.
transmitter can diffuse to remaining receptors, Axonal degeneration, e.g. the polyneu-
subsequent release of neurotransmitter is less ropathies of diabetes mellitus, alcoholism, toxic-
and less likely to make contact and so the ity due to heavy metals, nerve entrapment and
response fades. The muscle cells are able to Friedreich's ataxia (Zouri et al 1998):
replace the receptors but the autoimmune attack
will strike again, in the same or different • see clinical changes first (weakness,
muscles. numbness, atrophy)
Muscle tone. In the skeletal muscles of a • slowing of nerve conduction velocities and
healthy person there will always be some motor loss of large fibres
units firing, which means that the muscle will • reduction in action potential amplitude
feel firm. This is referred to as the 'tone' of the • more prominent distally than proximally
muscle. In LMN or muscle damage, the muscle (longest fibres affected first)
will feel flabby, because of loss of this tone. • fibrillation seen on electromyograph.
Tendon reflexes. Reflexes will be weak or Segmental demyelination, e.g. vasculitis of
absent, because of interruption of the final rheumatoid arthritis (acquired, chronic),
common pathway. A single reduced or absent Guillain-Barre syndrome (acquired, acute/
reflex suggests mononeuropathy or radiculopa- chronic), Charcot-Marie-Tooth disease/peron-
thy. A reduction or absence of all lower limb eal muscular atrophy/hereditary motor and
reflexes suggests polyradiculopathy, cauda sensory neuropathy (inherited, chronic):
equina lesions, peripheral polyneuropathy or a
myopathy. In the latter there will be no sensory • electrophysiological changes seen first
deficit. • dramatic fall in nerve conduction velocities,
maybe even total conduction block
• worsens proximally.
Hospital tests
Charcot-Marie-Tooth disease is interesting
Again, the tests selected vary according to the
because two subtypes have been identified:
suspected cause. For example, if diabetic
HMSN type I, which shows primarily segmental
polyneuropathy is suspected, the diagnosis
demyelination, and HMSN type II, which shows
could be confirmed by a combination of sensory
mainly axonal degeneration (McLeod & Lance
testing, nerve conduction tests and blood glucose
1989b).
measurements.
Electromyography. This uses a needle elec-
Nerve conduction. To measure motor conduc-
trode inserted into the muscle to show the elec-
tion velocities the stimulating electrode is placed
trical activity of the muscle in response to an
along the path of the nerve and the recording
electrical stimulus. Abnormal results are detected
electrode is placed over the belly of the muscle.
in dysfunction of motor nerves, neuromuscular
Amplitude and duration of the action potential
junction lesions and in myopathies (Matthews &
are also recorded. The lower limit of normal con-
Arnold 1991). Electromyography is the only
duction velocities in the lower limb is 40 m/ s.
means of electrophysiological testing for
Nerve conduction tests, whether sensory,
myopathies:
motor or mixed nerve, do not give definitive
diagnoses but help to confirm diagnosis: e.g. by • if due to motor nerve denervation (e.g.
comparing the affected side with the healthy side poliomyelitis), will see reduced recruitment,
150 SYSTEMS EXAMINATION
Table 7.17 Differences between upper motor neurone and lower motor neurone lesions
fibrillation, then a reduction in nerve action reflexes necessary for accurate movement. The
potential amplitude basal ganglia also play an important part in the
• if due to changes at the neuromuscular coordination of movement. Damage to these
junction (e.g. myasthenia gravis), will see a parts of the nervous system may have an effect
reduction in recruitment on gait and coordination. Conditions that may
• if due to muscle disease (e.g. Duchenne's affect coordination and proprioception function
muscular dystrophy), will see spike are listed in Table 7.18.
potentials on the electromyograph.
Tests may be performed that are specific to Observation
particular conditions, such as detection of the
Careful observation of motor activity can give
presence of antibodies to cholinergic receptors in
an indication of a deficit in posture, balance or
myasthenia gravis.
coordination; for example, a stamping gait may
Nerve and muscle biopsies. These are obtained
be due to loss of proprioception as occurs in
in an identical manner to those described for
sensory nerve biopsies. Histological examination
of nerve and muscle tissue will show structural
abnormalities, and biochemical tests will detect Table 7.18 Conditions that may result in poor coordination
enzyme dysfunction: e.g. in distinguishing Part Conditions
Duchenne's muscular dystrophy from the treat-
able connective tissue disease of polymyositis, Cerebellum Tumour
Multiple sclerosis
which also shows muscle weakness and atrophy Arnold-Chiari malformation
of limb girdles. Friedreich's ataxia
The differences between UMN and LMN Other hereditary spinocerebellar
ataxias
lesions are summarised in Table 7.17. Hypothyroidism
Repeated head trauma as in boxing
Basal ganglia Parkinsonism
ASSESSMENT OF Huntington's chorea
COORDINATION/PROPRIOCEPTION Wilson's disease
FUNCTION Sydenham's chorea
Ascending pathways Subacute combined degeneration
The receptors in the muscles, joints and tendons of the spinal cord
all feed position sense information to the cerebel- Guillain-Barre syndrome
lum and cortex. In turn, the cerebellum and the Tabes dorsalis
Alcoholism
cortex bring about vital postural reflexes and
NEUROLOGICAL ASSESSMENT 151
tabes dorsalis, where the ascending tracts in the (hypo /bradykinesia) as seen in Parkinson's
dorsal columns degenerate. The patient will not disease, or jerky writhing movements (choreo-
know where his body is in space and so lifts his athetosis) as seen in the inherited disease of
legs much higher than necessary to clear the Huntington's chorea (Case history 7.4) or the
ground. The patient will also be unaware of benign and brief effects of Sydenham's chorea,
when his foot is about to make ground contact associated with rheumatic fever.
and so stamps the foot down. This has the
advantage of stimulating pressure receptors
proximally, as vibrations from the foot travel up
Clinical tests
the leg and so provide much needed informa- Proprioception in joints. To test proprioception
tion to the brain. distally, the practitioner holds the sides of the
The cerebellum has modifying influences on hallux between forefinger and thumb. While the
the UMNs in the cortex and on brain-stem nuclei. patient's eyes are shut, the toe is moved up and
It receives rich proprioceptive information and down and the patient should be able to state the
adjusts the activity of the UMNs to ensure that final position of the toe. The sides of the hallux
the actual action and intended action are are held rather than the dorsal and plantar sur-
matched. The cerebellum is essential for smooth, faces, to avoid additional pressure information
accurate movement and posture and balance. being generated. This information travels from
Dysfunction of the cerebellum or of its afferent receptors in joints in the largest-diameter, fastest
and efferent tracts produces characteristic effects nerve fibres of the A-alpha class into the spinal
that are easily observable. cord, up to the cerebellum in the ipsilateral
Dysarthria. Here cerebellar dysfunction affects spinocerebellar tracts and to the conscious
the speech muscles and produces a scanning cortex in the dorsal columns. A positive result
speech, with inappropriate syllabic stress and shows that the pathway to the cortex is intact.
volume. An inability to give the correct responses would
Dysdiadochokinesia. This is where actions are be seen in conditions such as tabes dorsalis.
no longer smooth, continuous movements, but Romberg's sign. This test can be used to
are broken down into their component parts, confirm proprioceptive disturbance in the dorsal
producing clumsy, jerky actions. columns or peripheral nerves (Fuller 1993d).
Tremor. The tremor associated with cerebellar
defect is due to the dysfunction of the stretch
reflex and is an intention tremor, i.e. one which
increases in amplitude as the person tries to carry
Case history 7.4
out any tasks with the affected limb. The tremor
disappears at rest. A 30-year-old Caucasian male attended the clinic
Gait. If maintenance of balance is upset, the complaining of sore corns. Questioning revealed that
he was mentally handicapped. Examination showed
patient will feel unsteady and adopt a wide base warm, hyperhidrotic feet with a poor skin condition
of gait. As voluntary movement is also affected, and fibrous lesions on the plantar aspect of the feet.
the gait will be clumsy or staggering, as if drunk. The left foot had marked pes cavus deformity. The
gait revealed limping and shuffling with excessive arm
Such gait is described as ataxic. The patient may movement in order to maintain balance.
complain of deviating to one side, which sug- Over a period of a few years further mental and
gests the dysfunction is limited to that hemi- physical deterioration became apparent. The patient's
brother was similarly affected and so apparently had
sphere. been their father.
Basal ganglia. Although the basal ganglia also Diagnosis: A diagnosis of Huntington's chorea was
have a modifying role on voluntary movement, made. This disease is inherited as an autosomal
condition with complete penetration and late onset,
the effects of their dysfunction is quite different and is characterised by progressive chorea and
from that of the cerebellum. Damage to the basal dementia.
ganglia produces either a poverty of movement
152 SYSTEMS EXAMINATION
In a patient with Parkinson's disease, there is upright posture is adopted. The normal response
no habituation with the glabellar tap reflex. The is an increase in heart rate of greater than 11 beats
glabellar tap reflex involves the practitioner per minute. A loss of response suggests parasym-
gently, slowly and repeatedly tapping the fore- pathetic abnormality.
head of the patient between the eyes. In a healthy Blood pressure. Repeat the above test measur-
person, the first tap or two will elicit the eye- ing blood pressure in the two positions. The sys-
blink reflex, but this will rapidly habituate. tolic blood pressure should fall on standing by
The frequency of the tremor may be measured approximately 30 mmHg and the diastolic pres-
via hospital tests but usually the above clinical sure by about 15 mmHg. An increased drop sug-
tests and a positive response to drug therapy gests sympathetic abnormality. Failure of the
will be sufficient to confirm the diagnosis of cardiovascular system to compensate for pos-
Parkinson's disease. tural effects can lead to postural syncope.
Valsalva manoeuvre. This is not advisable if
there is evidence of proliferative retinopathy. The
ASSESSMENT OF AUTONOMIC patient is asked to take a deep breath and exhale
FUNCTION against a closed glottis for 10-15 seconds and
As explained earlier, the autonomic nerves inner- then breathe normally. The pulse rate is taken
vate the viscera and internal structures such as during the Valsalva manoeuvre and on release.
blood vessels, since they enable the nervous Heart rate should increase during the manoeuvre
system to maintain homeostasis (see Fig. 7.9). and fall on release. No increase during the
Medical history may reveal abnormalities of manoeuvre suggests sympathetic abnormality
bowel and bladder function. and no decrease on release suggests parasympa-
thetic abnormality. These tests reveal abnormal
responses of the baroreceptor reflex, which impli-
Observation cates defects in innervation of the cardiac pace-
maker tissue rather than peripheral autonomic
There will be various signs which would suggest
neuropathy, for which there are no clinical tests.
autonomic neuropathy such as abnormal sudo-
Certain signs may suggest peripheral autonomic
motor responses in the skin and abnormal car-
(sympathetic) neuropathy:
diovascular responses in the functioning of the
heart and peripheral blood vessels (Faris 1991). • a dry skin due to failure of sudomotor
Sudomotor neuropathy usually leads to an nerves
absence of sweating and a dry skin, although it • a warm foot due to lack of arterial
may produce hyperhidrosis. Vasomotor neu- vasoconstriction
ropathy usually produces a warm red skin and • engorged dorsal veins, due to lack of venous
an absence of vasoconstriction in response to vasoconstriction.
cold although it may occasionally produce a pro-
Signs of parasympathetic neuropathy are
longed vasoconstriction. It may also lead to pos-
disorders of bowel and bladder function and
tural hypotension. Neuropathy of nerves to the
impotence.
cardiac pacemaker tissue may lead to failure of
The condition commonly associated with
the heart to respond appropriately to the
autonomic neuropathy is diabetes mellitus,
demands of the body, e.g. an absence of tachy-
where the foot will often appear red and feel dry
cardia in response to exercise.
and warm. There may be coexistent neuropathy
of other small fibres such as pain and tempera-
ture fibres (A-delta and C), as well as large-fibre
Clinical tests
(A-alpha and A-beta) involvement, giving
Heart rate. The pulse is taken while the patient rise to the picture of a typical neuropathic foot
is in a supine position and repeated when an (Ch, 17). Less common conditions exhibiting
154 SYSTEMS EXAMINATION
REFERENCES
Booth J, Young M 2000 Testing the reliability of 10 g Coppini D V, Weng C, Young P J, Sonksen P H 2000 The
monofilaments. Diabetic Medicine 17: S74 'VPT score' - a useful predictor of neuropathy in diabetic
Boulton A J M (ed) 2000 The pathway to ulceration. In: patients. Diabetic Medicine 17: 488-490
Boulton A J M, Connor H, Cavanagh P R (eds) The foot in Epstein 0, Perkin G, de Bono D, Cookson J 1992 Clinical
diabetes, 3rd edn. J Wiley, Chichester, p 22 examination. Gower Medical, London
Boulton A J M, Gries FA, Jervell J A 1998 Guidelines for the Faris I 1991 The management of the diabetic foot. Churchill
diagnosis and outpatient management of diabetic Livingstone, Edinburgh
peripheral neuropathy. Diabetic Medicine 15: 508-514 Fuller G 1993a Neurological examination made easy.
Budd K 1984 Pain. Update Postgraduate Centre Series. Churchill Livingstone, Edinburgh, p 135
Update, Guildford Fuller G 1993b Neurological examination made easy.
Cassella J P, Ashford R L, Kavanagh-Sharp V 2000 Effect of Churchill Livingstone, Edinburgh, p 135
applied pressure in the determination of vibration Fuller G 1993c Neurological examination made easy.
sensitivity using the neurothesiometer. The Foot 10: 27-30 Churchill Livingstone, Edinburgh, p 107
NEUROLOGICAL ASSESSMENT 155
Nystagmus
Dysarthria Friedreich's ataxia
Scanning speech Cerebellum Stroke
Diminished, pendular reflexes Spinal cord Tumour
Intention tremor Vitamin B12 deficiency
Ataxic gait Syringomyelia
Dysdiadochokinesia Spina bifida
Fuller G 1993d Neurological examination made easy. Golding D N, Rose D M, Selvarajah K 1986 Clinical tests for
Churchill Livingstone, Edinburgh, pp 41-42 carpal tunnel syndrome: an evaluation. British Journal of
Galardi G, Amadio 5, Maderna L et al 1994 Rheumatology 25: 388-390
Electrophysiologic studies in tarsal tunnel syndrome - International Consensus on the Diabetic Foot 1999
diagnostic reliability of motor distal latency, mixed nerve International Working Group on the Diabetic Foot, p 32
and sensory nerve conduction studies. American Journal Kalter-Leibovici 0, Yosipovitch G, Gabbay U, Yarnitsky D,
of Physical Medicine and Rehabilitation 73: 193-198 Karp M 2001 Factor analysis of thermal and vibration
Ganong W 1991a Reviews of medical physiology, 15th edn. thresholds in young patients with Type 1 diabetes
Lange, London, p 200 mellitus. Diabetic Medicine 18: 213-217
Ganong W 1991b Reviews of medical physiology, 15th edn. McClintic J R 1980 Basic anatomy and physiology of the
Lange, London, pp 132-133 human body. John Wiley, New York
156 SYSTEMS EXAMINATION
McGill M, Molyneaux L, Yue D K 1998 Use of the Van Schie C H M, Abbott C A, Shaw J E, Boulton A J M
Semmes-Weinstein 5.07/10 gram monofilament: the long 1998 A simple method for measuring temperature
and the short of it. Diabetic Medicine 15: 615-617 perception threshold in diabetic neuropathy. Diabetic
McLeod J, Lance J 1989a Introductory neurology, 2nd edn. Medicine 15: S66
Blackwell Science, Oxford, pp 210-211 Wareham A, Rayman A, Rayman G 1997 Pin-prick sensory
McLeod J, Lance J 1989b Introductory neurology, 2nd edn. thresholds in detecting risk of neuropathic ulceration.
Blackwell Science, Oxford, p 282 Diabetic Medicine 14: S32
Matthews P, Arnold D 1991 (eds) Diagnostic tests in Wilkinson I M S 1993a Essential neurology, 2nd edn.
neurology. Churchill Livingstone, Edinburgh Blackwell Science, Oxford, p 135
Melzack R 1992 Phantom limbs. Scientific American, April: 90 Wilkinson I M S 1993b Essential neurology, 2nd edn.
Nakayama H, Noda K, Hotta H, Ohsawa H, Hosoya Y 1998 Blackwell Science, Oxford, pp 49-50
Effects of ageing on numbers, size and conduction Wilson K J W 1990 Ross & Wilson Anatomy and
velocities of myelinated and unmyelinated fibers of the physiology in health and illness. Churchill Livingstone,
pelvic nerve in rats. Journal of the Autonomic Nervous Edinburgh
System 69: 148-155 Winkler A S, Ejskaer N, Edmonds M, Watkins P J 2000
Root M L, Orien W P, Weed J H 1977 Normal and abnormal Dissociated sensory loss in diabetic autonomic
function of the foot. Clinical biomechanics - volume 2. neuropathy. Diabetic Medicine 17: 457-462
Clinical Biomechanics Corporation, Los Angeles, p 254 Young M, Matthews C 1998 Neuropathy screening: can we
Vander A J, Sherman J H, Luciano D S 1998 Human achieve our ideals? The Diabetic Foot 1: 22-25
physiology, 7th edn. McGraw Hill, New York, pp Zouri M, Feki M, Hamida C B et al1998 Electrophysiology
238-239 and nerve biopsy: comparative study in Friedreich's
Van Gijn J 1975 The Babinski response: stimulus and ataxia and Friedreich's ataxia phenotype with
effector. Journal of Neurology, Neurosurgery and vitamin E deficiency. Neuromuscular Disorders 8:
Psychology 38: 180-186 416-425
FURTHER READING
Berkow R (ed) 2000 The Merck manual. Merck Sharp & medicine: principles and practice, 2nd edn. Lippincott,
Dohme Research Laboratories, New Jersey Philadelphia
Fuller G 1993 Neurological examination made easy. Kandel E, [essel T, Schwartz J 1991 The principles of neural
Churchill Livingstone, Edinburgh science. Elsevier, New York
Joel A, Delisa J B (eds) 1993 Electrodiagnostic evaluation of Wilkinson I M S 1998 Essential neurology, 2nd edn. Blackwell
the peripheral nervous system. In: Rehabilitation Science, Oxford
CHAPTER CONTENTS
Introduction 157
TERMS OF REFERENCE
The body is divided into three cardinal planes:
sagittal, frontal (coronal) and transverse (Fig. 8.1).
These planes form the reference points from which
to describe:
157
158 SYSTEMS EXAMINATION
t - - - - Frontal plane
Joint motion
Sagittal plane. Motion in the sagittal plane pro-
duces extension and flexion. The term flexion
Transverse denotes the bending of a joint, whereas extension
plane denotes the opposite, i.e. straightening of a joint.
The terms used to describe sagittal plane motion in
the foot are slightly different from those used to
describe such motion at the hip and knee (exten-
sion and flexion). At the ankle (Fig. 8.2), subtalar
joint (STJ), midtarsal joint (MTJ), metatarsopha-
langeal joint (MTPJ), interphalangeal joint (IPJ)
and first and fifth rays, sagittal plane motion is
termed dorsiflexion and planiarilexion. Dorsiflexion
denotes a raising of the whole or part of the foot
towards the leg, whereas plantarflexion denotes the
movement of the dorsal aspect of the foot away
Figure 8.1 Cardinal planes of the body: sagittal. frontal from the leg.
and transverse. Sagittal divides the body into right and left
halves. frontal divides the body into front and back and Frontal (coronal) plane. Motion in the frontal
transverse divides the body into upper and lower sections. plane produces abduction and adduction of the
The diagram shows midplanes but the terms refer to any thigh and leg and inversion and eversion of the
plane parallel to the appropriate midplane.
foot. This is because the foot lies at right angles to
the leg, so the terminology used to describe
movements of the foot differ from that for the leg
• position of a part of the body
and thigh. Abduction is when the distal segment
• joint motion moves away from the midline of the body and
• position of a joint
adduction when it moves towards the midline.
• deformity of a part of the body.
For example, in order to do the 'splits' gymnasts
must abduct their legs. Inversion of the foot is
when the plantar aspect of the foot is tilted so as
Position of a part of the body
to move towards the midline of the body.
The cardinal body planes are used as reference Eversion is when the plantar aspect of the foot is
points to describe positions within the body. tilted so as to face away from the midline of the
Anterior (to the front of) and posterior (to the rear body (Fig. 8.3).
of) describe positions in the frontal plane, e.g. the Transverse plane. Motion in the transverse
patella lies anterior to the knee joint. Distal (away plane produces internal and external rotation of
from the centre) and proximal (towards the the thigh and leg and adduction and abduction of
centre) describe positions in the transverse plane, the foot. Internal rotation occurs when the anterior
e.g. the interphalangeal joints (IPJs) lie distal to surface of the distal segment rotates medially in
the metatarsophalangeal joints (MTPJs). Medial relation to the proximal segment and external
(towards the midline of the body) and lateral rotation when the opposite occurs - the anterior
(away from the midline of the body) describe surface of the distal segment moves laterally in
positions in the sagittal plane, e.g. the navicular relation to the proximal segment (Fig. 8.4). In the
ORTHOPAEDIC ASSESSMENT 159
A B C
Figure 8.2 Sagittal plane motion at the ankle A. Dorsiflexion: movement of the foot toward the anterior aspect of the tibia
B. Neutral position C. Plantarflexion: movement of the foot away from the tibia.
Figure 8.3 Frontal plane motion in relation to the midline of the body (black line) A. Inversion: the foot is lifted up and
away from the line B. Eversion: the foot is moved down and towards the line.
160 SYSTEMS EXAMINATION
A B
c D
foot the use of the terms adduction and abduction Deformity of a part of the body
is dependent upon the site of the reference point:
the midline of the body or the midline of the foot. The term 'deformity' is used to describe a fixed
Functionally, the midline of the body is usually position adopted by a part of the body. Terms
used as the reference point: abduction of the foot used to denote deformity usually have the
is where the distal part of the foot moves away suffix -us:
from the midline of the body and adduction when • Sagittal plane - equinus when the foot or part of
the distal part of the foot moves towards the the foot is plantarflexed, e.g. ankle equinus,
midline of the body (Fig. 8.4). Anatomically the and extensus when the foot or part of the foot
midline of the foot is commonly used as the ref- is dorsiflexed, e.g. hallux extensus. Calcaneus,
erence point: e.g. adductor hallucis is inserted although rarely seen, is used to describe the
into the lateral side of the proximal phalanx of calcaneus when it is in fixed dorsiflexion, e.g.
the hallux and is so termed because it brings talipes calcaneovalgus.
about adduction of the hallux - movement of the • Frontal plane - varus and valgus (Fig. 8.5).
hallux towards the midline of the foot. • Transverse plane - adductus or abductus.
Triplanar motion. The position of the joint axis
together with the shape of the articulating surfaces
can result in joint motion in more than one plane.
If a joint axis is positioned at an angle of less than
900 to all the cardinal body planes triplanar motion
occurs - pronation and supination. Pronation is the
collective term for dorsiflexion, eversion and
abduction and supination for plantarflexion, inver-
sion and adduction. In the foot the subtalar and
midtarsal joints produce triplanar motion.
Position of a joint
To describe the position of a joint the suffix -ed is
used:
• sagittal plane - extended and flexed (thigh and
leg); dorsiflexed and plantarflexed (foot)
• transverse plane - internally and externally
rotated (thigh and leg); adducted and abducted
(foot)
• frontal plane - abducted and adducted (thigh
and leg); inverted and everted (foot)
• triplanar - pronated and supinated (foot).
It is important that a distinction is made
between joint motion and position; a joint moves Genu valgum Genu varum
(knock knees) (bow leg)
in the opposite direction to the position it is in. For
A B
example, at heel-strike the foot is slightly
supinated (position) but as soon as the heel con- Figure 8.5 Frontal plane deformity of the legs A. Genu
tacts the ground pronation (motion) occurs at the valgum (knock knees): the knees are close together and the
medial malleoli are far apart B. Genu varum (bow legs):
subtalar joint in order to absorb shock from ground the knees are far apart and the medial malleoli are close
contact. together.
162 SYSTEMS EXAMINATION
To gain a full and detailed picture of the function affected limb. Compare ranges of motion, end
of the locomotor system, the following factors feel (the sensation the examiner feels when he
must be assessed: pushes the joint being examined to the end of its
range of motion) and muscular strength. It is
• gait
• alignment and position of the lower limb helpful to arrange your testing so that the most
• joint motion painful test is last. This ensures that the condition
• muscle action. will not be aggravated by your testing procedure
or make the patient apprehensive.
Practitioners vary as to the sequence in which Not all of the tests will be necessary for each
they assess the above. There is no one correct component of the lower limb assessment. The
sequence; practitioners should adopt the sequence selection of tests used will depend on the findings
and approach they feel most comfortable with. as the examination proceeds, and should be
However, it is essential that a systematic approach influenced by the history and observations in
is adopted to ensure vital pieces of data are not order to rule out needless testing: having said that,
omitted. For the purposes of this chapter the fol- it is necessary to be thorough enough to rule out all
lowing sequence has been adopted: other possibilities by applying a holistic approach.
1. Gait analysis. This will focus on the position Exclusion of all possible injured structures in addi-
and alignment of the body and foot-ground tion to vascular, visceral and systemic conditions
contact. will be required.
2. Non-weightbearing. This will focus on the Referred pain associated with local nerve
assessment of joints and muscles. entrapments or radicular patterns of pain in which
3. Static weightbearing. This will focus on the spinal nerves or nerve roots are irritated need to
position and alignment of the body and the be considered. In addition, it is important to rule
relationship of the foot to the ground during out the joint above and below, especially if the
stance. history suggests other joint involvement.
Furthermore, it is useful to remember that a
To achieve a successful assessment it is impor-
problem that affects one part of the system can
tant that the patient is at ease and cooperates with
lead to problems elsewhere in the system. This is
and has confidence in the practitioner. The practi-
because the lower limb functions as one mechani-
tioner should always be sensitive to the patient's
cal unit; as a result a problem in one part has to be
needs and explain what she is about to do, and
compensated for in another part of the system.
why, prior to undertaking the assessment.
Compensation is a change in structure, position
Qualitative and quantitative measurement should
or function of one part in an attempt to adjust to an
be undertaken where necessary, but the data must
abnormal structure, position or function in another
be meaningful and reproducible if they are to be of
part. For example, a scoliosis of the spine may lead
any use in assessing improvement or deteriora-
to an apparent leg-length discrepancy, which will
tion. Various measuring devices may be used; their
affect foot function. Conversely, a problem affect-
use will be discussed in the appropriate sections.
ing the foot, e.g. an uncompensated rearfoot varus,
may lead to discomfort/pain at the knee.
General assessment guidelines The process of assessment follows a standard
Always observe and functionally assess the joints format:
bilaterally. It is valuable to obtain an overview of • general observation of the patient
both limbs, particularly if the onset of the • specific joint observation
problem is insidious, the pain is diffuse and non- • palpation
specific or if during testing a number of joints • examination of joint movement
appear to be implicated. Where only one limb • muscle assessment
is affected, it is often helpful to start with the • undertaking special tests
unaffected limb first, then repeat the test on the • arranging further investigations.
164 SYSTEMS EXAMINATION
General observation of the patient The process of joint assessment should be based
upon the following approach:
The assessment process starts in the waiting room.
Observation of the patients' demeanour, facial • range of motion (ROM)
expression, seated posture and how they get up • direction of motion (DaM)
from the chair will provide valuable clinical infor- • quality of motion (QOM)
mation. In addition, the way in which the patient • symmetry of motion (SaM)
walks into the clinic, together with use of walking • dislocation and subluxation.
aids, provides additional information as to mobil-
Range of motion (ROM) is the amount of
ity and how this might be influencing lower
motion at a joint and is usually measured in
limb / foot function.
degrees. The ROM at a joint can be compared
with the expected ROM for that joint; e.g. if only
Specific joint observation 20° of motion is found at the first MTPJ when the
expected norm is 70° (28% of the normal ROM)
Observation of each lower limb joint prior to it can be concluded that the ability of this joint to
examination is useful to establish the presence of carry out normal function is impaired (hallux
any clinical features synonymous with pathology, limitus). Often a guesstimate of the amount of
e.g. oedema, contusion, erythema, local muscle joint motion is made from observation.
wasting, alteration in shape or the presence of Protractors, tractographs and goniometers can
scars. In addition, comparison of symmetry of con- be used to quantify joint motion (Fig. 8.6). A joint
tralateral parts, abnormal posture/evidence of may show a normal ROM but the direction of the
limb shortening and abnormal joint movement motion (DaM) may be abnormal. It is, therefore,
during gait are additional clinical clues to underly- important to note the direction as well as the
ing pathology. range. For example, the total ROM of transverse
plane rotation at the hip is 90°; 45° internal rota-
Palpation tion and 45° external rotation. If the ROM is 90°
but there is 70° of external rotation and 20° of
Palpation of the limb segment or joint for clinical
features such as raised/lowered skin temperature,
swelling/effusion, tenderness, pain or abnormal
lumps/nodules provides additional information
to help establish a diagnosis.
.~
of a joint may be due to a range of factors: trauma,
infection, loose body (osteochondritis diseccans),
Examination of the joint, information from the
medical and social history and results from X-ray ~
and lab tests will enable a diagnosis to be made. If c
a patient complains of a painful joint the character-
istic features of the pain should be recorded.
Prior to examining a joint it is important that the
joint is warmed up (moved through its range of
Figure 8.6 Devices used to measure joints
motion); this relaxes the ligaments and muscles A. Protractor B. Tractograph C. Finger goniometer.
and also reduces the viscosity of the synovial fluid. D. Gravity goniometer.
ORTHOPAEDIC ASSESSMENT 165
internal rotation then the ROM would be normal Table 8.2 Joint changes
but the DaM would be abnormal. Normal joint Type of sensation Indication
motion should occur without crepitus, pain or
resistance (quality of motion or QOM). The Joint stiffness Inflammatory/degenerative
changes
ROM and DaM of motion of a joint, e.g. hip,
should be the same for both limbs (symmetry of Tightness or tension Swelling or protective muscle
spasm
motion or SaM). The presence of asymmetry of
Popping Muscle tear or strain
motion should always be noted. Joint motion
can be affected by the ligaments around the Snapping Tendon slipping over bony
prominence
joint. It is important as part of joint assessment
Clicking Meniscal tear or patella rubbing
to identify any dysfunction of the ligaments, e.g. femoral condyles
ligament tear or contracture of a ligament.
Grating Osteoarthritis or osteochondritis
Finally, joints should be assessed as to whether
Crepitus (tendon) Inflammation of tendon
they are subluxated or dislocated. Dislocation
occurs where there is no contact between articu- Crepitus (joint) Articular damage or loose body
lating surfaces of the joint and subluxation Tearing Muscle or ligament tear
where there is only partial contact. Tingling Neural or circulatory pathology
The range of active and passive movement of Warmth Local inflammation or infection
each respective lower limb joint should be exam- Numbness or Local nerve or nerve root
ined, documented, compared and contrasted with hypersensitivity compression
the contralateral side. It is useful to assess whether
passive movement of the joint provokes any pain
or guarding (sometimes seen in hallux Iimitus). In
addition, it is valuable to document the response to neutralise the effects of other muscles prior to
resisted testing (strong/weak/painless/painful) testing the muscle in question. One way in which a
and stability of the joint. This will determine the muscle can be neutralised is by flexing the joint
integrity of the articulating surfaces and ligaments. which the muscle crosses so that tension is
Provoking crepitus on joint movement is an indi- removed.
cation of joint damage. Table 8.2 summarises the Muscles should be tested for:
main joint changes that can be detected during
joint assessment. • strength
Often it is helpful to be able to differentiate • tone
between articular and capsular damage. In a • spasm
lesser MTPJ this can be achieved by comparing • bulk.
the results of a compression test (compression of Strength. The Medical Research Council (MRC)
the metatarsal head against the proximal phalanx system is commonly used for grading muscle
- to test for articular damage) with a distraction strength (Crawford Adams & Hamblen 1990):
test (dorsiflexion/plantarflexion of a distracted
proximal phalanx against the joint capsule dor-
o = no contraction
1 = a flicker from muscle fasciculi
sally/plantarly).
2 = slight movement with gravitational effects
removed
Muscle assessment 3 = muscle can move part against gravity
4 = muscle can move part against gravity +
Muscles bring about motion at joints. To identify
resistance
the cause of joint dysfunction and/or pain it is
5 = normal power.
important to differentiate between muscle, liga-
ment and joint abnormality. As a number of Muscle strength can be assessed by the patient
muscles may affect anyone joint, it is important to bringing about the motion (active) or by the prac-
166 SYSTEMS EXAMINATION
diagnosis. Occasionally, however, it may be neces- Table 8.3 Dysfunctions that can influence gait
sary to arrange specialist investigations to confirm Neurological
the diagnosis or to consider other options. A
May involve dysfunction of one or a combination of the
number of possibilities are available, including: following parts of the CNS and/or PNS:
specialist imaging techniques and haematological,
• motor, e.g. CVA
biochemical and nerve function tests. In addition, sensory, e.g. tabes dorsalis, blindness
histological examination of specimens, elec- • cerebellum, e.g. Friedreich's ataxia
tromyography (EMG), video/treadmill gait analy- • basal ganglia, e.g. Parkinson's disease
Structural
GAIT ANALYSIS • limb-length inequality, e.g. DOH, polio,
femoral/tibial fracture
Gait involves complex neuromuscular coordina- alignment disorders: coxa valgalvara, genu
tion of the lumbar spine, pelvis, hips and those valgum/varum/recurvatum, tibial/femoral torsion,
rearfoot varus
structures distal to them. Any dysfunction in the
lower limb will become observable during gait. A
variety of neurological, systemic and structural
dysfunctions can influence gait (Inman et a11981) planes can be assessed. Gait should be observed
(Table 8.3). The effects of the dysfunctions listed with the patient both barefoot and wearing shoes
in Table 8.3 may lead to gross or relatively minor (with and without orthoses).
changes to gait. Gross disorders are readily Gait analysis commences with the patient
observed, whereas those that lead to relatively entering the room. At this point the patient is less
minor changes, e.g. rearfoot varus, may not be so conscious of being observed and is less likely to
obvious. act unnaturally. The practitioner's eye should
Gait can be adequately assessed with few aids, run from the patient's head to ground level,
providing that sufficient room is available; observing foot-ground contact. At this stage
ideally there should be a walkway 1.1 m wide there are some key points the practitioner should
and 6 m long. A treadmill may be used; this facili- address about the patient's gait (Table 8.5).
tates the observation of a sufficient number of Gait is divided into a swing phase and a stance
strides without the patient having to make fre- phase; stance phase relates to the period of the
quent turns and is especially appropriate if there gait cycle when the foot is in contact with the
is not enough room for a 6 m walkway. It is ground and swing phase to when it is not. Stance
important that the patient is appropriately attired phase is easier to visualise than swing phase; it
(ideally shorts and 'l-shirt) so that key parts can consists of the contact, midstance and propulsive
be observed; these are summarised in Table 8.4. stages (Fig. 8.8). Contact phase starts when the
This section concentrates on the observation of heel makes ground contact; this is followed by
gait. Methods of analysing gait are discussed in the rest of the foot. During contact phase the foot
Chapter 12; these can provide a very useful pronates in order to absorb shock from the effects
adjunct to information obtained from observa- of ground reaction. Midstance starts when all the
tion and are particularly useful in the monitoring foot is in ground contact and ends with heel lift.
of gait changes. The patient's gait must be During midstance the foot starts to re-supinate
observed from the posterior, anterior and lateral ready for propulsion. Propulsion starts at heel lift
views in order that movement in all three body and ends when the hallux leaves the ground.
168 SYSTEMS EXAMINATION
Table 8.4 Anatomical and functional features to observe The movement and relationship of both limbs
during gait
during gait is summarised in Table 8.6.
Head position The following section considers each of the
Shoulder position specific pointers listed in Table 8.4.
Head. The head should not show excessive
• Arm swing
movement. Altered positions may include twisting
• Trunk position/rotation
(torticollis), due to muscle contracture, or tilting on
Pelvic tilt
one side as a result of pain or limb-length inequal-
Limb motion ity (LLI). In type I compensation for LLI the head
• Thigh segment will tilt down on the long limb side due to cervical
Patellar position (transverse plane) scoliosis. In type II and III compensation for LLI
Knee position (frontal/sagittal plane) the head will tilt down on the short limb side.
• Tibial position Shoulder position. Both shoulders should be
• Ankle
level. Unilateral tilting may be due to LLI or sco-
liosis. In children under 12 years with LLI the
Calcaneal position
shoulders will always tilt down on the short limb
Navicular position
side (type III compensation). In adults where sec-
Midtarsal joint (position/movement) ondary scoliosis can present the shoulders will
Metatarsals (anterior/lateral views) tilt down on the long side (type I and type II com-
• Toe position pensation). Fixed deformities should be distin-
Foot position/shape guished from flexible vertebral deformities (see
Muscle activity static weightbearing examination).
Propulsion
Arm swing. Arm swing is a feature of normal
forward progression. The arms should swing to
Swing phase
even out leg movement. The upper torso will act
to decelerate lower limb motion. Some subjects
fail to swing their arms; this alone is not abnor-
During propulsion the foot continues to mal but can affect spine position during walking:
supinate; the fifth metatarsal head is the first to there is a tendency to lean either forward or back
leave the ground, followed in sequence by the as the arms do not swing. Arm and hand position
others. The hallux should be the last to leave the may point to signs of injury or motor disability
ground. Assessment of foot-ground contact and and should be recorded: e.g. flexed position of
swing phase can be facilitated by high-quality arm and hand held close to the body suggests a
video recording and playback with freeze frame. cerebral vascular accident (eVA). In addition, in
Table 8.5 Questions the practitioner should consider when assessing the patient's gait
Does the patient lurch or look uncoordinated? This suggests ataxia and requires examination of the cerebellum and
nervous system.
Does the patient have any postural problem? Is the posture abnormal?
Does the spine appear curved?
Does one leg/foot lead, followed by the other without obvious asymmetry or alteration in cadence?
Does the face shows signs of pain or anxiety? Could this be an antalgic gait?
Does the patient appear to be overweight in relation to his/her height?
Does the whole foot contact the ground when shod?
Does the foot look straight, adducted or abducted?
ORTHOPAEDIC ASSESSMENT 169
Table 8.6 Stance phase of gait showing 'normal' movement of the left and right limbs
A B
c D
Figure 8.8 Series of photographs taken at 400 frames per second A. The right heel contacts the ground; forefoot motion is
decelerated by the extensor muscles B. The metatarsal heads have contacted the ground but the toes are still dorsiflexed
C. The right foot completes forefoot contact and the left heel is about to leave the ground (heel lift) D. Propulsion: the fifth
and fourth toes are no longer in ground contact and the third, second and first are about to follow in that order.
170 SYSTEMS EXAMINATION
patients with LU, the arm on the shorter limb observation of transverse plane motion. Excessive
side will be held away from the body to help internal or external rotation should be noted; it
maintain balance and will hang lower than the may be due to proximal or distal abnormality. If
contralateral arm. the patellae are squinting with an in-toed gait it
Trunk position/rotation. Observe for obvious suggests the cause of the in-toeing is suprapatel-
structural abnormalities likely to influence gait lar, whereas if the patellae are facing forward
posture such as spinal kyphosis, scoliosis or lor- with an in-toed gait the inference is that the cause
dosis. Excessive amounts of trunk rotation will of the in-toeing is infrapatellar. Excessive exter-
increase energy expenditure during gait and can nally facing (fish eye) patellae are generally asso-
often be associated with myopathy such as ciated with external femoral torsion.
Duchenne's muscular dystrophy and spastic Torque conversion is the means by which
neurological gaits. In addition, excessive upper motion of the thigh and leg influences the foot;
body movements with the arms swinging across the subtalar joint (STJ) is the interface between
the body may be caused by faulty hip or lower the leg and foot and is where torque conversion
limb mechanics. takes place. Internal rotation of the leg is trans-
Pelvic tilt. This forms the pivot of lower limb ferred into pronation of the foot (required for
function. The pelvis moves in all three cardinal shock absorption) and external rotation of the leg
planes in order to provide smooth up and down is transferred into supination of the foot
(sinusoidal) motion. Tilting may arise from neu- (required for stability of the foot during propul-
rological problems, spinal deformity, LU (pelvis sion). However, excessive transverse rotations of
tilts down on side of short limb) and injury. the leg during gait will influence the angle of
Pelvic tilting can also present in osteoarthritis of gait and, subsequently, promote prolonged and
the hip due to weakness of gluteus medius abnormal pronation or supination of the foot,
(resulting in Trendelenburg gait). leading to foot and leg pathology.
Limb motion. Do the limbs present a normal Knee position (frontal/sagittal planes). Sagittal
forward progression during gait rather than the plane motion of the knee joint during gait is out-
exaggerated circumducted movements typical of lined in Table 8.6. Alteration in sagittal plane
a CVA patient? knee motion will affect the third determinant of
Thigh segment. Thigh movement is a reflection gait. If the knee does not flex it causes the hip to
of the transfer of pelvic motion through the hip lift further and allows greater height on that side.
joint. Excessive transverse plane rotation (internal To swing the leg from stance through swing back
and external rotation) should be noted; this may be to stance again the pelvis has to rotate more and
due to a variety of factors, e.g. abnormal femoral has a vertical displacement which should appear
torsion or version. obvious. Excessive extension of the knee (genu
Patellar position (transverse plane). As long as recurvatum) should be noted if it occurs during
the patella proves to have normal alignment then gait.
it can be used as a reference point to determine Frontal plane problems (genu valgus/varum)
the extent of transverse plane motion of the leg. can be identified from observing the position of the
The amount of transverse plane rotation at the knees and the tibiae. The normal tibial outline
knee should be slightly greater than at the hip shows a slight genu varum because muscle distri-
and may therefore be easier to observe than at the bution results in lateral bulk. Bowing of the legs
thigh. At heel contact the leg should internally (genu varum) or knock knees (genu valgum)
rotate (patellae face inward); throughout mid- should be noted (see Fig. 8.5). Valgum of the hip
stance and most of propulsion the leg should (coxa) can produce the effect of a genu varum. In
externally rotate (patellae face outward) (see Fig. addition, osteoarthritis of the medial knee can
8.4). Alternatively, if the patella has an abnormal cause a genu varum deformity. Conversely, coxa
alignment, a bisection line drawn through the vara can produce a genu valgum. If a genu varum
tibial tubercle with a black felt marker may assist or valgum is present, it should be noted if it is bilat-
ORTHOPAEDIC ASSESSMENT 171
eral or unilateral. A unilateral deformity may Navicular position. At heel contact the foot
suggest injury, infection or growth disturbance at pronates in order to absorb shock from ground
the epiphysis in earlier life. Tumours are a rare contact. During pronation the talar head ad ducts
cause but should always be considered. against the navicular and as a result the distance
Tibial position. Bowing of the tibia in the between the ground and the navicular reduces.
frontal plane (tibial varus), a cause of rearfoot As the foot progresses into midstance and then
varus, or sagittal plane bowing (sabre tibia), seen toe-off the foot re-supinates (talus abducts); at
in Paget's disease, should be noted. this point the distance between the navicular and
Ankle. The ankle complex provides smooth the ground increases. If the talonavicular promi-
transference of weight from heel to toe. A nence is visible for more than a moment, or if the
minimum of 10° dorsiflexion is required to allow extent of the displacement is abnormal, careful
the leg to pass over the foot during midstance. examination of the cause must be considered
Equinus is the term used to indicate loss of during the non-weightbearing examination.
dorsiflexion. Toe walking and/ or an early heel Midtarsal joint (MTJ). During midstance and
lift may indicate an ankle equinus but non- propulsion the MTJ plays an important role in
weightbearing examination of the ankle joint maintaining foot stability in order to withstand
must be carried out before a definitive diagnosis the forces on the foot generated by uneven sur-
can be made. Unstable ankles may have frontal faces and particularly during propulsion.
plane instability, which shows as tilting hesita- Functioning of the MTJ is difficult to observe
tions. The subtalar joint works in concert with during gait. However, if there is abnormal prona-
the ankle (talocrural) joint. Inman (1976) tion at the subtalar joint the forefoot will appear
regarded the talocrural (TCJ) and subtalar (STJ) abducted on the rearfoot at the site of the MTJ; an
as the 'ankle joint' because they have a symbiotic increased concavity of the lateral border of the
relationship. The TCJ provides predominantly foot at the level of the calcaneocuboid joint will
sagittal plane motion and the STJ frontal and be apparent. This is an important sign of dys-
transverse plane motion. If one of these joints is function, which may result in forefoot deformity
unable to produce motion, e.g. after surgical (Fig. 8.9). Unlocking of the midtarsal joint,
arthrodesis (joint in fixed position), then the known as 'abductory twist', can occur during the
other compensates. last half of midstance should re-supination of the
Calcaneal position. The posterior position of the STJ fail to occur. The MTJ unlocks and causes the
calcaneus should be observed. The calcaneus con- forefoot to abduct on the rearfoot, resulting in a
tacts the ground in a slightly inverted position. As less springy propulsive phase.
a result of ground contact the calcaneus everts, The metatarsals. Forefoot loading during the
without the need for active muscle contraction, in contact phase should be observed from the ante-
order to bring the medial tubercle of the calcaneus rior viewpoint (Fig. 8.8A-C). The fifth metatarsal
into ground contact. The position of the calcaneus head makes ground contact first, followed in
moves very quickly from an inverted to an sequence by the other metatarsals; the first
everted position; it is therefore often easy to miss metatarsal head is the last to make ground
subtle changes. At the end of midstance the calca- contact. At propulsion, the reverse should
neus lifts off the ground in order to prepare the
foot for propulsion (Case comment 8.2). An early
heel lift or a heel that makes no ground contact Case comment 8.2
suggests a neurological problem, an ankle equinus Given that the average time of contact is between
or hamstring tightness. Rapid eversion of the cal- 650 and 750 rns, information has to be rapidly
caneus at heel contact can be associated with com- absorbed by the observer. Practitioners may think
there is an ankle equinus as a result of gait analysis
pensation for a rearfoot deformity, e.g. fully only to find that on video replay the timing of heel lift
compensated rearfoot varus (sometimes described is in correct sequence with the opposite foot.
as a heel strike pronator).
172 SYSTEMS EXAMINATION
Figure 8.9 The foot should be viewed from the posterior aspect to determine subtalar joint and midtarsal joint position during
midstance. The midtarsal joint offers a useful gauge to determine deformity due to abnormal pronation, leading to a medial
shift in the talonavicular relationship. The lateral border may be very apparent as the foot pronates abnormally. The
photograph shows moderate pronation with abduction at the midtarsal joint.
happen; the fifth is the first to leave the ground, should be noted. The position of the digits
followed in sequence by the others, with during the stance phase is influenced by the
the first being the last to leave ground contact intrinsic muscles Oumbricals and interossei) and
(Fig. 8.80). During propulsion, motion at the first the long and short flexors and extensors. The role
MTPJ should be observed from the lateral side; of the intrinsic muscles is to provide transverse
ideally, the MTPJ should dorsiflex to approxi- plane stability at the distal and proximal IPJs and
mately 70 0 • prevent the toes from buckling under the effects
Toe position. Toes should be dorsiflexed at of contraction of the extensors and/or flexors.
contact (Fig. 8.8A,B). Once the first metatarsal Clawing of toes during gait can occur if the
has contacted the ground on the medial side, all flexors have a mechanical advantage over the
toes should be plantigrade (Fig. 8.8C). At propul- intrinsic and extensor muscles. Conversely, toe
sion the hallux should be the last to leave the clawing can also occur if there is increased exten-
ground. Any change in normal digital position sor muscle activity prior to heel lift.
ORTHOPAEDIC ASSESSMENT 173
Figure 8.11 The flat-footed and abducted gait has been brought about by muscle paresis (weakness) in the lower leg.
Extensive tests have shown no obvious diagnosis. The gait shows shuffle-waddling. There is marked abduction with bilateral
ground contact for most of the stance phase. The left foot shows medial roll off as the leg prepares to move into swing.
metatarsal formula, excessive internal rotation of foot twists outwards in order to bring the foot
the leg. The foot may compensate for lack of into a more medial position for toe-off.
propulsion by rolling off its medial border (Fig. Abnormal pronation. Abnormal pronation can
8.11), by propelling from a hyperextended be classified as excessive pronation and/or
(dorsiflexion) first IPJ rather than MTPJ or by an pronation occurring when the foot should be
abductory twist. This is when the distal part of supinating. Signs of abnormal pronation during
the foot twists outwards during propulsion. gait are excessive/prolonged internal rotation of
Whatever the cause, the foot is prevented from the leg, eversion of the calcaneus, abduction at
re-supinating during the later stages of mid- the midtarsal joint, an apropulsive gait and
stance. However, once the heel lifts off the abnormal phasic activity of the muscles.
ground the effect of ground reaction, which pre- Early heel lift. This may vary from the heel
vented the re-supination, is reduced and the fore- making no contact with the ground (toe walking)
ORTHOPAEDIC ASSESSMENT 175
to a relatively normal heel contact but an early heel gerated elevation of the hip suggestive of the gait
lift. Heel lift should normally occur at the end of of a duck or penguin is seen in Duchenne's mus-
midstance prior to propulsion. An early heel lift cular dystrophy (Sutherland et aI1981).
can give rise to a bouncy gait. The most common Festinating gait. Small accelerating shuffling
cause is an ankle equinus. steps are taken often on tip-toe. This gait pattern is
Limb-length inequality (LLI). One shoulder is typically associated with Parkinson's disease.
usually lower than the other, and there may be a Ataxic gait. This condition produces an unstable
functional scoliosis. The determinants of gait are poorly coordinated wide base of gait pattern.
affected and the gait appears uneven. The foot of It is primarily seen in patients with cerebellar
the shorter leg is usually in a supinated position pathology.
and the foot of the longer leg abnormally pronates. Helicopod gait. The feet describe half-circles as
Early heel lift may occur in the shorter leg and pro- they shuffle along during contact and early mid-
longed flexion of the knee of the longer leg. stance phase. This condition is seen frequently in
Trendelenburg gait. This is characterised by a hysterical disorder.
lurching/waddling gait where the pelvis tilts to
the affected side. Associated with congenital dys-
NON-WEIGHTBEARING EXAMINATION
plasia of the hip and hip osteoarthritis (due to
weak gluteus medius), Trendelenburg gait can The prime purpose of the non-weightbearing
present following Achilles tendon lengthening examination is to undertake an assessment of the
procedures and will remain as long as posterior leg joints and muscles of the lower limb. Information
muscle weakness persists. from this part of the examination may explain the
Painful knee joint. Avoidance of extension. cause of a gait abnormality or the patient's pre-
Painful hip joint. It is commonly held in slight senting problem. For example, a foot may in-toe as
flexion, abduction and external rotation because a result of an osseous and/ or soft tissue problem of
this puts least stress on the capsule or inflamed the leg; the purpose of the non-weightbearing
synovial membrane. Walking speed and time examination is to establish which is most likely.
spent on the involved hip is reduced, e.g. A flat couch is required for the patient to lie on.
osteoarthritis, Perthes' disease and slipped capital The patient should feel comfortable and relaxed
femoral epiphysis. and should not wear restrictive clothing.
Foot drop or steppage gait. A high knee lift is Non-weightbearing examination involves an
produced during gait to ensure ground clearance assessment of the following:
of the affected limb. It is often associated with per-
oneal damage (Charcot-Marie-Tooth disease), • hip
weak tibialis anterior or poliomyelitis. • knee
Circumducted gait. A CVA victim has the char-
• ankle
• subtalar
acteristic features of unilateral limb weakness and
will circumduct (rotate the leg in an arc) and flex • midtarsal
• metatarsals
the elbow and hand towards the body. Movements
• metatarsophalangeal joints (MTPJs)
are made slowly to maintain balance. Jerky move-
• digits (proximal and distal interphalangeal
ments suggest muscle coordination problems; the
joints - IPJs)
nature of upper and lower motor neurone deficits
• alignment of the lower limb.
are described in Chapter 7.
Scissoring gait. The legs cross the line of pro-
gression during gait in cerebral palsy. Circum-
Hip examination
duction is necessary in order to produce forward
motion. The hip joint is both a mobile and stable joint.
Dystrophic/atrophic gait. An exaggerated alter- Stability is provided by the depth of the acetabu-
nation of lateral trunk movements with an exag- lum, strong capsule, capsular ligaments and sur-
176 SYSTEMS EXAMINATION
rounding muscles. Mobility occurs in all three pelvis while the other hand holds the opposite leg
body planes. just above the anterior knee and moves the leg
The primary presenting problem is often hip towards the body to the point of resistance.
pain (coxodynia), This is felt deep in the groin, Loss of sagittal plane motion may be due to
whereas pain on the outside of the femur is often pain, femoral nerve entrapment or effusion in the
referred pain from the spine. A hip problem can hip joint as the anterior ligaments (iliofemoral and
occasionally result in pain being referred (via the pubofemoral) will be under greater tension and
obturator nerve) to the knee. A patient who cannot resistance than usual. Any asymmetry should be
accurately localise pain in the knee should be sus- noted.
pected of having a disorder of the hip. The main Frontal plane. To assess abduction and adduc-
cause of hip pain is osteoarthritis, a particularly tion at the hip the patient lies supine and the prac-
common condition in the elderly. An X-ray of the titioner holds the leg just below the anterior knee.
hip should be considered if confirmation of a The leg with the knee extended is moved across
disease process is necessary or diagnosis unclear, the opposite leg (adduction) and then brought
e.g. osteoarthrosis, Perthes' disease. back and abducted. The pelvis should be stabilised
It is not usually necessary to examine every during this assessment by placing a hand on the
patient's hip. The hip should only be examined if opposite iliac crest. There should be less adduction
the patient complains of discomfort or pain in the than abduction at the hip. Tightness of the adduc-
area and/or gait analysis reveals an abnormality tors on abduction can lead to a scissors-type gait:
which affects normal pelvis and thigh/leg motion. this is when one or both legs have a tendency to
Observation of the hip for gross deformity, cross over during gait and can be seen with cere-
muscle wasting, oedema, contusion and scar will bral palsy.
provide valuable information about potential or Transverse plane. Internal and external rotation
past pathology. In addition, palpation of the hip of the lower limb is essential for normal gait.
region for joint, muscle pain/tenderness or bursitis Ideally, the total range of transverse plane motion
(e.g. greater trochanter bursitis due to overuse, in an adult should be 90°, comprising 45° internal
weakness of gluteus medius on the opposite side and 45° external rotation. Females tend to show
or LLI) is helpful. Where a hip examination is indi- more internal rotation than males (Svenningsen et
cated, a series of tests on the hip joint itself in addi- al 1990). The range of transverse plane motion at
tion to the muscles acting upon it is undertaken.
the hip decreases with age and the DOM changes extended. The practitioner may note a differ-
from symmetry to more external than internal ence in the ROM and DOM at the hip when the
rotation. knees are flexed compared to when they are
To assess transverse plane rotation the patient extended. It was thought that this technique
lies in a supine position. The hip and knees are could be used to detect the presence of torsion
flexed and the leg is moved medially and laterally (bone influence) or version (soft tissue
as one would the arms of a clock. A gravity influence). Torsion was said to exist if there was
goniometer can be used to assess the range of no difference between the ROM and DOM at the
motion (Fig. 8.13). Asymmetry in the DOM should hip with the knees flexed and extended and
be noted. For example, a patient who shows 70° version if there was a greater ROM when the
internal rotation and only 20° external rotation has knees were flexed. It was considered important
an internally rotated femur which will affect to make a distinction as torsion cannot be
normal lower limb function and may result in treated conservatively while version can. This
abnormal pronation at the subtalar joint. concept, while plausible, is not consistent with
The test can be repeated with the patient in bone torsion measurement and is open to mis-
the same position but with the hip and knees diagnosis. However, it is important when
A B
Figure 8.13 The hips are in a flexed position A. A gravity goniometer is used to assess the amount of internal femoral
rotation B. A gravity goniometer is used to assess the amount of external femoral rotation.
178 SYSTEMS EXAMINATION
undertaking an assessment of the muscles and any flexion deformity should disappear. A
around the hip to see if there are any soft tissue tight tensor fasciae latae may be the cause of an
contractures, which may be responsible for lim- apparent limb length discrepancy.
iting motion. Contracture of capsular structures Thomas's test. Iliopsoas consists of psoas
of the hip will limit hip movement when these major, psoas minor and iliacus (the prime flexors
structures are on-stretch (hip extended), of the hip). Thomas's test is used to rule out the
whereas contracture of the medial hamstrings presence of iliopsoas contracture. If a flexion
will limit external hip rotation with the hip in a deformity exists the affected leg will flex at the
flexed position. knee (see Fig. 8.12) (Case comment 8.3). Further-
Scouring/circumduction test. This test is used to more, the femoral nerve can be irritated by a taut
assess QOM and joint congruency in patients com- iliopsoas group. Damage to the nerve will lead to
plaining of groin pain. The hip is flexed and weakness of the quadriceps, as well as loss of
adducted and the practitioner rotates the hip to sensation on the anterior and medial aspects of
test for any crepitations. If pain is provoked during the leg (Case comment 8.4).
this manoeuvre with the hip internally rotated a Ely's test. This test is used to assess hip flexor
lesion of the acetabular labrum should be sus- (rectus femoris) tightness or contracture. The
pected. A posterolateral force applied to the hip patient lies prone and the knee is slowly flexed as
will test the integrity of the posterior/lateral hip far as possible until the heel comes close to the but-
capsule. tocks. Observe the buttock/hip during this
Patrick's or faber's test (flexion abduction exter- manoeuvre. The point at which the buttock rises
nal rotation). The patient lays supine with one leg off the couch on the tested side indicates the degree
straight. The other knee and hip are flexed so that of hip flexor tightness.
the heel is placed on the knee of the straight leg. Ober's test. This test is designed to assess for
The knee is then slowly lowered into abduction. iliotibial band contraction or tightness. The
Gentle pressure is applied to the flexed knee while patient lies on his side and the outer limb with
the opposite hand stabilises the pelvis over the the knee extended is moved anteriorly and then
opposite anterior superior iliac spine. This test adducted towards the couch (Fig. 8.14A). This
stresses the medial hip capsule by placing an stretches the lateral structures, primarily the
anteromedial force on the hip, the integrity of the
iliofemoral! pubofemoral ligaments and also
assesses for sacroiliac discomfort.
Sacroiliac joint provocation test. Patients who Case comment 8.3
experience pathology of the sacroiliac joint may Thomas's test: while the patient flexes the hip, the
complain of pain in the region of the hip. It is there- practitioner must observe the opposite (contralateral)
fore important to be able to exclude pathology in thigh for any sign of elevation. The lumbar spine must
lie flat. If the iliopsoas muscles are tight, the
the sacroiliac joint. To isolate and test this joint the contralateral hip will rise as the ipsilateral hip will
practitioner places her hands on the anterior supe- force the lumbar spine against the COUCh. Fixed
rior iliac spines of the pelvis and presses down flexion will cause an apparent LLI.
B C
180 SYSTEMS EXAMINATION
iliotibial band. A modified form of the test sepa- Laseque's (straight-leg-raise) test. This test will
rately tests the short fibres of the knee; this is provoke pain in patients with hamstring muscle
achieved by flexing the knee and repeating the inflexibility, severe hip pathology and also tests
manoeuvre. mobility of nerve roots L4 to 52. Where no pathol-
Piriformis test. With the patient lying on his ogy is present the leg should make an angle of 70°
side, the hip and the knee are flexed to 90°. The to the supporting surface (Gajdosik et al 1993,
examiner places one hand on the pelvis for stabili- Kendall et al 1993). There is no significant differ-
sation and with the other hand applies pressure at ence in hamstring flexibility between males and
the knee, pushing it towards the couch. This puts females (Gajdosik et al 1990).
the piriformis muscle on tension. If tightness of the
piriformis muscle is impinging on the sciatic
Functional tests
nerve, pain may be produced in the buttock and
also down the leg. Also, in this position the If the patient's pain has not been reproduced
strength of the external rotators of the hip can be during formal examination, then functional tests
tested by asking the patient to externally rotate the should be performed. A single leg squat can be
hip against resistance (Fig. 8.14B). used to assess pelvic control. Abnormalities of
Adductor strength test. The adductors have excessive lateral or anterior tilt may be noted. Step-
their insertion on the medial side of the femur up or step-down tests may also be useful.
along the linea aspera. The adductor muscles are
important during the swing phase, stabilising the
contralateral side of the hip against the pelvis as
the leg swings forward. Adductor strength can
be tested as in Figure 8.14C. Gracilis, a partial
adductor, rotates the femur on the hip. As it
shares some of the function of the adductors, it
can be examined with them. However, this
muscle crosses the knee and lies between the sar-
torius and semitendinosus on the medial aspect
of the knee. The knee should be extended to
include the action of gracilis, but flexed to
remove its influence.
Abductor strength test. The abductors include
the gluteus medius and minimus as well as tensor
fasciae latae. Together they act through the iliotib-
ial tract. Abductor strength is best assessed when
the subject lies on his side. The patient should raise
the upper leg away from the couch against gravity
and resistance.
Trendelenburg's test (Stork test). This tests the
stability of the hip and the ability of the hip B
abductors to stabilise the pelvis on the femur.
The patient stands on one leg with the other knee
flexed; the pelvis should tilt upwards or stay
level on the side of the lifted leg. A positive
Trendelenburg sign occurs when the reverse Figure 8.15A,B A. Normal knee anatomy: (1) anterior
happens: the pelvis tilts downwards, indicating cruciate (2) posterior cruciate (3) meniscus
(4) collateral ligament (5) cartilage (6) ligamentum
weak glutei. Osteoarthritis of the hip can patellae surrounding patella (7) tibial tubercle
produce a positive Trendelenburg sign. B. Diagrammatic representation of the joint margin.
ORTHOPAEDIC ASSESSMENT 181
C
Figure 8.15C Photograph of the joint margin corresponding to B. (Fig. 8.15A,B on facing page.)
182 SYSTEMS EXAMINATION
the foot the tibia is externally rotated and a valgus action with the quadriceps and a functional
stress is applied. A positive test will elicit a equinus at the ankle joint. The 90: 90 test is per-
'popping' or 'snapping' sound or sensation. The formed with the patient supine. The knee and hip
test is repeated with internal rotation and a varus are flexed to 90°. The practitioner holds the leg
stress for the lateral meniscus. Ensure that snap- and extends the knee until resistance is met. If the
ping and clicks due to normal tendon movement knee can be fully straightened or to within 10°,
over prominences are not misdiagnosed as patho- then the hamstrings are within normal limits. If
logical lesions. the leg can only be partially extended it indicates
Apley's compression test. The patient lies tight hamstrings.
prone and the knee is flexed and the foot Any asymmetry should be noted. To assess
grasped. The practitioner creates a compression whether this is due to a tight biceps femoris or
at the knee joint while producing a rotation semitendinosus, stretch can be placed on the
movement. A noisy and painful response sug- biceps femoris muscle by medially rotating the
gests meniscus damage. extended leg and on the semitendinosus by later-
ally rotating the leg (Fig. 8.18).
Muscle testing
Quadriceps. The practitioner should inspect
the tone of the quadriceps. Wasting of the
medial vastus in particular may occur as a result
of knee dysfunction. A tape measure can be
used to assess muscle bulk in this area and
monitor any change as a result of treatment (see
Fig. 8.7). The circumference of both legs should
be measured at a standard distance of 10 cm
above the superior pole of the patella. The
rectus femoris muscle is a weak flexor of the hip
but a powerful extensor of the knee. As part of
the quadriceps group of muscles, rectus femoris
is an important stabiliser of the knee, in con-
junction with the vasti, and is needed to swing
the leg forward in gait. Pain at its insertion
(anterior inferior iliac spine) can arise with a
strong kicking action. Examination of the rectus
femoris muscle is undertaken with the patient
sitting on the edge of the couch with the knees
flexed. To assess the strength of this muscle the
patient is asked to extend the knee while the
practitioner attempts to resist this active motion
(Fig. 8.17).
Hamstrings. The tone of the hamstrings
should be inspected. From an extended knee
position the strength of the hamstrings is tested
by asking the patient to flex their knee (push
down) against resistance. The 90: 90 test is used
to identify tightness and contracture of the ham-
string muscle group. Tight hamstrings may cause Figure 8.17 Rectus femoris is tested by extending the knee
knee flexion, creating an inefficient antagonist against resistance.
186 SYSTEMS EXAMINATION
Functional tests
If the patient's pain has not been reproduced
during formal examination functional tests such as
squat,lunge, hop, step-up or step-down should be
performed.
Laboratory tests
X-rays (anteroposterior and skyline views) may
be requested to gain a full picture of the extent
of osseous damage to the knee and to rule out
osteoarthritis, loose bodies, a fragmented
patella or bipartite patella. Ultrasound or mag-
netic resonance imaging (MRI) will demonstrate
thickening/swelling around a tendon, the pres-
ence of any tendon tears or degeneration and
meniscal damage. Assessment of joint aspirate
will rule out haemorrhage, in, e.g. haemophilia,
or pus, in, e.g. infective arthritis. Arthroscopy
can be combined with surgical exploration of
the joint.
Tibia/fibular examination
The tibiofibular segment should be examined for
soft tissue swelling. Bilateral swelling suggests a
systemic rather than local cause. Unilateral leg
oedema in women over 40 years is a common
sign of intrapelvic neoplasm. Local swelling is
common over inflammatory lesions and stress
fractures. Local bone swelling is suggestive of an
old fracture or neoplasm (e.g. osteoid osteoma).
Figure 8.18 90 : 90 test. The leg can be laterally and
medially rotated to identify specific areas of tightness. The
Multiple or single exostoses occur in the tibia in
photograph shows the leg laterally rotated to identify tight diaphyseal aclasia. Thickening of the ends of the
medial hamstrings. tibia is seen in osteoarthritis and rickets.
The tibiofibular segment should be examined
for areas of tenderness. An enlarged and painful
Qangle
tibial tuberosity can be seen in Osgood-Schlatter's
The 'Q angle' is the position the patella adopts in disease, tenderness over the proximal/lateral area
relation to the direction of pull of the quadriceps of the tibia is associated with Brodie's abscess or
tendon. A line is drawn from the ASIS to a line osteitis, whereas pain in the region of the head of
bisecting the patella. If the angle of this line to the the fibular can be due to proximal tibiofibular joint
bisection of the patella is greater than 15° the osteoarthritis. Anterior pain between the tibia and
patient is said to have a high Q angle. This sug- fibular following trauma is seen in anterior tibial
gests medial displacement of the patella and is compartment syndrome, whereas pain directly
often associated with greater than normal internal over the anterior tibial border is associated with
rotation and anterior knee pain. tibial stress fracture. Tenderness in the region of
ORTHOPAEDIC ASSESSMENT 187
A C
B D
Figure 8.20 Ankle joint dorsiflexion A. Non-weightbearing assessment of ankle joint dorsiflexion with the knee extended and
the foot in the neutral position. Restriction of motion may be due to tight gastrocnemius, soleus or bony block B. A tractograph is
used to measure the amount of dorsiflexion C. Non-weightbearing assessment of ankle joint dorsiflexion with the knee flexed and
the foot in a neutral position. Restriction with the knee flexed due to a bony block or tight soleus D. Assessment of ankle joint
dorsiflexion weightbearing.
displacement in the frontal plane and the Stability in the sagittal plane can be tested by
patient should find the movement pain-free. applying a forward and then a backward push
Tenderness from the lateral ligaments (calca- on the TCJ while the knee is flexed and the foot is
neofibular and talofibular) should be noted in contact with the examining couch. This is the
before stressing the joint at the extreme ends of drawer test and should reveal minimal positional
inversion and eversion. The anterior joint line change and no discomfort. This test assesses the
should be pressed upon firmly at the tibial integrity of the anterior talofibular ligament. The
plafond. The talus may have less stability if the talar tilt test will assess the integrity of the calca-
inferior transverse tibiofibular ligament is neofibular ligament laterally and the deltoid lig-
affected as this holds the distal end of the tibia ament medially. With the patient supine the
and fibular within the ankle mortise. calcaneus is grasped and moved medially and
190 SYSTEMS EXAMINATION
Alteration of the axis can favour motion in one the leg bisection (non-weightbearing). Subtalar
direction at the expense of motion in another. The varus or rearfoot varus (discussed under static
knee and foot are affected by the axial position of examination) can affect the function of the rear-
the STJ (Green & Carol 1984). foot during gait and may lead to excessive prona-
Joint motion. To measure triplanar motion at tion of the foot and delay re-supination of the
this joint one would have to measure the motion foot during gait.
produced in each plane; this is impossible to
achieve clinically. The amount of frontal plane Abnormal pronation
motion at the STJ can be measured, and this is
used as an indicator of the ROM at the STJ. It is Abnormal pronation, i.e. excessive STJ pronation
important that there is an adequate ROM and during contact phase and/ or STJ pronation occur-
appropriate DaM at the STJ for normal prona- ring when the STJ should be supinating during
tion and supination of the foot. midstance and propulsion, is one of the most
To assess frontal plane STJ motion the patient common disorders of the lower limb. A large
lies prone with the ankle and foot hanging over degree of frontal plane motion in the foot (due to
the edge of the couch. The distal third of the leg is uncontrolled STJ pronation) is thought to predis-
bisected; this line is used as a reference point for pose to forefoot pathology and ankle dysfunction,
measuring the ROM and DaM. The calcaneus is whreas a greater degree of transverse plane tibial
moved into its maximally inverted position and rotation is thought to predispose to leg and knee
the posterior surface of the calcaneus is bisected pathology.
(Fig. 8.22A). A tractograph is used to measure the The presence of four or more of the following
angle between the bisection of the leg and the indicates abnormal pronation:
bisection of the posterior surface of the calcaneus.
The calcaneus is placed in its maximum everted • more than 6° between the relaxed calcaneal
position and a reading is taken of the angle stance position (RCSP) and the neutral
calcaneal stance position (NCSP)
between the bisection of the leg and the bisection
of the posterior surface of the calcaneus (Fig. • medial bulging of the talar head or 'midtarsal
8.22B). Although this technique is helpful for clin- break' - quantified using the navicular drift
ical assessment, it is not considered accurate technique (Menz 1998)
(Elveru et aI1988). Milgrom et al (1985) examined • lowering of medial longitudinal arch -
272 male infantry recruits and an error in excess of quantified using the navicular drop technique
(Mueller et a11993)
20% was identified. It is also recognised that for
research purposes its reliability and validity are • more than 4° eversion of the calcaneus
poor (Menz 1995). Some consider it to be so poor • Helbing's sign (medial bowing of the tendo
as to suggest that this method of examination no Achilles)
longer be used to determine the measurement of • abduction of the forefoot at the MTJ (concavity
STJ movement (Buckley & Hunt 1997). A weight- of lateral border of foot)
bearing assessment of STJ ROM would theoreti- • apropulsive gait.
cally be a better indicator of the range utilised Numerous conditions arising in the lower limb
during walking. There is normally twice as much may lead to abnormal pronation; many of them
inversion as eversion (2: 1 ratio). Many patients have been highlighted in this chapter (the list is not
appear to have a 3 : 1 ratio of inversion to eversion exhaustive):
without any abnormal sequelae arising.
• internal or external torsion of the leg/ thigh
• tibial (genu) valgum/ varum
Subtalar varus
• coxa vara/ valga
Subtalar varus implies that the neutral position • ankle equinus
of the calcaneus is varus (inverted) in relation to • rearfoot varus
ORTHOPAEDIC ASSESSMENT 193
A B
Figure 8.22 Assessing frontal plane motion at the ST J A. The distal third of the leg is bisected and a line is drawn at the
bisection point. The posterior surface of the calcaneus is moved into its maximally everted position and the angle between the
bisection of the leg and the bisection of the calcaneus is measured B. The calcaneus is moved into its maximally inverted
position and the angle between the bisection of the leg and the bisection of the calcaneus is measured.
the foot during midstance and propulsion. To without affecting the rearfoot. This means that
assess the strength of these muscles the patient the forefoot might invert while the heel remains
should be asked to move his foot into supination vertical; the converse does not occur.
against resistance. Joint motion. To assess the motion at the MTJ
Dorsiflexors. The main dorsiflexors of the the practitioner must stabilise the STJ and
foot are the long extensors and tibialis anterior. prevent any motion occurring at this joint by
To assess the strength of the anterior muscles firmly holding the heel with one hand and
the patient should be asked to dorsiflex the holding the foot just distal to the midtarsal joint
ankle with the foot in inversion against resis- with the other. The MTJ should then be moved in
tance. Weakness of the anterior group is often the sagittal, transverse and frontal planes. There
linked to neurological problems, e.g. polio- should be most motion in the sagittal and trans-
myelitis. The plantarflexors have a work capac- verse planes and minimal motion in the frontal.
ity 4.5 times that of the dorsiflexors. If the The position of the axes will affect the amount of
dorsiflexors are weak the foot is held in a motion at the MTJ: e.g. a high (vertical) oblique
plantarflexed position as the plantarflexors have axis will result in an increase in transverse plane
a mechanical advantage. motion but a reduction in sagittal plane motion.
Evertors. The evertors of the foot are the
peronei. To assess the strength of the peronei the
Metatarsal examination
patient should be asked to evert the foot against
resistance. The evertors are not as powerful as The first and fifth metatarsals have independent
the invertors and in the case of neurological axes of motion and produce triplanar motion.
problems and/ or muscle imbalance the invertors The second metatarsal is firmly anchored to the
have a mechanical advantage over the evertors intermediate cuneiform and has least motion; the
and the foot is held in an inverted position (fol- third has less motion than the fourth metatarsal.
lowing a CVA). Tonic spasm of the peroneal Whereas the first and fifth metatarsals provide
muscles can occur; this is noted particularly with triplanar motion, the central three only move in
tarsal coalitions. A local anaesthetic can be the sagittal plane. The ability of the first
administered in order to differentiate between a metatarsal to plantarflex is important in order
muscle spasm and a tarsal coalition. that the medial side of the foot makes ground
contact during gait and the first MTPJ can
dorsiflex during propulsion. Patients commonly
Midtarsal joint
present with cutaneous changes associated with
The MTJ comprises two synovial joint com- dysfunction of the metatarsals, especially the first
plexes: talonavicular and calcaneocuboid. The and fifth. Sometimes one of the metatarsals may
MTJ is also known as the transtarsal or Chopart's be held in a plantarflexed position. The position
joint, and is an articulation between the rearfoot of the metatarsals can subsequently affect foot
and forefoot. The MTJ has two axes: longitudinal mechanics and gait.
and oblique. The longitudinal axis provides Joint motion. Clinical assessment of first and
frontal plane motion facilitated by the ball and fifth metatarsal motion can only be satisfactorily
socket joint of the talonavicular articulation. The undertaken in the sagittal plane. Unlike most
oblique axis involves both calcaneocuboid and joints, motion at the first and fifth rays is mea-
calcaneotalonavicular joints and primarily pro- sured in millimetres, not degrees. To assess sagit-
duces transverse and sagittal plane motion. tal plane motion the patient can be in a supine or
Limitations of motion at the ankle joint are com- prone position. The feet must be allowed to hang
pensated at the oblique axis of the MTJ. free of the couch. The practitioner places one
The MTJ assists in reducing impact forces and hand, with the thumb to the plantar surface,
helps to prepare the foot for propulsion. It can around the lateral side of the forefoot including
also accommodate walking on uneven terrain the second metatarsal while maintaining the foot
ORTHOPAEDIC ASSESSMENT 195
in its neutral position. The other hand, again with motion can be assessed using the thumb tech-
the thumb to the plantar surface, is placed nique (Kelso et al 1982) (Fig. 8.23A,B). A Sagittal
around the first metatarsal. The first metatarsal is Raynger provides an alternative means of assess-
moved into maximum dorsiflexion and ing first metatarsal motion (Fig. 8.23C,D)
plantarflexion. It is usual to find approximately (Kilmartin et al 1991). Sagittal plane motion of
10 mm in each direction (Fig. 8.23A,B). Lack of the fifth metatarsal can be undertaken using the
plantarflexion of the first ray is known as same approach. The validity of this technique is
metatarsus primus elevatus. The amount of questionable, however, as it may not represent
A B
C D
Figure 8.23 Assessment of motion at the first ray A. Measurement of dorsiflexion of the first ray using the thumb test
B. Measurement of plantarflexion of the first ray using the thumb test C. Dorsiflexion of the first ray measured with a Sagittal
Raynger (reproduced by courtesy of Nova Instruments) D. Plantarflexion of the first ray measured with a Sagittal Raynger
(reproduced by courtesy of Nova Instruments).
196 SYSTEMS EXAMINATION
the range the first or fifth metatarsal moves Metatarsophalangeal joints (MTPJs)
through during gait.
Deformity. Deformity of the metatarsals is said The MTPJs are the joints between the metatarsals
to occur when the ROM or DOM of one or more and the proximal phalanges; they produce
metatarsals is asymmetrical or the metatarsal motion in the sagittal plane. During the propul-
heads do not lie in the same plane. Table 8.8 sive period of gait it is important that
refers to the various positions and terms associ- dorsiflexion occurs at these joints in order to
ated with the deformities affecting the rays; these facilitate toe-off.
may be congenital or acquired. It is not unusual Joint examination. The ROM and DOM in
for a problem affecting the metatarsals to be uni- the sagittal plane should be assessed for all
lateral. MTPJs; they should have a free range of motion
Metatarsal parabola. The metatarsal parabola without pain or restriction (Fig. 8.24). The first
should also be assessed and documented using MTPJ has the greatest range of motion: approxi-
the palpation technique (Spooner et al 1994), as mately 70-90° dorsiflexion and 20° plantarflexion
abnormal metatarsal length is known to be asso- (Bojson-Moller 1979). The ROM and DOM at the
ciated with pathology. A short first metatarsal first MTPJ can be assessed with a tractograph or
can be associated with the development of hallux finger goniometer. The practitioner should
valgus, whereas a long first metatarsal can cause appreciate that the declined angle of the first ray
hallux rigidus. Shortening of a lesser metatarsal accounts for at least 15° of dorsiflexion at rest.
(e.g. brachymetatarsia) can result in the develop- A lack of dorsiflexion at the first MTPJ is
ment of intractable plantar keratosis, metatarsal- known as hallux limitus, and a complete absence
gia or hammer toe deformity. as hallux rigidus. The presence of either of these
conditions, but particularly hallux rigidus, will
affect toe-off and can lead to an apropulsive gait
Table 8.8 Abnormal positions ofthe metatarsals and overloading of one or more of the other
Position Description metatarsal heads. Some authors also consider
that this interferes with the angular momentum
Normal position Thefirst and fifth metatarsals of the body (Miyazaki & Yamamoto 1993) and
exhibit equal motion above and
below the second/fourth metatarsal predisposes to the development of chronic pos-
of 10-20 mm (5-10 mm in each tural complaints (Dananberg 1986, 1993). Hallux
direction) flexus is not so common; this is where the proxi-
Metatarsus primus Reduces ability offirst metatarsal mal phalanx adopts a plantarflexed position.
elevatus to bear weight and overloads
central (dorsiflexed first metatarsal) Hallux extensus (trigger toe) is where the proxi-
metatarsals. Differential diagnosis mal phalanx is abnormally dorsiflexed; it is often
forefoot varus. Shows limited associated with pes cavus.
plantarflexion and cannot be
reduced below level ofsecond Restriction of movement at MTPJs could be
metatarsal due to osteophytes, loose bodies or articular
Flexible plantarflexed Thefirst metatarsal may appear damage, e.g. osteochondritis dissecans. The
first metatarsal pronounced on the plantar surface effects of Freiberg's disease may be to produce an
ofthe foot with a cleft between the enlargement of the metatarsal head and early
first and second metatarsal heads.
Most ofthe movement is in the osteoarthritic changes; this usually affects the
plantar direction. Loading the second or third metatarsal. In some patients, par-
metatarsal head produces ticularly younger ones, the clinical appearance of
reduction ofthe position
the joint may appear normal and X-rays may
Rigid plantarflexed Thefirst metatarsal cannot be
first metatarsal reduced at all from its plantarflexed reveal no abnormalities. It is essential in these
position. Theforefoot tends to rotate cases that spasm of flexor hallucis brevis and/ or
in inversion during weightbearing; abductor hallucis is ruled out via the use of local
this affects rearfoot function
anaesthetic blocks.
ORTHOPAEDIC ASSESSMENT 197
A B
C D
Figure 8.24 Assessment of motion at the MTPJs A. Dorsiflexion of the first MTPJ B. Plantarflexion of the first MTPJ
C. Dorsiflexion of the second MTPJ D. Plantarflexion of the second MTPJ. In both cases (first and second MTPJ) dorsiflexion is
greater due to the shape of the articular surfaces.
A B
there is a difference of more than 5 cm between the allel to the couch). The practitioner bends down
knees genu varum is suspected; if it is impossible until her eyes are level with the malleoli and
to bring the malleoli together a genu valgum is observes the relationship of the malleoli to each
present (Beeson 1999). Obesity may prevent the other. The amount of malleolar torsion can be
knees and malleoli being brought together. measured in three ways:
Malleolar torsion. Torsion of the leg can affect • Estimate by using the thumb technique. Place the
the position of the foot, adducted (in-toe) and thumb of each hand anterior to the malleoli;
abducted (out-toe), as well as the position of the the medial malleoli should be one thumb's
patellae. Assessing the amount of tibial torsion thickness anterior to the lateral malleoli.
clinically is impossible, but it is suggested in the • Traciograph. The protractor end of the
literature that assessing the relationship of the tractograph should be held on the fibula side;
tibia and fibula malleoli to each other gives an one arm of the tractograph is placed parallel to
indication of torsion in the leg (Hutter & Scott the couch and the other arm is moved until it
1949, Lang & Volpe 1998). To measure malleolar bisects the malleoli.
torsion the patient lies in a supine position with • Gravity goniometer. The ends of the arms of the
the legs extended on the couch. The femoral gravity goniometer are placed on the malleoli
condyles should lie in the frontal plane (i.e. par- and the goniometer is held vertical (Fig. 8.26).
ORTHOPAEDIC ASSESSMENT 199
When the techniques were examined, the assessed by placing the foot in its neutral posi-
gravity goniometer fared best (Hayles & Lang tion; the patient may be either supine or prone
1987). Recent work suggests that there is good but it is important that the foot hangs free of the
agreement between the gravity goniometer and couch. The neutral position of the foot is defined
CT scan measurements (Lang & Volpe 1998): as the foot being neither pronated or supinated.
13-18° of malleolar torsion is considered normal. To put the foot into the neutral position the prac-
Tibial torsion is considered to be 5° more than titioner should feel on the dorsum of the foot for
malleolar torsion (Elftman 1945, Lang & Volpe the talar head. The foot should be moved into
1998), therefore normal tibial torsion is 18-25°. pronation and supination; while the foot is
Forefoot to rearfoot alignment. The plantar pronating the talar head can be felt protruding on
plane of the forefoot should lie parallel to the the medial side of the talonavicular joint and
plantar plane of the rearfoot (Fig. 8.27B). The while the foot is supinating it can be felt protrud-
relationship of the forefoot to the rearfoot is ing on the lateral side of the talonavicular joint
(Fig. 8.28). Neutral position is achieved when the
talar head cannot be palpated on either side. As
the foot is non-weightbearing it is also necessary
to 'lock' the midtarsal joint in order to reproduce
the position the foot would adopt if it were
weightbearing. In order to lock the midtarsal
joint the talar head should be held in its neutral
position and a slight dorsiflexing force applied to
the fourth and fifth met heads until the foot is at
90° to the leg. The neutral position of the foot
therefore acts as a reference point from which
joint motion and the position of parts of the foot
can be assessed. While the foot is held in its
neutral position a tractograph or a forefoot-
measuring device can be used to measure any
deviation of the forefoot to the rearfoot in the
frontal plane; the forefoot may be inverted or
everted to the rearfoot (Fig. 8.27C,A). Minor dif-
ferences between the forefoot and rearfoot are
usually insignificant and are often due to exam-
iner error, but quite high angles of discrepancy
can exist in excess of 15°.
An inverted forefoot may be due to:
Medial Lateral
Figure 8.27 Assessment of forefoot to rearfoot relationship A. Everted forefoot: the forefoot is everted to the rearfoot B. Ideal
forefoot to rearfoot relationship: the forefoot is parallel to the rearfoot C. Inverted forefoot: the forefoot is inverted to the rearfoot.
This condition can be reduced with the medial side of the foot should not be in
treatment. It can be difficult to differentiate ground contact. Pressure is applied to the
between a forefoot supinatus and forefoot dorsum of the first ray: with a supinatus,
varus. Various techniques are suggested. One there should be some give and the first ray
is to get the patient to stand; the foot is put should plantarflex; with forefoot varus, any
into its neutral position. With both conditions pressure on the dorsum of the first ray
ORTHOPAEDIC ASSESSMENT 201
-------------------------_._-_.
However, noticeable differences in foot length A true scoliosis can be differentiated from a func-
(two to three shoe sizes) indicates a mobile foot tional scoliosis by asking the patient to bend
which excessively pronates during gait. No dif- forward. If the spine is still deviated when the
ferences between the two is indicative of a rigid hips are flexed a true scoliosis exists; if vertebrae
foot. alignment improves it is likely to be a functional
scoliosis.
STATIC EXAMINATION
(WEIGHTBEARING) Angle and base of gait
To complete the assessment, the patient should A normal angle and base of gait is when the feet
be observed standing. Information from this part are slightly abducted (approximately 13° from
of the assessment should help to complete the the midline of the body) and the distance
picture of lower limb alignment, give an indica- between the malleoli is approximately 5 cm (see
tion of whether compensation is occurring at the Fig. 8.4A). Frontal plane deformity of the legs -
STJ and enable deformities of the forefoot to be genu valgum or va rum - may be very noticeable
observed. It may be helpful to ask the patient to when the patient stands and will affect the base
walk on the spot for a few steps and then tell him of gait, i.e. the gap between the malleoli will be
to stop. The position the patient adopts on stop- greater (genu valgum) or less (genu varum) (see
ping can be accepted as the normal angle and Fig. 8.5). The angle of gait will be affected by tor-
base of gait. As with gait analysis, the patient sional problems affecting the leg. Excessive inter-
should be observed from head to toe. The follow- nal torsion will lead to an adducted base of gait
ing should be noted: and squinting patellae, whereas excessive exter-
nal rotation will lead to an abducted base of gait
• head
(greater than 13°) (Fig. 8.4B-D). Torsional prob-
• shoulders
lems may be due to bony or soft tissue problems;
• spine
the true cause should be identified from the non-
• pelvis
• angle and base of gait weightbearing assessment.
• relaxed and neutral calcaneal stance position
• longitudinal arch Relaxed (RCSP) and neutral (NCSP) calcaneal
• toes stance position
• foot width and length.
The relaxed calcaneal position is an indicator of
Points related to the position of the head, STJ motion when weightbearing. This position
shoulders and pelvis are the same as those made can be used to assess whether compensation for
for gait analysis. Any abnormality may be indica- any proximal (e.g. tibial varum) or distal (e.g. fore-
tive of an LU, neurological or spinal problem. foot varus) deformities has taken place at the STJ.
The shape of the lower limb and distribution of The RCSP is measured by bisecting the poste-
muscle bulk should be noted. There should be rior surface of the calcaneus; the angle this line
symmetry of muscle bulk, although there may be makes with the ground is measured (Fig. 8.29A).
slight variation between the dominant and reces- The amount of calcaneal eversion or inversion
sive side of the body. This is particularly true (frontal plane) can be measured. Values greater
where one side, arm and/or leg engages in a than 4° eversion indicate the presence of abnor-
greater level of activity than the other. mal pronation:
• 0-4°: normal limits
Spine
• 4-7°: moderate pronation requiring treatment
The position of the vertebrae should be observed if symptomatic or a cause for concern
for the presence of kyphosis, lordosis or scoliosis. • 8° and above: marked pronation.
ORTHOPAEDIC ASSESSMENT 203
The causes of an abnormal everted RCSP are cal position. Although excessive pronation has
numerous, e.g. compensated forefoot varus, occurred, the RCSP will appear vertical and not
compensated ankle equinus, tibial valgum and everted.
varum, internal and external torsion of the leg. An inverted RCSP may be due to a neurologi-
If the calcaneus does not have an everted posi- cal problem, an uncompensated varus deformity
tion during RCSP it does not mean that abnor- affecting the rear- or forefoot, subtalar joint
mal pronation is not occurring. Compensation damage, tonic spasm of the invertors of the foot
for a rearfoot varus involves excessive STJ or the presence of a plantarflexed first ray.
pronation in order to bring the medial tubercle The NCSP is measured by placing the foot into
of the heel into ground contact and provide its neutral position while in ground contact and
shock absorption during the contact phase of bisecting the calcaneus (Fig. 8.29C). The angle
gait. A 10° rearfoot varus will require 10° of between the bisection of the posterior surface of
pronation in order to bring the heel into a verti- the calcaneus and the ground should be mea-
A B
sured; usually the calcaneus is in a slight army life. However, there is rather more to foot
inverted position. This is known as rearfoot function and mechanics than the height and
varus and may be due to the presence of a sub- shape of the longitudinal arch.
talar varus (see non-weightbearing assessment of The patient should be asked to stand on tiptoe
the STJ) and/ or tibial varum. and the position of the foot arch should be noted.
The presence of a tibial va rum can be assessed With rigid flat feet the arch height does not
during assessment of the NCSP. While the foot increase when the patient stands on tip toe; with
is in NCSP a bisection of the posterior surface of a flexible flat foot the arch height increases. Rigid
the leg should be compared to the ground. flat feet may be due to bony coalitions (synos-
Ideally the bisection of the leg should be vertical toses), contractures due to muscle imbalance or
to the ground (Fig. 8.29B). An angle of less than neurological paralysis with subsequent soft tissue
90° when measured from the medial side of the contractures. The shape and size of the arch can be
bisection of the leg indicates a tibial valgum and captured by taking a footprint; this can be used to
an angle greater than 90° indicates a tibial monitor changes.
varum. It was thought that the NCSP position
was a composite of the STJ plus the tibial posi-
Toes
tion. For example, a value of 7° rearfoot varus
might be deemed to be made from 4° STJ varus There are three main categories of pathomechani-
and 3° tibial varum. A tibial valgum would con- cal causes of lesser hammer toe syndrome.
versely have a negative effect upon the presence Flexor stabilisation. A contraction (hammer-
of an STJ varus. Because of the inaccuracy and ing) of all the lesser toes with an associated
error in measuring these values, however, this adductovarus deformity of the fifth and some-
concept is questionable. times fourth toes (quadratus plantae losing its
It is important to note the difference between mechanical advantage). This can occur in an
the RCSP and NCSP in order to assess the com- excessively pronated foot during late stance
pensation that occurs for proximal or distal phase when flexor digitorum longus and/or
problems (Fig. 8.29A,C). It is normal for there to flexor digitorum brevis have gained mechanical
be a difference of up to 6° between RCSP and advantage over the interossei muscles.
NCSP; this is because most people have a slight Pronation of the STJ allows unlocking of the
subtalar varus and need to pronate to provide midtarsal joint, resulting in forefoot hyper-
shock absorption. mobility. The flexors fire earlier and longer than
The limitations of comparing NCSP with RCSP normal in an attempt to stabilise the forefoot.
is that it only provides information regarding These muscles are ineffective at stabilising the
frontal plane motion of the rearfoot. Some forefoot but effective in overpowering the small
authors suggest that sagittal plane motion interosseous muscles, thereby causing hammer-
(Mueller et al1993, Payne & Dananberg 1997) or ing or clawing of the toes.
transverse plane motion (Nawoczenski et al Flexor substitution. A straight contraction of
1995) may be a better indicator of foot pronation. all the lesser toes (with no adductovarus of the
fourth and fifth toes). This can occur in a
supinated foot during late stance phase when the
Longitudinal arch
flexors have gained mechanical advantage over
Arch shape is affected by the rearfoot and fore- the interossei muscles. This digital deformity
foot position, the declination angles of the occurs when the triceps surae muscle is weak
metatarsals, the inclination angle of the calcaneus and the deep posterior and lateral leg muscles try
and the tone and activity of intrinsic and extrin- to substitute for the weak triceps. Flexor substi-
sic muscles. In the past flat-footed people were tution is the least common of the three categories
rejected for the army as it was considered that that create pathological hammer toe syndrome of
their feet would not cope with the demands of the lesser toes.
ORTHOPAEDIC ASSESSMENT 205
Digital formulae should be noted. Usually Table 8.9 Classification of toe deformities
the first toe is longest or the first and the Toe deformity Description
second are of equal length - 1 > 2 > 3 > 4 > 5,
1 = 2 > 3 > 4 > 5. An excessively long toe, e.g. the Hallux abductus Hallux abducted more than
15° from the midline of the body
fourth, may be impacted in footwear, resulting in
toe deformity and secondary lesions. Hallux abductovalgus As above, but the hallux is
also rotated so that the hallux
Deformities of the lesser digits (toes 2-5) can nail faces towards the midline
be described in various ways; unfortunately, of the body
there is no commonly agreed set of definitions. Hallux abductus Distal hallucal phalanx abducted
When assessing and recording the presence of interphalangeus away from the midline of the body
digital deformities, the best approach is to Hallux varus Hallux adducted towards the
midline of the body
describe the plane that the deformity is in - e.g.
sagittal - and whether the deformity is fixed or Hallux limitus Reduced dorsiflexion at the
first MTPJ
mobile. A fixed deformity implies that there is no
Hallux rigidus Complete lack of dorsiflexion
motion at the joint due to soft tissue changes and at the first MTPJ
possible bony ankylosis; such deformities can Hallux flexus Plantarflexion of the hallux at
only be corrected by surgery. Table 8.9 lists and the first MTPJ
defines the main toe deformities. Hallux extensus Dorsiflexion of the hallux at the
first MTPJ
Hyperextended hallux Distal phalanx of the hallux
LIMB-LENGTH INEQUALITY dorsiflexed
Once gait analysis, non-weightbearing and static Hammer toe Dorsiflexion at the MTPJ,
plantarflexion at the proximal
weightbearing examinations have been com- IPJ and either normal position
pleted it may be necessary to assess for limb- or dorsiflexion at the distal IPJ
length inequality. Claw toe Dorsiflexion at the MTPJ,
An LLI can have profound effects on the func- plantarflexion at the proximal
tioning of the musculoskeletal system, affecting and distal IPJs
the spine, sacroiliac and hip joints as well as the Retracted toe Claw toe where the apex of the
toe is not in ground contact
foot. A difference of greater than 1 cm can affect
Mallet toe Plantarflexion at the distal IPJ
normal body alignment. In a sedentary person a
small discrepancy may have a negligible effect Adductovarus fifth Fifth toe rotated so that nail is
facing away from the midline of
upon posture, but if a person increases his level of the body and the toe is adducted
physical activity, the effects of any imbalance (moved towards the midline of
become amplified. the body)
A leg-length discrepancy may be real, apparent Dorsally displaced One or more toes is in a
dorsiflexed position in
or environmental. A real limb-length discrepancy comparison to the other toes
is due to a difference in the length of the femurs
or the tibiae and is common after a hip replace-
ment. An apparent limb-length discrepancy may
be due to a number of factors, e.g. osteoarthritis
coexist. The possible effects of treatment should
of the hip or a scoliosis. In addition, an environ-
be considered prior to commencing treatment
mental limb-length discrepancy may exist; this
(Case comment 8.6).
can be due to uneven footwear or camber of
The presence of a limb-length discrepancy can
roads. It is important to identify the difference in
be observed during gait analysis:
length between the limbs and to differentiate
between a real and apparent discrepancy prior to • shoulder tilt to one side
commencing treatment. It should be noted that a • unequal arm swing
real and an apparent limb-length inequality may • pelvic tilt
ORTHOPAEDIC ASSESSMENT 207
be used for surgery, exposes the patient to need- • The patient stands in the RCSP position
less radiation. (Fig. 8.29A).
Distinction between a real or apparent differ- • The position of the ASISs is assessed to see if
ence can be achieved by measuring each limb they are level.
from a common reference point above the pelvis; • The feet are then placed in the NCSP (Fig.
the xiphisternum is usually used. The metal end 8.29C).
of the tape is placed on the xiphisternum and the • The position of the ASISs is assessed to see if
distance from the xiphisternum to each malleolus they are level.
is measured with the patient (Fig. 8.33B). If • If the ASISs are not level in either the RCSP
values are the same, then the LLI is likely to be and NCSP, and the extent of the discrepancy
apparent. The cause usually lies at the hip or remains the same in RCSP and NCSP, a
pelvis, where a fixed deformity makes the limbs true LLI should be suspected. If the ASISs
appear unequal so that the body compensates by are on the same level in the NCSP but differ
tilting laterally. An alternative method can be for the RCSP, an apparent LLI should be
used with the patient weightbearing: suspected.
B Positioning for
xiphisternum
Figure 8.33 Assessment of a true and apparent leg-length inequality A. Measurement from the anterior superior iliac spine
(ASIS) to the medial malleolus B. Measurement from the xiphisternum to the medial malleolus.
ORTHOPAEDIC ASSESSMENT 209
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Sgarlato T E 1973 A compendium of podiatric biomechanics. and clinical value. Foot and Ankle 13: 462--468
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Subotnick S I 1979 Cures for common running injuries. Heinemann, Oxford
Anderson World, California Williams P L, Warwick R (eds) 1989 Gray's anatomy, 36th
Sussman R E, Piccora R 1985 The metatarsal sesamoid and edn. Churchill Livingstone, Edinburgh
CHAPTER CONTENTS
Introduction 213
----.---------------._--_ _---..
Of the most common disorders, most can affect Table 9.1 Functions of the skin
the lower limb (Gawkrodger 1992): Functions of the skin Specific property
• fungal and other skin infections Barrier properties Physical: thermal/mechanical/
• dermatitis/eczema radiation
• psoriasis Chemical: irritants/allergens/
water loss
• warts Microbiological: infections/
• tumours (benign and malignant). infestations
Sense organ Touch/vibration/pressure/
temperature
SKIN STRUCTURE AND FUNCTION Nociception
Other Thermoregulation and assistance
The skin (or integument) is the largest organ in maintaining blood pressure
system and covers around 1.8 m 2 • Much more Vitamin D and cholesterol
than just an inert wrapping, the skin is a highly production
active organ that fulfils many functions (Table
9.1) which are determined by its structure. The Across the whole body surface, there are con-
skin comprises three layers: an epithelium (epi- siderable regional variations in the skin's struc-
dermis) and a connective tissue matrix (the ture, which in turn dictates its specific
dermis) firmly bound together at the dermo- properties. These local variations may then
epidermal junction (Fig. 9.1); below the dermis influence the microclimate and therefore the
lies the subcutaneous (fat) layer. pattern of organisms. Such variation may also
' t - - - - - - Hair
Skin surface
Epidermis
Apocrine gland
Figure 9.1 Normal skin (not to scale) showing epidermis and dermis and the skin appendages, excluding nail.
216 SYSTEMS EXAMINATION
account for the typical distribution of skin however, in darker skins the melanin granules are
disease. much more dense and less susceptible to degra-
dation as they ascend through the epidermis.
Merkel's cells are specialised nerve endings of
Epidermis unknown origin, possibly a modified ker-
The epidermis (Plate 9) is an avascular structure, atinocyte (McKee 1996) found in the basal layer.
relying on the diffusion of materials across the Their function is thought to be the perception of
dermo-epidermal junction for nutrients and light touch. They are typically only found in
waste disposal. It is principally composed of ker- specific regions of the skin, being numerous on
atinocytes (corneocytes), which make up approxi- the volar (pulp) surfaces of the fingers and toes,
mately 80% of the cells, as well as melanocytes, in the nail beds and the dorsum of the foot.
Merkel's discs and Langerhans' cells. Appendages Prickle cell layer (stratum spinosum). The new
of the epidermis include the nails, sweat glands cells generated by the active basal layer pass into
and sebaceous glands (Fig. 9.1). the stratum spinosum. Here they become more
The epidermis can range in thickness from polyhedral in shape. Internally, large numbers of
around 0.4 to 1.5 mm, depending on the anatom- keratin filaments (tonofilaments) surround the
icallocation; it is divided into four layers. nucleus, whereas externally the cells have abun-
Basal layer (stratum germinativum). For the most dant spinous processes. These are desmosomes,
part, the basal layer consists of a single, undulat- bonding adjacent cells together, and are an
ing layer of cuboidal keratinocytes. The cells important component of the epidermis, as they
within this layer are firmly attached to the resist mechanical stress. In the upper part of this
dermo-epidermal junction (OED by tonofilaments layer are the first lamellar granules. These secre-
which arise from the cytoplasm of the cells linking tory organelles contain many substances such as
into the hemidesmosomes anchored into the DEJ glycoproteins, phospholipids, sterols and lipases.
(Venning 2000). These mitotically active cells gen- Their significance is still being debated but it has
erate the cells of the more superficial layers of the been suggested that these granules are responsi-
epidermis. ble for the barrier function found higher in the
Scattered throughout this layer are specialist epidermis (Freinkel & Traczyck 1985).
cells known as melanocytes. In sun-exposed areas Langerhans' cells make up about 8% of the
(e.g. the face) they may have a ratio of 1 in 4, epidermis and are particularly found in the
whereas on unexposed areas such as the plantar stratum spinosum. They are derived from bone
surface of the foot their numbers may decrease to marrow and are dendritic in structure, forming
1 in 30. These cells are well developed in the epi- no apposition with the cells around them.
dermis of humans as we have a relatively hairless Functionally, these cells are outposts of the
integument. Melanocytes are dendritic cells immune system in the epidermis, recognising
which produce a pigment melanin in specialist and presenting antigens to sensitised T lympho-
organelles known as melanosomes. These cytes and they have an important role in hyper-
melanin granules then pass along the dendritic sensitivity and allergic reactions. Patients with
processes of the cell and are distributed evenly to specific skin diseases may have reduced
adjacent keratinocytes. The melanin forms a pro- numbers of Langerhans' cells.
tective cap over the cell nucleus, its function Granular layer (stratum granulosum). By the
being to limit the amount of harmful ultraviolet time the ascending cells have reached the granu-
radiation reaching the DNA within the nucleus. lar layer they are much more flattened in appear-
Recently, it has been proposed that melanin also ance and are packed with keratohyalin granules.
has a role in mopping up free radicals, which These granules are primarily composed of pro-
arise as a result of inflammation within the skin teins and various types of keratins. As the cells
(Norlund 1994). The amount of melanin pro- move up towards the next layer of the epidermis
duced across various races is roughly equal; the lamellar granules migrate to and fuse with
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 217
the cell membrane, expelling their contents into (scratching, etc.), desiccation and hydration
the intercellular space. The ejected lipid material (Forslind 1994). Drying of the epidermis, central
is then organised into sheets at the junction with to many skin diseases, causes keratinocytes to
the stratum corneum. This forms a hydrophobic shrivel and lose apposition, leading to fissuring,
barrier (an almost watertight seal) along the junc- while excessive hydration strips the lipid barrier
tion of the two layers. In eczematous plaques, from the epidermis.
this process of extrusion is often reduced, leading
to increased water loss through the epidermis
Control of the keratinisation process
and resultant fissuring (Cork 1997).
Horny layer (stratum corneum). As the cell The epidermis can be considered an active
becomes cornified it loses a percentage of its organ, constantly generating keratinocytes in the
water content and has a very flattened appear- basal layer which, in a period of 28-70 days,
ance with around 15-20 layers of keratinocytes. ascend through the superior layers, and undergo
The remaining intracellular water accumulates, a cycle of maturation, keratinisation and desqua-
acting as a plasticiser with intracellular keratin, mation. Regulation of this process is complex,
and causes the cell to swell. This improves the but local factors within the epidermis, dermis
barrier seal to the epidermis and prevents and other tissues can modulate the rate of prolif-
fissuring of the skin under normal tensile forces eration (i.e. inflammatory mediators in the
(Cork 1997). Cells at this level begin a little dermis, tissue growth factors, fibroblasts,
understood pre-programmed cell death with vitamin A derivatives, etc.). Disease processes
most of the intracellular material undergoing may also disturb the normal equilibrium.
breakdown, leaving just the keratin and protein Psoriasis often accelerates epidermal transit time
matrix within these now cornified cells. to as little as 5 days, whereas skin carcinomas
Remnants of organelles and melanin pigment may trigger an uncontrolled proliferation of cell
may be present within the stratum corneum. growth within the epidermis.
Normally, cells in this layer have lost their
nucleus, but it may remain in incompletely kera-
tinised cells (parakeratosis). The deeper cells in
Derma-epidermal junction (DEJ)
this layer are densely packed and so this area is The point at which the dermis meets the epider-
often referred to as the stratum compactum (orig- mis is known as the dermo-epidermal junction.
inally called the stratum lucidum). This is a basement membrane divided into a
As cells ascend the stratum they continue to number of layers, crossed by a complex of
change. Modifications to the lipid membranes of filaments, keratins and proteins that form an
the keratinocytes reduce adhesion, and so cells anchoring surface between the dermis and epi-
become less densely packed. There is also degra- dermis. In areas of greater mechanical stress, to
dation of desmosomes, which further weakens enhance adhesion the dermis makes regular
cellular adhesions until the cells ascend to a level finger-like folds into the overlying epidermis,
where desquamination is likely - the stratum known as dermal papillae. These are comple-
dysjunctum. mented by protrusions from the epidermis into
the dermis, known as rete pegs or epidermal
ridges. This undulation serves to increase the
The skin as a barrier
surface area of attachment and is a major feature
The whole process of cell generation, maturation of the plantar surface of the foot, where mechan-
and degradation strives to create an effective ical stresses can be high. Pathologically, the DEJ
barrier from water loss and from invading organ- is the site of many pathologies and this can lead
isms, allergens or irritants. Many mechanisms to loss of adhesion and the development of blis-
are in place to help fulfil this function. However, tering diseases (i.e. epidermolysis bullosa, der-
the main threats to this barrier include trauma matitis herpetiformis).
218 SYSTEMS EXAMINATION
Occupation. Many occupations expose the skin cells, decrease potentially leave the skin more
to irritants and allergens. The patient may need open to infection and malignant change. Also,
to wear a particular garment or item of footwear any inflammation that occurs as a result of
as part of his job and that is causing the problem. decreased immune surveillance tends to be
It may be that other members of the workforce dampened down; hence, signs of inflammation
are similarly affected. Outdoor workers or may seem less acute. With ageing, the nails may
workers who are exposed to wet or cold will also reduce their rate of growth and often become
have problems particular to them: for instance, thicker and slightly yellow in colour.
skin cancer is higher in those with outdoor occu-
pations.
Social history. It is useful to know who is at Clinical examination
home with the patient as they may be able to Clinical examination of the skin uses a variety of
help with the treatment. Enquiries about senses. Sight is obviously the most important,
smoking should be made when considering cir- but touch and smell are also valuable. Many
culatory problems, and alcohol consumption is trainees unused to dermatological assessment
relevant to a number of skin conditions, partic- will shy away from touching the skin. This is
ularly psoriasis. clearly a natural reaction, but must be overcome
Family history. A number of skin conditions in order to assess the area fully. Observation is an
run in families, e.g. palmoplantar keratoderma. important stage in examination and it is impor-
Recessively inherited diseases may skip genera- tant to follow a particular pattern:
tions, so information is required about distant
relations too. • general distribution (localised, widespread or
regional)
Recognising the norm in the assessment of skin is • individual lesion morphology
essential. Normal variations are seen due to race • assessment of other structures
and the normal ageing process. Any given popu- • assessment of the nail
lation will include a significant range of skin • assessment of the sweat glands.
colours. Lesions that appear red or brown on
white skin, for example, often appear black or
General distribution
purple on pigmented skin and mild redness may
be masked completely. In addition, some condi- When a widespread eruption is suspected, it is
tions have a distinct racial predisposition (e.g. important to look and ask about all of the skin.
melanoma in Caucasians). However, across all Patients may often be reluctant to discuss other
races, normal skin will not be different from sur- areas or simply not connect them to the current
rounding skin and will feel smooth. condition. For example, scalp psoriasis can
As the skin ages, it appears more translucent mimic dandruff. A patient concerned with scaly
with irregular pigmentation. Thinning of the skin plaques on his knees may not connect the two,
occurs at all levels, including the subcutaneous particularly if the dandruff has been present for
layer, which may be evident on the plantar area some time. Many disorders have a typical pattern
of the foot. Natural turgidity and elasticity seen or predilection for specific sites, although it
in younger individuals is lost. Pinching of the should be remembered that patterns could occa-
skin results in 'tenting', as the skin fails to return sionally vary from the norm. Eczema has a
to its natural shape. As a result of decreased common pattern - affecting the flexor surfaces of
sweat and sebum production, the normal skin the arms and legs along with the face. Symmetry
surface barrier is compromised and so is more of the eruption should also be recorded as this
prone to the effects of drying and irritation. A usually denotes an endogenous condition. Table
reduced immune response as the numbers of T 9.2 highlights examples of the distribution pat-
and B lymphocytes, along with Langerhans' terns of various dermatoses.
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 221
------_._---_._----------
Table 9.2 Common patterns of skin disorders • Koebner's phenomenon, i.e. warts, psoriasis
Condition Typical distribution pattern
(Plate 10), lichen planus, molluscum
contagiosum.
Atopic eczema Antecubital and popliteal fossa,
face, neck, hands Note that some disorders may have a number of
Contact dermatitis Hands, face, feet configurations. Koebner's phenomenon is where
Psoriasis Extensor surfaces of knees and skin lesions of a specific disease may appear at a
elbows, scalp, back, nails site of trauma which was previously unaffected.
Lichen planus Flexor surfaces of wrist, ankles, The edge of the lesion should also be inspected. Is
oral cavity, genitalia it discrete or ill-defined? For example, psoriasis
Erythema nodosum Anterior surfaces of shins and fungal infections have much more marked,
well-defined edges than eczema. Surface contour
should also be noted (Fig. 9.3).
Individual lesion morphology Colour. To interpret the skin colour of lesions,
good lighting is essential, as temperature and
Individual lesions should be assessed. A magni-
dependency will modify appearances. Rashes or
fying glass is useful along with good lighting.
lesions that are pink, purple or red will be due to
Initially it is important, if there is more than one
blood. If the blood is within vessels gentle pres-
lesion, to describe the arrangement (Fig. 9.2).
sure will whiten or blanch the lesions - this is
This can include:
erythema, and can be viewed best through a
• annular (ring-like), i.e. psoriasis, lichen glass slide or tumbler. If it is not possible to
planus, granuloma annulare blanch the lesion, this may be due to extravasa-
• nummular (round, coin-like), i.e. nummular tion (loss of blood constituents into the skin) or
eczema pigmentation due to melanin.
• discoid (disc-like), i.e. eczema, psoriasis Touch. It is possible to determine surface
• reticulate (net-like), i.e. livedo reticularis changes in texture and whether the skin disease
• arcuate (curved), i.e. contact dermatitis relates only to the surface of the skin or whether
• grouped, i.e. insect bites, dermatitis it relates to the structures beneath. Light touch is
herpetiformis required to perceive superficial changes (i.e.
texture of a surface lesion), whereas progressively
o Annular
Flat-topped
Nummular ~ Pedunculated
o 0 0 0 0 0 0 Linear ~ Dome-shaped
Grouped
~ Umbilicated
°A~
oW· Satellite
o 0 • Verrucous
... e
o
Arcuate Spire (acuminate)
Figure 9.2 The various configurations of lesion patterns. Figure 9.3 The different surface contours of lesions.
222 SYSTEMS EXAMINATION
deeper pressure will reflect changes to the lower Table 9.3 List of primary skin lesions
structures in the dermis and subcutaneous layers. Term Description and example
Oedema (collection of fluid within the tissue)
feels flocculent under the fingers. Typical surface Erythema Redness, often due to inflammatory
response
changes include a soft moist texture due to exces-
sive sweating or a dry and roughened texture due Macule Flat, differently coloured, e.g. freckles,
vitiligo
to a lack of sweating, i.e. anhidrosis. Deeper
Papule Palpable, solid bump in skin, e.g.
lesions may be described as hard, nodular, lichen planus
mobile, soft, etc.
Nodule Palpable, deeper mass than a papule,
Odour. Skin odour is a neglected aspect of skin e.g. ganglion, rheumatoid nodule
examination but is useful. Colonisations of Plaque Elevated, disc-shaped area of skin
pseudomonas, staphylococcus, or diphtheroids over 1 cm in diameter, e.g. psoriasis
have distinctive smells (microbiology may help to Tumour Large mass over 2 cm in diameter,
confirm this) as do odours associated with exces- e.g. lipoma
sive sweating (bromhidrosis) and incontinence. Cyst Subdermal, fluid-filled fibrous swelling,
When examining individual lesions, clear loosely attached to deeper structures,
e.g. dermal cyst
descriptions using well-recognised terms are
essential. This allows good communication Weal Large oedematous bump, e.g. insect bite
between health professionals. In dermatology, Vesicle Tiny, pinprick-sized collection of fluid,
e.g. mycosis, pompholyx
there are many descriptive terms: some obvious,
others less so. Familiarity with this terminology Bulla Serous fluid/blood-filled intraepidermal or
dermoepidermal sac, e.g. bullous
will ensure good inter-professional communica- pemphigoid
tion. Skin lesions can be classified as to whether Pustule Vesicle or bulla filled with pus, e.g. acne,
they are primary or secondary. Primary lesions pustular psoriasis
arise due to the initial effects of a condition; sec- Burrow Short, linear mark in skin visible with
ondary lesions evolve from or as a complication magnifying lens, e.g. scabies
of primary lesions. The distinction between Ecchymosis Large extravasation of blood into the
primary and secondary is not always clear; some tissues, i.e. bruising
lesions can be classed as primary or secondary Petechia Pinhead-sized macule caused by blood
(Tables 9.3 and 9.4). Some of the more common seeping into skin
terms used in assessing the surface of the skin are Telangiectasiae Permanently dilated small cutaneous
blood vessels
described below.
Scaly. Normally the skin sheds skin cells indi-
vidually or in small clumps. This is imperceptible
to the eye. If the skin is weathered or diseased, cal appearance and history. While avoiding
skin shedding becomes abnormal, the clumps of hurting the patient, try to remove the crust as this
skin become larger and appear as flakes or scales. often obscures the true pathology. Crusting is a
These scales may be small, as in the dryness common feature in eczema.
(xerosis) of atopic eczema, or large, as in Hyperkeratosis and lichenification. If keratin is
ichthyosis. Scratching the surface of skin is abnormal, it forms thickened areas as shedding
helpful as it accentuates scaling and may help fails. These can be localised, appearing as horns
with diagnosis. Psoriasis will demonstrate pin- on the skin and usually reflect a viral or neoplas-
point bleeding when scratched and the scaling tic process. Sometimes the surface can be papillo-
will become more pronounced (Auspitz sign). matous (warty). The areas of thickening can be
Crusting and exudation. When the skin is more diffuse, e.g. chronic plantar eczema or
injured or infected, it bleeds, oozes serum or dis- corns. Such areas are less flexible and will often
charges pus. This is an exudate; it dries to form a crack, forming deep fissures. Lichenification is a
crust, which is distinguished from scale by clini- reaction of the skin to chronic rubbing or scratch-
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 223
--------_._----------------------_._-
Table 9.4 List of secondary skin lesions Macules and patches. These are localised
Term Description and example
impalpable areas of colour change: macules are
less than 1em in diameter and patches are greater
Scale Flake of skin, e.g. mycosis, psoriasis than 1 cm.
Crust Scab, dried serous exudates, e.g. acute Papules, plaques and nodules. A papule is any
eczema lesion less than 1 em in diameter that rises above
Excoriation Scratch marks, e.g. pruritus the surface of the skin. A nodule is larger than
Fissure Crack in dry or moist skin 1 em in diameter, but otherwise similar to a
Necrosis Non-viable tissue papule, and usually due to pathology within the
Ulcer Loss of epidermis; may extend through dermis. A plaque is a raised lesion that is wider
the dermis to deeper tissue, e.q. than it is thick and often represents epidermal
venous ulcer pathology.
Scar Fibrous tissue production post-healing Vesicles, bullae, pustules and abscesses. Small
Keloid Excessive production of fibrous tissue blisters less than 1 cm are called vesicles. Blisters
post-healing larger than 1em are called bullae. Pus-filled vesi-
Striae Lines in skin that do not have normal cles or bullae are pustules, large pustules are
skin tone, e.g. striae tensae in
pregnancy, Cushing's disease
abscesses.
Weal. These are transient papular or plaque-
Purpura Purplish lesions which do not blanche
under pressure, e.g. vitamin C like swellings of the skin due to dermal oedema
deficiency and frequently seen in urticaria.
Urticaria 'Nettle rash', e.g. drug eruption, allergy, Scars. These can be macules, papules or
heat plaques and are a feature of repair following
Lichenification Patchy 'toughening' of skin, e.g. chronic dermal injury. A glossary of terms can be found
eczema in Tables 9.3 and 9.4.
Haematoma Blood-filled blister
Sinus Channel that allows the escape of
pus or fluid from tissues Assessment of other structures
When examining the skin, other structures such
as the nails, hair and mucous membranes may
ing and involves the whole epidermis. The add clues to the diagnosis. For example, lichen
affected area of skin thickens and the skin mark- planus commonly causes lesions in the mouth;
ings become more pronounced. It is a common this may be an important finding in differentially
feature of atopic eczema and usually occurs on diagnosing it from other conditions such as
the flexures. eczema and psoriasis. Palpation of the lymph
Excoriations, erosions and ulcers. Excoriation nodes is important in patients with suspected
means scratch and is usually a feature of itching skin malignancy.
or, less commonly, pain. It may represent under-
lying skin pathology such as scabies or eczema or
Assessment of the nail
indicate disease elsewhere, e.g. renal or hepatic
failure. Erosions are partial-thickness breaks in Inspection of the nails should be included as part
the surface of the skin caused by physical injury of the main dermatological assessment. The nail
including excoriation or where blisters have has evolved as a rigid structure to improve dex-
broken. An ulcer is an area of full-thickness skin terity but in the foot the nail is purely a protective
loss, usually covered by exudate or crust. plate overlying the deeper structures and acting
Atrophic. The surface of the skin is depressed as a counter pressure to the volar tissues (Baran
and blood vessels are visible beneath. It may be et al 1996). The nail unit (Fig. 9.4) is well pro-
due to atrophy of the epidermis or dermis. The vided with a rich neurovascular supply and, as a
skin is often pale and wrinkled. result, is sensitive to internal changes, often man-
224 SYSTEMS EXAMINATION
Vertical collagen
fibres in dermis
PHALANX
Intermediate nail
matrix
Limit of lunule
ifesting these subtle changes in the nail structure. Table 9.5 Glossary of nail conditions
External factors too, such as trauma, can modify Condition Definition
nail shape. Therefore, a proper footwear assess-
ment should be undertaken, to complete the clin- Onychauxis Thickening of the nail plate,
usually due to trauma
ical picture, when looking for reasons for
Onychogryphosis Thickened nail with a distortion
changes in nail shape, colour, etc. A glossary of in the direction of growth
the main terms used to describe nail changes can Onycholysis Separation of the nail from the
be found in Table 9.5. nail bed, distal to proximal
Key aspects of examination should include Onychomadesis Separation of the nail from the
assessment of the following factors. nail bed, proximal to distal
Pattern of affected nails. It is important to Onychocryptosis Ingrowing toe nail
always assess finger nails as well as toe nails and Involution An inward curvature of the
note any findings. Often finger nails may show lateral or medial edges of the
nail plate, towards the nail bed
changes more readily (i.e. clubbing). Where only
one or two nails are affected, or one foot, local Splinter haemorrhage Longitudinal, plum-coloured linear
haemorrhages (around 2 mm in
causes should be suspected, whereas nail length) under the nail plate
changes in all digits in both feet and hands sug- Paronychia Inflammation of the tissues
gests a systemic or internal cause. On the foot, surrounding the nails
the length or the position of the toes may give Onychomycosis Fungal infection of the nail plate
clues to local nail abnormalities. Typically, the Chromonychia Abnormal coloration of the nail
longest toe may show nail changes as a result of tissue
interaction with footwear. Koilonychia Transverse and longitudinal
Rate of nail growth. There is great variation concave nail dystrophy which
gives a spoon-shaped
between individuals in the rate of nail growth. appearance
The average rate for a finger nail is 0.1 mm/ day Clubbing Increased longitudinal curvature
(or 3 mm/month), whereas toe nails grow at a of the nail plate with enlargement
half to a third of this rate (Zaias 1980). of the pulp of the digit
Consequently, a normal finger nail will grow Beau's lines Transverse ridging of the nail
completely in about 6 months, whereas a toe nail plate seen as the result of a
temporary cessation of nail growth
will take 12-18 months. Such information is
ASSESSMENT OFTHE SKIN AND ITS APPENDAGES 225
useful to determine the approximate time of Table 9.6 Causes of nail spooning and clubbing
events: e.g. the time of trauma to a nail, the likely Koilonychia (spooning) Clubbing
clearance time of a haematoma. Most systemic
Idiopathic Idiopathic
disorders lead to a decline in the rate of nail
growth but a few may have the opposite effect Hereditary Hereditary
(psoriasis, hyperthyroidism, nail trauma and Iron deficiency anaemias Lung disease:
drugs). bronchiectasis
Insulin-dependent diabetes lung cancers
Shape of the nail plate. The breadth of the nail
abscess
matrix and length of the nail bed normally Physiologically thin nails lung infections
dictate the shape of the nail plate (finger nails (i.e. children) fibrotic lung disease
being rectangular and toe nails, quadrangular). Psoriasis emphysema
asthma in childhood
The contour of the underlying phalanx, and toe Alopecia
position, may modify this. The most commonly Cardiovascular disease:
occurring nail shape alteration in the toe nail is Lichen planus congestive heart failure
subacute bacterial
transverse over-curvature or involution (pincer Raynaud's disease endocarditis
nail). This is typically seen in the nail plate of myxoid tumours
Scleroderma/systemic congenital heart disease
the hallux and is often accompanied by pain sclerosis
when direct pressure is applied to the nail. If Alimentary disease:
Renal transplant ulcerative colitis
there is an underlying subungual exostosis
Thyroid disease Crohn's disease
(Plate 11), lifting of the distal nail plate occurs, gut cancers
often accompanied by pain. Frequently seen in Acromegaly
Endocrine:
young adults, a lateral X-ray will differentiate active hepatitis
Occupational (immersion
between this and other causes of painful nails in oils, acid and alkali) auto-immune thyroiditis
(e.g. onychocryptosis). Internal causes of nail acromegaly
shape alterations include koilonychia (spoon- Other:
ing) and clubbing: their causes are listed in polycythaemia
Table 9.6. cirrhosis
malnutrition
Colour of the nail plate and bed. Changes in nail
colour (chromonychia) may arise as a result of
external or internal factors. Finger nails, in par-
ticular, are vulnerable to occupational causes Surface texture. The surface of the nail is nor-
such as chemical agents. Colour change can mally smooth but changes may occur. Subtle
occur on the surface of the nail, within the nail longitudinal lines may arise with age or as a
plate itself or below in the underlying nail bed or result of minor trauma, although specific diseases
lunula. The use of a powerful pen torch or laser may accentuate their appearance (rheumatoid
pointer shone in the pulp of the digit, through arthritis, peripheral vascular disease and lichen
the nail plate, can help to isolate the source. Table planus). Solitary lines or ridges may signify a
9.7 lists the more common causes of chromony- tumour within the matrix or be the result of a pre-
chiao Splinter haemorrhages are plum-coloured vious paronychial infection. Transverse lines are
streaks of about 3-4 mm seen running longitudi- common in the hallux as a result of repeated
nally under the nail plate. These are the result of minor trauma from footwear. When transverse
extravasation of blood between the nail bed and lines affect the majority of nails simultaneously
plate. Typically they are caused by trauma, they are known as Beau's lines and may repre-
though, if the majority of nails are affected, dis- sent a sudden period of illness. By noting their
orders such as rheumatoid disease, vasculitis or distance from the cuticle, a rough calculation can
skin diseases (psoriasis and eczema) should be be made as to the time of the illness. Pits are
suspected. small erosions in the nail found on the surface of
226 SYSTEMS EXAMINATION
Table 9.7 Causes of nail discoloration (chromonychia) Onychomadesis is the less common of the two
Discoloration Cause
conditions. Proximal detachment occurs most
frequently due to acute bacterial infection of
Nail bed the proximal nail fold or an acute skin eruption
Brown Idiopathic, subungual wart affecting the nail bed such as a blister or psoriatic
White Anaemia, cirrhosis, renal disease plaque.
Green Pseudomonas infection, blistering diseases Nail thickness. Thickening of the nail (ony-
Yellow Subungual corn, wart or exostosis, jaundice chauxis) is probably the most commonly
Brown/black Haematoma
observed toe nail condition. Long-term trauma to
Lunula the nail plate can lead to hypertrophy of the nail,
Red Congestive heart failure, alopecia often with a brown discoloration. Typically, the
Brown/black Haematoma, melanoma, melanonychia condition affects the hallux or longest toe as a
result of footwear interaction. Other conditions
Nail plate
such as fungal infections, psoriasis and lichen
White Onychomycosis, trauma, onycholysis planus may also lead to onychauxis. Onycho-
Yellow Nicotine or urine staining, yellow nail
syndrome, jaundice
gryphosis is a more severe thickening of the nail
Brown Mycotic infection, onychauxis, plate often with gross deformity and a deviation
onychogryphosis, shoes dyes, melanoma in the direction of nail growth. Pachyonychia
congenita is a rare inherited disorder hallmarked
by congenital thickening of the nail plate.
the nail plate. When only a few nails are affected Periungual changes. The periungual tissues
it is considered a variant of normal but multiple seal the nail unit from damage but may show
nail involvement is seen in a number of skin dis- disease themselves. These tissues may be
eases such as psoriasis, lichen planus, eczema breached by inappropriate nail care or prolonged
and alopecia. immersion, e.g. water, chemicals, etc., leading to
Loosening or shedding of the nails. Onycholysis infection or chemical irritation and thus parony-
is the detachment of the nail from the bed in a chia. Acute paronychia is more commonly asso-
distal to proximal fashion, whereas onychomade- ciated with infection, whereas the chronic variety
sis occurs in the opposite direction. The aetiology is often confined to the hands, most often as a
for both conditions is similar (Table 9.8) but it is result of irritant reactions. Other periungual con-
most frequent as the result of trauma, particularly ditions include tumours:
overzealous nail care or fungal infection. The loos-
ened area is usually white, although in some • Periungual warts - usually asymptomatic,
disorders the area may adopt a different colour. easily diagnosed by their appearance.
• Corns/callus - found within the nail sulci-
may lead to pain on compression of the nail
Table 9.8 Causes of nail shedding
plate. Nail edges may be thickened or
Level of separation Cause involuted.
• Subungual exostosis - diagnosed by X-ray,
Onycholysis Trauma (nail surgery, nail picking)
may lead to lifting of the nail plate.
Peripheral vascular disease
Psoriasis
• Fibromas - associated with tuberous sclerosis.
Rheumatoid arthritis • Malignant tumours - basal cell carcinoma,
Subungual tumours squamous cell carcinoma, subungual
Eczema melanoma.
• Glomus tumours - causes of extreme pain
Onychomadesis Nail matrix infection or inflammation
when exposed to slight trauma or changes in
Subungual blistering
temperature, often visible by digital illumi-
Drugs
nation. Rarely are they found in the toe.
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 227
Microsporum species are the main types excised in their entirety, whereas larger lesions
detectable by this method (fluorescing green), need to have a carefully placed sample taken that
but other pathogens also fluoresce, notably ery- includes both normal and abnormal skin. It is
thrasma (caused by Propionibacterium minutissi- good practice to refer suspicious pigmented
mum and fluorescing coral pink). lesions for expert assessment rather than biopsy.
Mycology. Fungal disease usually affects the The three main biopsy techniques are punch,
most superficial aspects of the skin and so is easy shave and ellipse. Punch biopsies are a simple
to remove for assessment by scraping. A 15 blade method of obtaining tissue for histology which
is ideal to do this. After carefully scraping across does not require much technical skill. The punch
the skin, the scale is collected either on a glass is similar to an apple core and comes in a range
slide or onto a small piece of black paper. Where of sizes from 2 mm to 7 mm diameter. The punch
possible, if blisters are present, the whole roof will penetrate the skin to a maximum depth of 7
should be removed. The undersurface of the or 8 mm and so is useful for epidermal and
blister is then scraped to remove the fungal superficial dermal pathology. Shave biopsies are
debris onto a glass slide; the remaining skin is a simple method of getting biopsy specimens,
sent for culture. With nails, a clipping from the effective for assessing superficial skin disease
most proximal part of the affected nail is useful, using a razor or scalpel blade. Ellipse biopsy is
along with any subungual debris. Potassium useful for the removal of small lesions and for
hydroxide (20%) when applied to the sample on larger areas.
the glass slide will render the sample transparent
after 20 minutes or so, thus revealing the under-
Patch testing
lying fungal elements. The scrapings are then
sent for expert examination and culture, after Allergic contact dermatitis is a common problem
placing the sample onto folded black card. More on the lower leg, particularly associated with
than sufficient scrapings should be sent when- footwear, medicated dressing and topical thera-
ever possible to ensure a representative result. pies. Patch testing assesses this by applying pos-
Bacterial and viral culture. Infection with bacte- sible allergens to aluminium discs, which are
ria should be considered wherever inflammation placed onto the skin of the back and left in place
or pus is present. A swab is taken by rubbing it for 48 hours. The discs are removed and the skin
onto the affected area; if the lesion is a blister or is assessed on the day and 2 days later. Positive
pustule, the surface should be broken first with a reactions appear as red raised areas within the
sterile needle. The swab is moistened with some discs; sometimes the reactions can be very strong,
of the culture medium when assessing dry resulting in erosions and blisters.
lesions. Biopsy tissue can also be cultured. It is
important that this does not dry out, so it is sent
either in sterile water or within the culture
Recording of the assessment
medium of a swab. Viral specimens need a viral At the end of the skin assessment it is important
transport medium. Contact the microbiology lab to ensure accurate recording of the history and
before taking the sample, as some labs will take examination for a number of reasons:
the specimens themselves.
• to ensure good record keeping
• to act as a baseline, in case of any changes in
Histological assessment the progression of a condition
• to facilitate good communication with other
Clinical examination of the skin only allows a
medical professionals.
view of the surface morphology, whereas
histopathology is an easy and valuable adjunct The use of colour photography and video
whenever diagnosis is in doubt. Under local equipment may also add objective, recorded evi-
anaesthesia, small suspicious lesions are usually dence and allow the patient with poor mobility /
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 229
eyesight to visualise and appreciate their skin Table 9.10 Causes of hyperkeratosis
problem.
Cause Clinical features
Acquired
Assessment of corns and callus Palmoplantar keratoderma Normally arises in patients
from their twenties, in
Corns and callus are a discrete form of hyperker- patterns described above
atosis distinct from the secondary lesions seen Keratoderma climactericum Yellow/brown papules,
with other dermatological disorders. Callus which then coalesce to form
plaques (callosities) are hard, dense, yellowish thickened plaques across
the soles of menopausal
plaques of hyperkeratotic tissue usually found on women. Fissuring is
the plantar surface of the foot, whereas corns common
appear as darker, harder, invaginated areas of Reiter's disease Red hyperkeratotic rash
hyperkeratosis present either alone or within a may occur on the soles
called 'keratoderma
callus plaque. blennorrhagica'. Difficult to
Patients with calluses and/ or corns complain distinguish from pustular
of a number of symptoms, ranging from cosmetic psoriasis
irritation to severe pain affecting gait. Symptoms Chronic dermatitis Hyperkeratotic lesions may
include a stabbing pain when walking, which be observed accompanied
by fissuring and crusting
may persist when resting or subside into a dull,
soft tissue ache. Callus usually is reported as a Pustular psoriasis Yellow/brown sterile
pustules occur with a
stinging, burning sensation, which is worse just hyperkeratosis of the palms
after the start of rest and on resuming weight- and soles, typically in older
bearing. An illustrative description of callus patients
being like 'walking on stones' may be given. An Syphilis Distinctive copper pink
papules may occur on the
erythematous 'halo' may be evident around sole with hyperkeratosis
either lesion type.
Lymphoedema Dirty brown lesions may
Calluses and corns appear to form in response occur over oedematous
to over-prolonged and excess mechanical stresses areas of the foot and lower
(such as intermittent pressure, shear and friction) leg
from ground reaction forces on the foot and Hypothyroidism A mild hyperkeratosis may
footwear during gait. occur on the soles but
resolves with treatment
Corns and callus are always found on areas
Tinea pedis Hyperkeratosis may occur
exposed to mechanical stress and often in a as part of the eruption
pattern which relates to the biomechanics of foot
230 SYSTEMS EXAMINATION
function. The few surveys undertaken into the • diffuse callus beneath the third and fourth
incidence of callus and corn lesions on the foot metatarsal heads
are in general accordance as to their epidemio- • callus solely beneath the second, first and
logical features (Gillet 1973, Merriman et al1986, fifth metatarsal heads
Springett 1993, Whiting 1987). The commonest • dorsal corns on the fifth toes followed by the
sites and lesions include (Fig. 9.5): fourth, third and second
• interdigitallesions between the fourth/ fifth
toes followed by first/second and
101-2 third / fourth toes.
(2nd) 102-3
(4th) Sex incidence ratio is between 1 :2 and 1 :4 male
103-4 to female, with mode age of symptomatic onset
(3rd)
.... 104-5
between 40 and 70 years. The incidence decreases
·••·(1st) with reduced weightbearing and shoe wearing.
Oiffuse callus The site of the lesion, an indication of its
severity, size, texture (hard and glassy or soft),
Apices of duration and stimulators/ exacerbators, e.g. a
Site of seed toes particular activity and/or pair of shoes, should
corns be noted, along with colour differences and
lesion contours, bulk, depth and width.
Common site of It is assumed that the maceration which
seed corns appears as a milky yellow region under a callus
plaque or corn is due to excess trauma and, as a
Plantar aspect result, water is squeezed from the viable layers
of heel of the epidermis into the lower keratinised
layers of the stratum corneum. The features of
A Plantar aspect maceration and extravasation may be consid-
ered as clinical indicators of marked mechanical
2nd toe stress (Plate 12). Suitable management of these
3rd toe 2nd lesions is urgently required to prevent tissue
3rd breakdown and ulceration.
4th toe
2nd 0i'l:--- Subungual
5th toe corn
1st Types of corn
Seed corns. The aetiology of seed corns is not
clear. The empirically proposed association with
tension stress has neither been proved nor dis-
puted. These lesions appear similar in structure
and biochemically to other mechanically induced
hyperkeratoses. Unpublished work using high-
powered liquid chromatography (HPLC) shows
that they are not plugs of cholesterol as previ-
ously thought but, in common with other hyper-
keratoses, have a high cholesterol content
compared with normal plantar skin (O'Halloran
B Dorsum 1990). Seed corns tend to occur at the margins of
Figure 9.5 The common sites for corns and callus weightbearing areas of the plantar aspect of the
formation on the feet (Merriman et al 1987). foot either singly or as disperse clusters.
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 231
Hard corns. A hard corn (Plate 13) appears as a Other causes of hyperkeratosis. Palmoplantar
darker patch within the epidermis, often with a keratodermas (PPK) are a complex group of rela-
callus covering. Texturally it is hard, glassy and tively rare disorders which are difficult to clas-
dense when touched with a scalpel. When enucle- sify. Historically, such conditions were named
ated, a classic corn nucleus appears as a cone, purely on clinical and histological appearance,
although they may be any shape or multinucle- which has led to a confusing array of nomencla-
ate. Under greater trauma the contents of the ture (Ratnavel & Griffiths 1997).
papillary capillaries may be extruded into the The consistent feature within this group of dis-
epidermis as a brown-black stain (extravasation). eases is hyperkeratosis of the palms and soles.
A corn forming over a bursa may be associated Unlike normal callus, the amount is much
with the formation of a sinus into the bursal sac; increased with a rapid return rate following
infection may result. debridement. Typically, lesions bear no correla-
Vascular corns. When the skin is made translu- tion to any weightbearing patterns. Palmar
cent by application of water, alcohol or oil, clini- lesions may range from one or two minor patches
cal signs below the surface of the lesion become to complete involvement. The majority of these
apparent. Intrusions of vascularised dermal diseases are hereditary but spontaneous cases
tissue into the epidermis can be seen in vascular can arise. Clinically, PPK may be categorised into
corns and, if cut, this vascular tissue bleeds pro- one of four distinct patterns of disease:
fusely. These lesions usually occur at sites of
• diffuse PPK - diffuse hyperkeratosis across
excess mechanical stress, may have a relatively
the palms and soles (usually sparing the arch)
long history and may be painful on direct pres-
(Plate 14)
sure. These features suggest that the lesion is a
• focal PPK - discrete patches of hyperkeratosis
vascular corn rather than a foreign body or wart.
with normal skin in between
Some practitioners make a distinction between
• punctate PPK - numerous punctate corn-like
vascular and neurovascular corns; others con-
lesions spread across the palms and soles
sider that they are one and the same.
• PPK with ectodermal dysplasia - PPK of any
Soft corns. Soft corns occur interdigitally and
variety, with accompanying features of
appear as soft, soggy epidermal masses (macer-
ectodermal abnormalities (e.g. hyperhidrosis,
ated tissue) which can easily blunt the scalpel
neurological or dental malformations).
blade. Pain is a frequent complaint. The condi-
tion appears to be caused by poorly fitting Many other skin diseases may lead to the
footwear, disease processes affecting the skele- development of hyperkeratosis, which often
ton, e.g. rheumatoid arthritis, or biomechanical takes on a different texture from the mechanically
anomaly, e.g. excess pronation where the toe induced type. For example, in psoriasis the skin
tissues are compressed and sheared in ill-fitting may flake off with a scalpel and bleed due to mal-
footwear. formation of the epidermis (Au spitz sign). Callus
Fibrous corns. These arise from long-standing associated with ichthyosis tends to be thick and
corns and involve the presence of fibrous tissue tough and there will be evidence of the condition
in the dermis below the corn. The affected tissues on other body sites.
have an altered biomechanical behaviour: they
appear more firmly attached to deeper structures
than normal. Shear stresses occur at the tissue
BLISTERING DISORDERS
interface and, as this tissue is unable to dissipate The term blister is used to describe any fluid-
stress as efficiently as normal tissue, there may be filled lesion which may occur as the principal
a perpetuation of what appears to be chronic irri- feature of some relatively rare dermatological
tation of tissues, causing further fibrosis to disease or as a feature of more commonly seen
develop. The precise aetiology of these lesions is disorders (Table 9.11). Blisters can develop at a
not clear. number of levels in the skin:
232 SYSTEMS EXAMINATION
Table 9.11 Main causes of blistering on the lower limb acquired form, akin to EB simplex, which nor-
Disorders with blistering Disorders where blistering may
mally affects middle-aged patients with a similar
as the principal feature occur as a secondary feature pattern.
Epidermolysis bullosa Friction - most common Pemphigus is a relatively rare blistering disor-
Bullous pemphigoid
variety seen on the feet due der seen in middle age. Lesions tend to be
to pressure and shearing forces intraepidermal (which rupture easily) and have
Pemphigus
Fungal and bacterial infections an insidious onset often without a history of
Dermatitis herpetiformis (e.g. tinea and erysipelas)
(rare below the knee)
trauma. Unlike EB, pemphigus rarely affects the
Diabetes - an uncommon feet but oral lesions may be present. In both con-
complication associated with
hyperglycaemia ditions, Nikolsky's sign may be present - the
Thermal injury (e.g. burns,
ability to raise a blister when firm finger pressure
cryosurgery) is applied across the affected skin.
Eczema Bullous pemphigoid (Plate 15) is distinctive
Erythema multiforme
in that it usually affects the over-sixties with
large tense subepidermal blisters emerging on
Severe sunburn/photosensitivity
urticated skin, including the foot. Mucous mem-
brane involvement is not a common feature.
Typically seen on the extensor surfaces but
• Superficial. These blisters occur in the
rarely below the knees is dermatitis herpeti-
stratum corneum and are associated with
formis. Blisters are typically small and grouped,
infections, e.g. tinea pedis. Superficial blisters
with the appearance of herpetic lesions. Pruritus
are more prone to rupture, leaving open
is a common early symptom. Unlike pemphigus,
erosions which may be complicated by
oral lesions are not observed, but the majority of
secondary infection.
sufferers have also coeliac disease of the jejunum.
• Intraepidermal. These occur in the lower
layers of the epidermis, usually the stratum
spinosum, and are associated with, for
example, acute eczema and viral vesicles.
INFLAMMATORY CONDITIONS OF
THE SKIN
• Subepidermal. These occur at the
dermal-epidermal junction and are Eczema
associated with, for example, epidermolysis
Eczema is a descriptive term encompassing a
bullosa.
wide variety of inflammatory diseases, many of
Differential diagnosis requires a thorough which are pertinent to the lower limb. Clinical
history and examination (including information features vary greatly between each form of
on concurrent illness, drug therapies and family eczema and so are presented separately.
history) along with the general pattern and dis-
tribution of the disease.
Subtypes of eczema
Family history is a key feature in epidermoly-
sis bullosa (EB), an inherited group of disorders Atopic dermatitis. This increasingly common
where the skin reacts to minor trauma by blister- form of eczema presents at any age but is most
ing; hence the feet are commonly involved. The common in childhood. Itch is the main
spectrum of the disease ranges from EB simplex symptom, with rash localised to the flexures.
(minor blistering of the hands and feet with The itching and subsequent scratching can be
minimal scarring and little nail involvement) to a severe. In some patients dryness and scaling is
potentially lethal recessive dystrophic form (with the major feature. Patients often have other
more widespread blisters and scarring). As the allergic diseases such as hay fever or asthma.
disease is inherited, the onset is usually in child- The signs are all manifestations of scratching
hood. Epidermolysis bullosa acquisita is an and rubbing. First, the skin roughens and
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 233
reddens; with continued scratching the skin Lichen simplex. In this condition, patients
becomes broken and later infected. The usual usually complain of one or two itching patches. It
pathogen is Staphylococcus aureus, which pro- frequently occurs on the medial aspect of the
duces golden weeping and crusted skin. Later, ankles and lateral calves. The itching may be
the skin thickens with accentuation of the very severe and keep the patient awake at night.
normal skin folds (lichenification), with fissures The skin reacts to the scratching and rubbing by
developing where the skin is less flexible. becoming thickened and lichenified (see above).
Asteatotic eczema. This is a common form of Sometimes the lesions resemble plaques and
eczema usually seen in the elderly, especially other times nodules. The lesions are usually pink
those in institutional care. It results from low or brown and may be mistaken for lichen planus
humidity, poor rinsing of soaps or detergents or or psoriasis (see below).
over-vigorous washing. The usual symptom is Stasis dermatitis (venous eczema, gravitational
soreness and itching, most frequently on the eczema). This form of eczema affects the lower
shins. The skin is scaly, pink and the surface legs. It usually occurs in patients with venous
broken in a crazy paving pattern. disease (previous varicose veins or deep venous
Discoid eczema. Discoid eczema is a very thrombosis). Patients will complain of itching or
localised form of eczema. It presents as multiple, soreness and may have a history of previous
isolated, and coin-shaped lesions. Usually venous ulceration. The skin is red, scaly and
patients will complain of itching and, because of weeping, usually in association with an ulcer or
the shape of the lesions, assume they have a area of varicosity. The underlying skin may feel
fungal infection. On examination, the lesions are firm and be discoloured blue brown with previ-
red, scaly and superficially infected with golden ous leakage of blood into the skin. Occasionally,
crusting. Patients generally have dry skin or a the rash can spread beyond the areas of venous
previous history of eczema (Case history 9.2). disease. One should always consider allergic
contact dermatitis, as this is a common secondary
feature.
------------l Pompholyx. This is an acute eczema of the
Case history 9.2
palms and soles. It is usually associated with a
Emma was a 24-year-Old student nurse and was number of different forms of eczema elsewhere.
referred for treatment of her ingrowing toe nail. She As the plantar skin is so thick, instead of the skin
mentioned that her main symptom was itching rather
than soreness. She had wondered whether it was a weeping when it is inflamed, it forms small blis-
fungal infection. She had bought some antifungal ters under the skin instead. These can occasion-
cream and had been using it for 3 weeks. She was ally be mistaken for eczema elsewhere.
concerned, as the toe appeared to be worsening and
her 'infection' was spreading. She was otherwise well,
apart from a childhood history of hay fever and
eczema. She was currently living in the hospital Psoriasis
nursing residence. On examination, the nail appeared
normal although the nail bed was inflamed in relation This is a very common group of diseases. In its
to a 2 cm circular patch of redness and scaling. She most usual form, it consists of well-defined, red
had a number of similar lesions on her lower legs and plaques with loosely adherent silvery scale
some appeared infected. Her skin was generally dry.
Diagnosis: Diagnoses considered at that time localised to the extensor surfaces. Two percent of
were ringworm (fungal infection), although the culture the population is affected and may present at any
and microscopy were negative; Bowen's disease, age but the second and third decades are the
although Emma was really too young for this and had
not had much sun exposure; and psoriasis, but she commonest. Scaly areas develop over weeks or
did not have a family history or other signs of months in the scalp, around the sacrum and
psoriasis. Finally, a diagnosis of discoid eczema was umbilicus. The flexures and genitals may be
made. Emma used a weak steroid and moisturiser,
which cleared her symptoms quickly, and her skin affected. The nails have characteristic changes
returned to normal. that are a useful aid to diagnosis: they develop
pitting and ridging. The nail may come away
234 SYSTEMS EXAMINATION
from the nail bed (onycholysis) and the under- spread it affects the whole body. With this, there
surface of the nail can develop thick scaling. The is loss of normal skin function (barrier against
damage is only transient. Arthritis is commonly infection, heat and water loss) and patients
associated with psoriasis and may take on a can become very ill (death is not unknown,
number of forms. Disease severity of the arthritis usually due to coexisting conditions). This is
does not parallel the extent of the skin disease. called erythroderma.
Psoriasis and its variants commonly affect the
lower legs.
Vasculitis
This condition frequently presents on the lower
Subtypes of psoriasis
legs. The rash may have been precipitated by a
Classic plaque psoriasis. This symmetrical rash new medication or an infection or another
affects the extensor surfaces of the skin. On the inflammatory medical condition. Clinically, there
lower leg, the knees and shins are frequently is inflammation within the blood vessels that
involved and in this site may be thick and persis- results in leakage of blood into the surrounding
tent, covering the whole shin. The plaques are skin. Lesions do not blanch. Early lesions are
variable in size, pink, red or purple and well raised, red and itchy. Later, the skin may blister
demarcated. The scales are large and silver in or ulcerate. Occasionally, the rash may be very
colour and can be easily scraped away, revealing extensive; commonly, it is modified by areas of
pinpoint bleeding. Usually nail changes will be pressure and may be accentuated around the
evident on the toes. shoe or sock line. Apart from ulceration, skin
Guttate psoriasis. This acute variant follows a involvement is usually only a minor problem.
streptococcal sore throat. Within a couple of Generalised involvement is sometimes a
weeks, small innumerable plaques of psoriasis problem, with inflammation of vessels occurring
cover the body. The rash tends to resolve with no in the gut, joints and kidneys that occasionally
treatment in 2 to 3 months. Occasionally it can be may result in renal failure or, rarely, death.
recurrent or go on to develop into classical
plaque type.
Lichen planus (Plate 17)
Palmar plantar pustular psoriasis (Plate 16). This
variant occurs primarily in middle-aged, female Lichen planus (LP) is a common inflammatory
smokers. It is characterised by pustules on the condition that frequently affects the lower leg.
palms and soles, with or without classical disease The main presenting symptom is itch and rash.
elsewhere. The pustules initially are creamy The itch is often very severe; patients tend to rub
coloured; as they mature, they turn brown; more than scratch, as sometimes the rash is
finally, the roof falls away, leaving a scaly depres- tender. The rash may be very widespread,
sion. They are commonly mistaken for fungal or appearing characteristically on the wrists, shins
bacterial disease but culture of the pustule is and sometimes diffusely on the body. The mouth
always sterile. A single digit may be all that is is often sore; the genital mucosae can be
involved; in this form, the nail may be destroyed involved. Scalp involvement may lead to perma-
permanently. Smoking cessation does not help nent hair loss. The nails are also involved. The
the rash. clinical appearances are classical. The rash con-
Generalised pustular psoriasis and erythro- sists of multiple flat-topped, polygonal papules
derma. Occasionally, psoriasis may be pustular that have a shiny surface. The colour is pale pink
on the body. In this form, it is widespread, of through to violet and sometimes brown.
acute onset, often with systemic upset. Lakes of Resolving lesions often leave marked persistent
pus can develop on the skin which later scale. pigmentation. Nail involvement produces pits on
Patients usually have a previous history of pso- the nail surface; later, the nail thins and becomes
riasis. Occasionally, psoriasis can be so wide- abnormal, sometimes resulting in destruction of
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 235
the nails. Inside the mouth, LP can appear as desquamation (peeling) and, in the long term,
white lacy streaks on the mucosa to blisters to can increase the risk of malignant changes in the
ulcers. On the lower leg, LP can become very skin.
thick (hypertrophic). LP frequently develops in Chilblains (perniosis). This is a familial
areas of skin injury (koebnerisation), leading to vasospastic response to prolonged exposure to
bizarre linear forms of the rash. LP of the soles is cold. Typically, lesions begin on the apices of the
less distinct, but the symptoms are similar and toes, fingers and occasionally the ears. In women,
usually associated with more typical rash else- lesions may appear in the region just above the
where. Lichen planus is usually relatively short- footwear line where the ankle is only covered by
lived 0-2 years), but hypertrophic disease may thin hosiery (sub malleolar perniosis). The
become chronic. chilblain begins as an erythema, turning into a
purple, swollen lesion that may itch and burn.
Ulceration of lesions is not uncommon.
Granuloma annulare
Erythrocyanosis. A relatively common disor-
Frequently misdiagnosed as tinea, this eruption der, erythrocyanosis commonly affects young,
is an idiopathic disorder that predominantly overweight women, particularly those working
affects people under 30 years old (particularly in a cold environment. Exposure to cold invokes
children). Starting as a single red papule, it a vasospastic response, resulting in a purple-red
spreads concentrically (up to several centimetres discoloration in the buttock, thigh and shin area
in some cases), becoming concave in the centre accompanied by a burning sensation.
with a pink papular edge. The lesions, which can Erythema multiforme. This skin disorder is
be single or multiple, occur most commonly on characterised by symmetrical, concentric 'target'
the hand but also occur on the foot and shins. lesions occurring on the hands, feet and limbs.
Unlike tinea, the lesion is rarely scaly and does Individual lesions may have a blistered bluish-
not itch. Diagnosis is confirmed by biopsy. The red centre with a more vivid surrounding ery-
condition may be rarely associated with diabetes thema. Involvement of the genital, oral and
mellitus. Necrobiosis lipoidica may resemble conjunctival areas is not uncommon and appears
this lesion but tends to have a yellowish hue. in the more severe form of the disease known as
Stevens-Johnson syndrome. The causes are
diverse, but 50% of cases are idiopathic: known
Necrobiosis Iipoidica (Plate 18)
causes include drug eruptions and viral and
This condition occurs on the shin and is com- streptococcal infections. Differential diagnosis
monly seen in diabetics. Patients may be asymp- should include other causes of blistering and
tomatic or complain of rash or ulceration. The fungal infections. Negative fungal culture and
lesions start as red patches, which enlarge, the the symmetry of the eruption should establish
centre becomes depressed and the skin yellows. the diagnosis.
Blood vessels may be visible traversing the
patch. Occasionally, lesions ulcerate. Sometimes
the rash may precede the diagnosis of diabetes or
rarely may be the presenting feature. They are ALLERGIES AND DRUG REACTIONS
often multiple.
Allergic contact dermatitis (Plate 19)
Typically, this condition occurs as a result of the
Other inflammatory conditions skin becoming sensitised to a specific allergen (a
Sunburn. Exposure to sunlight (UVB radia- type IV hypersensitivity reaction), so that subse-
tion) will lead to an erythema after a latent quent exposure to the allergen produces an acute
period of 1-3 hours, depending on the amount reaction of erythema, weeping and blistering at
of exposure. Excessive exposure can lead to the point of contact.
236 SYSTEMS EXAMINATION
--- ---------------------------------------------
The site of the reaction depends on the area of and plantar surfaces of the toes, sparing the inter-
skin exposed to the allergen. Sensitisation is digital areas. Fissuring may accompany the con-
more rapid on thin or moist skin; hence, reactions dition. Differential diagnoses include tinea
are most commonly seen on the face and ante- infection, psoriasis, contact dermatitis and
cubital fossa. Due to its thickness, the plantar adverse drug reaction. The symmetry and glazed
surface of the foot rarely becomes involved. Shoe appearance of the condition, along with the
line eruptions tend to be seen on the margins patient's age, are usually enough to make the
where the skin becomes thinner towards the diagnosis. With a contact dermatitis, a positive
dorsum. The popliteal fossa is also an area of patch test would be obtained.
thinner skin and, occasionally, may show reac-
tions: e.g. to the dyes used in nylon tights.
The common allergens affecting the lower limb Drug reactions
are listed in Table 9.12. It is important to recog- Reactions to drugs may arise due to:
nise that sensitised T cells may spread from the
contact site and provoke eczematous type lesions • a true allergic reaction to a drug
elsewhere on the body. When the cause of the (hypersensitivity)
reaction is not apparent, patch testing should be • the effects of overdosage (toxic reaction)
undertaken to identify the causative agent. • side effects of a drug
Differential diagnosis should be made from • alteration, by the drug, of the normal
psoriasis and fungal infections. Depending on immune response.
the point of exposure lesions may be symmetrical The difficulty in differentiating the above
or asymmetrical with a well-defined edge. factors is that, potentially, they can all mimic vir-
Fungal cultures and microscopy will typically be tually any skin lesion. When a drug reaction is
negative. Allergic dermatitis rarely affects chil- suspected, a thorough drug history is required
dren and the elderly, possibly due to a less vigi- (including any over-the-counter preparations the
lant cell-mediated immunity. With psoriasis, patient may be using). Most often the offending
lesions should be present elsewhere and nail drugs are the ones taken in the last 2-3 weeks,
changes are likely. although reactions are not uncommon in drugs
taken safely for many years. Withdrawal from
Juvenile plantar dermatosis the drug usually results in resolution of the con-
dition within a week or two. Drug reactions
Juvenile plantar dermatosis is thought to be a affecting the lower limb are rare.
variant of contact dermatitis. The condition Typical patterns of drug eruptions include:
arises in schoolchildren as a scaly, erythematous,
glazed eruption, typically affecting the forefoot • toxic erythema - generalised erythema
accompanied by fever
• urticaria
Table 9.12 Common causes of allergies in the lower limb • erythema multiforme
Location Common allergen
• vasculitis - typically seen as a painful
purpura on the shins
Thigh (pocket area) Phosphorus sesquisulphate • erythema nodosum.
(matches)
Popliteal fossa Dyes in nylon tights
Foot and ankle Venous leg ulcer treatments INFECTIONS OF THE SKIN
Chromates (leather tanning)
Adhesives (epoxy resins) The surface of the skin is an effective barrier
Metals (nickel in buckles) against most environmental agents, but through
Medicaments, especially those injury to the skin surface or when exposed to vir-
containing lanolin and parabens
ulent organisms this barrier fails. The pattern of
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 237
disease is very much dependent on the type of broken; corns do not appear encapsulated and
infection and so will be considered accordingly. the skin striae are not broken but pushed to one
side. Any wart with an atypical appearance, par-
ticularly in the elderly or immunosuppressed,
Viral
should be biopsied as, rarely, the lesion may
Verrucae. Verrucae (Plate 20) are the predomi- undergo malignant change.
nant viral infection on the foot caused by infec- Molluscum contagiosum. This is a contagious
tion of the skin with human papilloma virus infection (usually of children) which usually
(HPV). Around 5% of 16 year olds will have involves the trunk but can affect the leg and foot.
warts at anyone time (Williams et al 1991). The Infection with the causative poxvirus, usually by
virus affects the stratum spinosum and causes close contact, leads to a papular lesion, which
hyperplasia and formation of a benign tumour. may range in size from a pinhead to a pea. The
Typically, the plantar wart is found under a point hard, shiny pedunculated lesion has a central
of high pressure, e.g. the metatarsal heads or a crater from which cheesy material may be
bony prominence (Glover 1990). In its early expressed by pinching it. The uniqueness of this
stages it appears as a small, dark, translucent lesion makes the diagnosis straightforward.
puncture mark in the skin. More mature lesions Herpes zoster (shingles). Shingles is a recrud-
show thrombosed capillaries, a 'cauliflower- escence of previous chicken pox, usually along a
rough' surface and are painful when pinched. single dermatome. It can occur at any age, but
The patient may complain of increased discom- most frequently in the elderly or immunosup-
fort on starting to walk after a period of rest, e.g. pressed. It presents as a 1-3-day history of pain
first thing in the morning. Different types of HPV or burning in one limb followed by haemor-
cause different wart lesions, e.g. flat, genital or rhagic blisters and later superficial ulcers. Pain
plantar. may persist for many weeks and months.
Verrucae protrude above the level of the skin Herpes simplex. Herpes simplex (cold sores)
unless they occur on weightbearing surfaces. rarely affect the lower leg, although they may
When they are found on weightbearing surfaces involve the thigh in rugby players (serum pox)
they protrude into the skin and, as a result, are following infected oral exposure to an eroded
more painful. Mosaic warts are made up of mul- area of skin on the sports field.
tiple, small, tightly packed individual warts and
may not be painful, whereas plantar warts may
Bacterial
be single or multiple and are usually painful.
Occasionally, periungual warts may develop Bacterial superinfection, which is very common
around the nail edge and lead to distortion of the particularly in the various forms of eczema, was
nail plate. discussed earlier. Primary bacterial infections are
Verrucae can usually be diagnosed from their less common (Plate 21). In all these conditions,
clinical appearance; however, they can be con- full assessment by bacterial swabs is essential.
fused with corns (particularly neurovascular or Ecthyma. This infection affects the full thick-
fibrous) and foreign bodies. Verrucae can occur ness of the epidermis. The main pathogens are
on non-weightbearing and/or weightbearing Staphylococcus aureus and Streptococcus pyogenes.
areas of the foot, unlike corns and most foreign The patient may have recently been to a humid
body injuries, which tend to occur solely on climate or had an insect bite. It presents as a
weightbearing areas. There may be multiple ver- shallow ulcer with a thick, crusted top.
rucae present, not only on the feet but also on the Cellulitis. Cellulitis or erysipelas is a serious
hands, the pinching of which tends to cause a infection usually of the lower leg caused most
sharp pain, whereas corns and foreign bodies commonly by Streptococcus pyogenes. It presents
give rise to pain on direct pressure. Verrucae as a flu-like illness that is rapidly followed by a
appear encapsulated and the skin striae are painful red advancing area, usually on the lower
238 SYSTEMS EXAMINATION
leg. The affected area becomes swollen and the Moccasin foot. The soles of the foot can be
skin discoloured. The skin may even blister, generally involved with fungus (Trichophyton
necrose and ulcerate. Commonly, a 'portal of rubrum), producing thickened scaly feet. Often
entry' is found such as tinea pedis (see below) or the disease affects both feet. The nails may also
a fissured patch of eczema. be involved. Most patients are unaware of the
Pitted keratolysis (Plate 22). Bacterial over- problem but will have a previous history of
growths on the sole of the foot secrete proteolytic infection.
enzymes that produce multiple pits within the Onychomycosis. Tinea pedis may progress to
epidermis. The pathogens are microaerophilic the toe nails (onychomycosis), typically as a
diphtheroids. This is particularly common in result of repeated trauma (e.g. from footwear).
patients with sweaty feet or who wear trainers. Infection may occur superficially on the nail plate
Usually it is asymptomatic, but sometimes the or subungually invading under the hypony-
skin thins sufficiently to be tender. Odour is com- chium. Proximal subungual involvement occurs
monly offensive in such patients. rarely in immunocompromised patients or fol-
Erythrasma. This bacterial infection of creases lowing chronic paronychia. Total nail involve-
and flexures occurs between the toes of the foot. ment and dystrophy may result.
It is commonly mistaken for tinea pedis. The Tinea incognito. Misdiagnosis of fungal infec-
pathogen is Propionobacierium minutiesimum, tion is a problem as often the incorrect diagnosis
The skin is usually macerated and red/brown in made is eczema. The use of topical steroids to
colour. Again, it has a strong odour and reduce inflammation consequently allows the
fluoresces coral pink in Wood's light. unsuspected fungus to grow unchecked by the
immune system. Patients present with a history
of a persistent rash, usually on the foot, which
Fungal
fails to respond to steroid creams. The potency of
There are four patterns of fungal infection of the the steroid used is often very high. The rash is
foot (tinea pedis). Asymmetry is a feature red, ill-defined with nodules within, that when
common to all subtypes. In all situations, scrap- squeezed express pus. Scrapings confirm the
ings are essential to fully assess for fungal presence of fungus (Case history 9.3).
disease. Interdigital scaling is the commonest
form, usually presenting as itching and fissuring.
INFESTATIONS AND INSECT BITES
This usually occurs between the third to the fifth
toes where the skin is most macerated. The rash Scabies. The mite Sarcoptes scabiei causes
initially begins on one foot, only later extending scabies. Itching is often severe despite sometimes
to the other toes, nails and other foot. A variety of having minimal evidence of infestation. Patients
fungi and yeasts are implicated. may describe itchy nodules or blisters. They will
Extension onto the dorsa of the foot (Plate 23). usually have family members presenting at the
In chronic disease, the fungus can spread onto same time with itch. The signs are generally that
the dorsa of the foot, producing itchy scaly rings of eczema but blisters and excoriations are more
with an active edge. Fungal culture will help dif- pronounced. The primary lesion is the burrow of
ferentiate this from discoid eczema. Typical the mite. It appears as a linear or serpiginous
fungal causes include Trichophyton rubrum and white line with scaly opening at one end and a
less commonly Epidermophyton floccosum. minute grey or red dot at the other end (the mite).
Blistering in the instep. The inflammatory reac- The mite may be extracted with a needle and
tion on the sole to fungus tends to produce blis- examined using a microscope. Scabies should be
tering (Trichophyton mentagrophytes). It is usually suspected in any patient with a pronounced itch,
unilateral. Removal of the blister roof will allow and other sites of involvement (hands and trunk)
closer inspection and it may be sent for culture. should be sought.
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 239
Typical disorders which may affect the skin freckles can also occur, particularly after pro-
include connective tissue and endocrine diseases. longed or excessive sun exposure.
Common systemic disorders and their effects on Lentigo. A lentigo is a lesion where there is an
skin are summarised in Table 9.13. increase in the number of melanocytes within the
skin, resulting in a pigmented patch. Lesions
usually occur in older patients and usually arise
PIGMENTED LESIONS
on sun-exposed sites. Again, the lesion is visible
Pigmented lesions represent a large part of and not palpable; it tends to be solitary and the
general dermatological practice; this is also the pigmentation within it is usually light and
case on the lower legs. Pigmented lesions arise as always even.
a result of a variety of processes, both neoplastic Seborrhoeic warts. These are particularly
and inflammatory. Close attention to the clinical common, developing with advancing age. They
history and signs will allow distinction between appear as well-defined, rough, warty, slightly
most lesions. raised lesions that have a stuck-on appearance.
Freckles or ephelis. These are probably the They usually occur on the trunk and proximal
most common pigmented lesions seen on the limbs but can arise on the lower leg. They do not
skin. They are most common in those with fair develop on the sole. They are always benign but
skin who have been exposed to sunshine. Lesions can become inflamed after minor trauma and
are usually innumerable; they are visible but not may be mistaken for malignancy.
palpable and the pigmentation within is usually Pigmented naevi. Moles are collections of pig-
evenly distributed and is generally slight. Darker mented naevus cells (melanocytes) in the skin
Diabetes mellitus Increased incidence of skin infections (fungal and bacterial), skin stiffening,
ulceration (neurovascular), diabetic bullae, necrobiosis lipoidica, granuloma annulare
Lupus erythematosus Erythematous scaly plaques with follicular plugging
Systemic lupus erythematosus Periungual erythema, splinter haemorrhages, onycholysis and leuconychia. On
the legs, erythromelalgia and erythema nodosum
Dermatomyositis Periungual erythema with characteristic 'ragged cuticles'. Occasional calcification
within the skin
Systemic sclerosis/scleroderma Tight waxy skin with later distal digital atrophy with calcinosis, ulceration and
occasionally gangrene
Ehlers-Danlos syndrome Fragile skin with frequent bruising, hypermobility, poor wound
healing, typically showing large scars upon the knees
Rheumatoid arthritis Skin atrophy, nodules, vasculitis with periungual infarcts, splinter
haemorrhages and onycholysis with longitudinal ridging of the nails
Hyperthyroidism Hyperhidrosis, clubbing, onycholysis, hyperpigmentation, pretibial myxoedema
Hypothyroidism Anhidrosis, leuconychia, pruritus, palmar and plantar hyperkeratosis
Acromegaly Hyperhidrosis, skin thickening, coarse hair
Hepatic disease Clubbing, spider naevi and pruritus
Renal disease Hyperpigmentation or skin yellowing, nail changes - half-and-half nails, onycholysis
Reiter's syndrome Keratoderma blennorrhagica
Internal malignancy Hyperpigmentation, palmoplantar keratoderma, secondary skin
tumours, pruritus, nail clubbing, bullous eruptions
ASSESSMENT OF THE SKIN AND ITS APPENDAGES 241
that contain the pigment melanin. The nature of raised. They can be differentiated from vascular
moles will vary enormously depending on how malformations in that they do not blanch. They
many naevus cells are present, where in the skin are almost always benign.
they occupy and how pigmented they are: obvi- Malignant melanoma (Plate 24). In the assess-
ously, the greater number of naevus cells there ment of pigmented lesions the potential diagno-
are, the larger and more protuberant the lesion. sis of melanoma should always be considered.
Lesions that are close to the epidermal surface There are a number of clinical symptoms and
tend to be red/brown in colour; however, the signs that should alert you to the diagnosis
further down the pigment is in the skin the bluer (Table 9.14).
the colour becomes. In addition, the intensity of Itching is an early and significant symptom
the colour will depend upon how much pigment that should be sought. Often, it may be the only
is being produced. Moles are sometimes present presenting symptom, particularly where the
at birth; their number increases during life, most melanoma is not in general view. There may be
commonly in the first two decades but can a change in the surface of the mole, skin creases
develop at any age. Moles may become larger may be lost, and hair follicles and pores may
and more pigmented with age and occasionally disappear. Almost always there will be an
may regress. The clinical appearances of moles increase in the size, shape or thickness of the
are infinitely variable, therefore making mole. This occurs over weeks and months and
classification on macroscopic grounds alone usually is asymmetrical. Colour will change
almost impossible; however, they can be defined within a mole; pigment can both increase and
according to their microscopic appearances and decrease within the same lesion. Also, as the
knowledge of these patterns may be useful in the melanocytes invade deeper into the skin, they
clinical setting. may appear blue or even black. Rarely,
Junctional naevi. Collections of melanocytes melanoma may lose all pigmentation, making
along the dermal-epidermal junction, junctional diagnosis very difficult clinically (although the
naevi are the usual type of mole for the sole of the patient may recall a pre-existing pigmented
foot. In this site the pigmentation usually follows lesion). Bleeding, the surface of a melanoma
the ridges and troughs on the epidermal mark- may ulcerate, particularly in advanced disease.
ings. They are usually impalpable, the colour is The tumour may have spread by the time it is
red brown, and is symmetrical. They commonly picked up; this may be clinically evident with
occur in children and generally 'mature' by tumours developing along the lines of lym-
melanocytes falling away into the dermis, forming phatic drainage (in transit metastasis), in the
intradermal naevi. Here, the melanocytes have all draining lymph nodes or at distant sites (for
fallen into the superficial dermis. Often, the instance presenting as fits, weight loss or short-
naevus cells stop producing pigment and plump ness of breath).
up. Clinically, the lesions are therefore protuberant Melanoma is very rare before puberty and
and pale or skin-coloured. They may continue usually occurs in large congenital moles. The
growing in adulthood. Compound naevi have
both junctional and intradermal components and
therefore share clinical features of both types of Table 9.14 Suspicious signs and symptoms in a
lesions. pigmented lesion
majority of melanomas develop in later life, Table 9.15 Principal tumours affecting the lower limb
occurring in fair individuals on sun-exposed
Benign Malignant
sites and most commonly in women on the lower
legs. Melanoma may arise on the sun-protected Dermatofibroma Bowen's disease
sole of the foot and, as it is hidden from view, it Seborrhoeic wart Basal cell carcinoma
usually presents late. Any unusual lesion on the Haemangioma Squamous cell carcinoma
foot should be suspected, particularly if there is Lipoma Melanoma
pigmentation (Case history 9.4). Clear cell acanthoma Kaposi's sarcoma
Pyogenic granuloma Porocarcinoma
Eccrine poroma Metastasis
SKIN TUMOURS Glomus tumour
senting as a well-defined, erythematous, scaly ated with human herpesvirus 8 and immunosup-
patch on the lower leg. When the scale is picked pression, notably HIV (Lebbe 1998).
off the surface may bleed and weep. It occurs Porocarcinoma. This rare sweat duct tumour
most commonly in women (suggesting a sun- often occurs on the lower leg. The history
related aetiology). The lesions are sometimes and clinical appearances are similar to see
multiple. Left untreated they may persist for but the tumours are more likely to recur and
many years; however, sometimes this disease metastasise.
can progress on to true invasive squamous cell Metastasis (Plate 26). Tumours of the lung,
carcinoma. prostate, thyroid, kidneys and breast rarely
Basal cell carcinoma. Basal cell carcinoma spread to the skin. Usually when they do, it tends
usually presents on the face but occasionally it to be the scalp and upper body. However,
occurs on the lower legs. Usually it presents as a tumours arising on the lower legs can metasta-
fleshy nodule with a pearlescent appearance, sise to the draining lymph vessels and nodes,
having small blood vessels grossing the surface. particularly melanoma and Sec. The tumours
Advanced lesions ulcerate and if neglected may will usually appear as subcutaneous nodules;
become very large. Despite being locally destruc- they may be large. They may be firm and may
tive they do not metastasise. Occasionally, they feel as if they are attached to related structures.
remain superficial and indistinguishable from The patient will usually have a history of pre-
Bowen's disease. vious tumours, but occasionally the metastasis
Squamous cell carcinoma. Squamous cell carci- may be the presenting feature.
noma (See) is a common malignant tumour of
the lower leg presenting as a lump or as a bleed-
ing ulcer. The tumour grows over a period of
SUMMARY
weeks and months. In time the tumour becomes
painful, particularly if it is invading bone or There is no point assessing a patient's skin unless
nerves. Usually it will develop on a background the information is to be used to benefit the
of sun damage but it is also associated with patient. A diagnosis is formulated from all the
exposure to arsenic and aromatic hydrocarbons. data gathered from the assessment and the prac-
Occasionally, it may develop with an old scar or titioner's knowledge and clinical experience.
leg ulcer; this should be considered, especially in Epidemiological data - information such as age
ulcers that fail to heal with conventional mea- and gender - may help. Information from obser-
sures or ulcers with fleshy or rolled edges. vation, clinical tests and special investigations
Metastasis generally tends to be a late event, will also help to reduce the list of possible condi-
usually to the regional lymph nodes. An see tions. In most instances the diagnosis will
that arises on the foot may invade deeply with become obvious, but on occasions it may not be
only minimal surface involvement, mimicking possible to reach a definitive diagnosis. In this
pressure or neuropathic ulcers. Often, in this site case a provisional diagnosis has to be made and
the tumour will have multiple sinuses that dis- the cycle of the disease process must be awaited
charge offensive-smelling material. for further enlightenment. Where a diagnosis is
Kaposi's sarcoma. This rare vascular tumour not available, the practitioner may decide to treat
was described originally on the lower leg in the symptoms. Occasionally, the effect of a treat-
males of eastern European extraction. It presents ment can be a diagnostic aid in itself; e.g. a vesic-
as blue-black or purple patches that later become ular eruption that resolves with the use of an
plaques and nodules. Tumours range in diameter antifungal implies that the aetiology was
from 1 to 3 cm; they are usually multiple. Later mycotic. When a condition is diagnosed, the
lesions may involute or ulcerate. Oedema may practitioner must decide what action is necessary
become a problem. Kaposi's sarcoma is associ- based on available evidence.
244 SYSTEMS EXAMINATION
REFERENCES
Baran R, Dawber R P R, Tosti A, Haneke E 1996 A text atlas perspective. Annals of Dermatology 6(2): 109-123
of nail disorders. Martin Dunitz, London Office of Population Census and Surveys 1991-1992
Cork M 1997 The importance of the skin barrier function. Morbidity statistics from general practice. Fourth
Journal of Dermatological Treatment 8: S7-S13 National Study 54: 22
Forslind B 1994 A new look at the skin barrier. A biophysical O'Halloran N 1990 A biochemical investigation into the
and mechanical model for barrier function. Journal of cholesterol content of seed corns. BSc dissertation,
Applied Cosmetology 12: 63-72 University of Brighton
Fortune D G, Main C J, O'Sullivan T M, Griffiths C E M 1997 Pasyk K A, Thomas S V, Hassett C A, Cherry G W, Faller R
Quality of life in patients with psoriasis: the contribution 1989 Regional differences in the capillary density of the
of clinical variables and psoriasis-specific stress. British normal human dermis. Journal of Plastic and
Journal of Dermatology 137(5): 755-760 Reconstructive Surgery 83(6): 939-945
Freinkel R, Traczyck T 1985 Lipid compositions and acid Ratnavel R C, Griffiths WAD 1997 The inherited
hydrolase content of lamellar granules of the foetal rat palmoplantar keratodermas. British Journal of
epidermis. Journal of Investigative Dermatology 80: Dermatology 137: 485-490
441-448 Ryan T J 1995 Exchange and the mechanical properties of
Gawkrodger D J 1992 An illustrated colour text of the skin: oncotic and hydrostatic forces control by blood
dermatology. Churchill Livingstone, London supply and lymphatic drainage. Wound Repair and
Gillet du P 1973 Dorsal digital corns. Chiropodist July Regeneration 3: 258-264
Glover M G 1990 Plantar warts. Foot and Ankle 11(3): 172-178 Shelley W B, Rawnsley H M 1968 Painful feet due to
Harlow D, Poyner T, Findlay A, Dykes P 1998 High herniation of fat. Journal of the American Medical
impairment of quality of life in adults with skin diseases Association 205: 308
in primary care. British Journal of Dermatology 139 Springett K P 1993 The influence of forces generated during
(SuppI51): 15 gait on the clinical appearance and physical properties of
Lawton S 2000 A quality of life for patients with skin skin callus. PhD thesis, University of Brighton
disease. Skin Care Campaign Directory, London Venning V 2000 The dermo-epidermal junction: an
Lebbe C 1998 Human herpesvirus 8 as the infectious cause important structure in dermatology. Dermatology in
of Kaposi sarcoma: evidence and involvement of Practice 8(1): 6-8
cofactors. Archives of Dermatology 134(6): 736-738 Whiting M F 1987 Survey of patients of large employer in SE
McKee P H 1996 Pathology of the skin with clinical England and Dept of Podiatry, University of Brighton.
correlations. Mosby-Wolfe, London Unpublished, protected data
Merriman L, Griffiths C, Tollafield D 1986 Plantar lesion Williams H C, Potter A, Strachan D 1991 The descriptive
patterns. Chiropodist 42: 145-148 epidemiology of warts in school children. British Journal
Montagna W (ed) 1960 Advances in the biology of the skin: of Dermatology 128: 504-511
cutaneous innervation. Pergamon Press, Oxford Zaias N 1980 The nail in health and disease. SP Medical,
Norlund J 1994 The pigmentary system: an expanded New York
FURTHER READING
Baran R, Dawber R P R, Tosti A, Haneke E 1996 A text atlas Lewis-Jones S 2000 The psychological impact of skin
of nail disorders. Martin Dunitz, London disease. Nursing Times 96(27): 2-4 (suppl)
Dawber R P R, Bristow I R, Turner W A 2000 A text atlas of Leung A K C, Chan P Y H, Choi M C K 1999
podiatric dermatology. Martin Dunitz, London Hyperhidrosis. International Journal of Dermatology
Goldsmith LA 1991 Physiology, biochemistry and 38: 561-567
molecular biology of the skin. Oxford University Press, Litt J Z, Pawlak G P 1997 Drug eruption reference manual.
Oxford Parthenon Publishing, London
Harman R, Mathews CAN 1974 Painful piezogenic pedal Windsor A 2000 Sampling techniques. Nursing Times
papules. British Journal of Dermatology 90: 573 96(27): 12-13 (suppl)
CHAPTER CONTENTS
Introduction 245
Why assess footwear? 246
Style 253
Suitable shoe styles 253
Unsuitable styles of footwear 255
A Insole B
Tongue
Topline
Quarter Stiffener
Eyelets --,...--,...--f--~/ -+---,ll---
(Oxford lacing) ,/n_- Heel
Throat line ----,1-----''''
--Toppiece
Figure 10.1 A. The 'anatomy' of a lace-up shoe, showing the parts of an Oxford-style laced shoe B. The reinforcing within
a shoe C. Alternative (Gibson) style of lacing.
Quarter. The sides and back of the shoe upper Linings. Linings (not illustrated) are included
are termed the quarters and their top edge forms in the quarters and vamps of some shoes to
the topline of the shoe. The medial and lateral increase the comfort and durability. The lining
sections often join in a seam at the centre of the for the bottom of the shoe is called the insock. It
heel. In lace-up shoes the eyelets for the laces may cover the entire length of the shoe, three-
form the anterior part of this section, whereas the quarters or just the heel section.
tongue is attached to the vamp (Oxford style) or Throat. The throat is formed by the seam
forms part of the vamp (Gibson style, Fig. IO.le). joining the vamp to the quarter. Its position
The inside of the quarter is usually reinforced depends on the style of the shoe. A lower throat
around the heel by the stiffener. This helps to line, i.e. a shorter vamp and longer quarters, will
stabilise the hindfoot in the shoe. In some chil- give a wider Ilower opening. This seam will not
dren's shoes and some athletic footwear the stiff- stretch and therefore dictates the maximum
ener is extended on the medial side to help resist width of foot for which the shoe can be used.
pronation. Insole. The insole is the flat inside of the shoe
Toecap. The upper may have a toecap stitched which covers the join between the upper and the
over or replacing the front of the vamp. It is made sole in most methods of construction.
into a decorative feature in some men's shoes, for Outsole. The outsole or sole is the undersur-
example brogues. face of the shoe.
248 SYSTEMS EXAMINATION
---' ,-,-----,_.
Shank. The shank reinforces the waist of the Collar and heel tab. The topline of a sports
shoe to prevent it from collapsing or distorting in shoe is often padded to form the collar. This may
wear. Shanks may not be needed in shoes with be shaped up around the back of the tendo
very low heels or in shoes where the sole forms a Achilles to form a heel tab. Heel tabs were
continuous wedge. designed to protect the tendo Achilles but some-
Heel. The part of the shoe under the heel of the times rub sensitive feet and may therefore need
foot, also called the heel, raises the rear of the to be removed.
shoe above ground level. A shoe without a heel Hindfoot stabiliser. One of the elements that
or a midsole wedge may be completely flat or may be incorporated into a sports shoe to
have the heel section lower than the forefoot, in attempt to counter pronation is the hindfoot
which case it is called a negative heel. The outer stabiliser, which consists of a plastic meniscus
covering on the surface of the heel, which can be between the midsole and the stiffener.
replaced when worn, is called the top piece.
Welt. The welt is a strip of material, usually
leather, used to join the upper to the sole in SHOE CONSTRUCTION
Goodyear-welted construction.
Lasts
The last is the mould on which most shoes are
The 'anatomy' of sports shoes made and its shape and dimensions will dictate
Since trainers replaced plimsolls sports footwear the fit and to some extent the durability of the
design has developed considerably, bringing shoe made on it. It is usually hinged around the
new construction methods and terminology to instep to allow it to be removed from the shoe
the footwear industry. The functions of sports when construction is completed. Last design and
shoes are different to those of ordinary shoes as, manufacture are skilled occupations involving
for example, they may be required to absorb the use of many measurements, some of which
shock or provide some medial to lateral stability. are shown in Figure 10.3. Most of these are
The parts of a sports shoe are shown in Figure volume measurements rather than the traditional
10.2 and the terms illustrated are described below. length and width measurements associated with
MUdguard. Reinforcing round the outside of shoe fit. The measurements of the last need to be
the rim of the toe is called the mudguard. different from the measurements of the foot to
Saddle. The saddle is reinforcing stitched to allow for movement in walking and the tightness
the outside of the shoe in the area of the arch. of fit required by the wearer. It is these factors
Heel tab
Collar
Saddle Outsole
Stuck-on (cement)
Figure 10.5 Comparison of measurements of shoe length
A. Centimetres B. Paris Point C. English sizing system As the name implies, this type of construction
D. American women's sizes. involves sticking the sole to the upper (Fig. 1O.6A).
FOOTWEAR ASSESSMENT 251
A C
Upper
B D
Upper--...,r/ Upper
Chainstitch
inseam Filler Insole Outsole Insole
Lock stitch
outseam Outsole
Upper _ _Ill
Figure 10.6 Common methods of shoe construction A. Cement B. Goodyear C. Stitchdown D. Moulded E. Strobel-
stitched method.
larger section forms the insole, vamp and quar- giving a smooth contour to the inside of the shoe.
ters, by being moulded upwards from the under- It is important to remember that the permeability
surface of the last. An apron is then stitched to the of leather is likely to be impaired by special coat-
gathered edges of the vamp and the sole is ings, e.g. patent leather.
stitched to the base of the shoe. This method is
used for flexible fashion footwear.
Synthetic upper materials
Some synthetic materials (the poromerics) are
Moulded methods
permeable and allow the shoe to 'breathe' but
In these methods the lasted upper is placed in a none have the permanent suppleness found in
mould and the sole formed around it by injecting leather. Most are slightly elastic and will stretch
liquid synthetic soling material (Fig. 10.60). to some extent during wear; however, they will
Alternatively, the sole may be vulcanised by con- return to their original shape when taken off. For
verting uncured rubber into a stable compound this reason shoes made of these materials should
by heat and pressure. These methods combine fit well and will not be as versatile at fitting awk-
the upper permanently into the sole and such wardly shaped feet as leather. Some synthetic
shoes cannot therefore be repaired easily. materials may form a single deep crease, which
Moulded methods can be used to make most can rub on the foot, instead of the many small
types of footwear. creases found in leather. This problem is likely to
be more pronounced when the shoes are too big.
Many synthetic materials can be produced
Force lasting
cheaply and are used to manufacture reasonably
There are many variations of this method but the priced shoes. Providing they fit well and perspi-
main one, which is increasing in use, is the sewn- ration is not allowed to build up inside, they can
in-sock or Strobel-stitched method (Fig. 10.6E). be completely satisfactory.
The upper is sewn directly to a sock by means of
an overlocking machine (or Strobel stitcher). The
Other upper materials
upper is then pulled (force lasted) on to a last or
moulding foot. Unit soles with raised walls or Woven fabrics such as cotton corduroy can be
moulded soles are attached to completely cover used to make soft uppers. These are classified as
the seam. This is a modern method which has breathable fabrics even if made of synthetic
evolved from the construction of sports shoes but fibres; however, they will usually only stretch in
is increasingly used for casual shoes. one direction. They can make comfortable
footwear, but it is essential that these fit well and
are well constructed with adequate reinforce-
Materials used in construction ment, particularly in the heel area.
Leather upper materials
Lining materials
The traditional material for shoe upper manufac-
ture is leather and it still has advantages over All the materials used for upper construction can
synthetic materials. The first of these is its per- also be used for linings; however, the combina-
meability. Permeable materials allow perspira- tion of a leather upper with a full lining made of
tion to escape from the foot, producing a drier a non-breathable, non-stretch material will have
environment, which is less conducive to fungal all the disadvantages of the lining materials and
growth. The second advantage is that leather none of the advantages of the leather. In practice
stretches with wear and will permanently mould full linings are rare, but when they are used it is
to the shape of the foot. Additionally, leather preferable that they be made of thin leather or
forms many tiny creases where flexing occurs, fabric. Many linings are made of synthetic mate-
FOOTWEAR ASSESSMENT 253
rial but are usually confined to the quarters and flexibility. Shank flexibility can be tested for by
the insock, where the loss of permeability and pressing down on the inside of the shoe on a flat
stretchability is not a problem. surface. A suitable shank would be completely
rigid or give slightly, but a shank that is too
Leather soling materials flexible will yield under this pressure and would
allow the shoe to twist when weightbearing.
The ideal soling material must be waterproof,
durable and possess a coefficient of friction high
enough to prevent slipping. As for upper con- Allergy to shoe components
struction, leather has been the traditional mater- Some components used in shoe construction can
ial for the construction of shoe soles but synthetic cause allergic contact dermatitis. Substances
materials are much more versatile than leather which sometimes cause skin problems are listed
which, besides being very expensive, has poor below.
gripping qualities. Rubber. Rubber, used for some soles, can be
present even in an all-leather shoe as it is a con-
Synthetic soling materials stituent of many adhesives.
The advantages that man-made soling materials Chemicals. The chemicals used in the process
have over leather are that they are more durable, which turns animal hide into leather (tanning)
have better resistance to water and have higher and dyes used to colour it can leach out of the
coefficients of friction and, therefore, better grip. leather when the foot sweats.
They can be made of flat material and be stuck or Other features. Materials such as nickel, used
sewn onto the upper like leather, or they can be in eyelets and shanks, or the fungicides used
made in a shaped mould which is either stuck on to protect the leather, can also produce skin
or moulded directly on to the upper. Extra grip irritation.
properties can be incorporated in the form of a Diagnosis of these conditions can be made
distinctive sole pattern with well-defined ridges from the localised area affected by the eruption.
or they can be moulded with cavities to reduce Treatment involves use of footwear constructed
the weight of the sole. These cavities need to be without the causative component. Fortunately
covered with a rigid insole or can be filled with these conditions are rare. Help to identify suit-
light foam to produce a more flexible sole. able footwear can be obtained in the UK from
Synthetic soling materials have been the subject organisations such as the Disabled Living
of a great deal of research, particularly relating to Foundation and the Shoe and Allied Trades
sports shoes, and this has led to new designs and Research Association.
construction methods being used in all types of
footwear. For example, two or more materials of STYLE
different densities can be incorporated into the
sole, e.g. to give a hard-wearing outer surface Figure 10.7 shows the seven basic shoe styles:
and a softer, more flexible midsole for greater lace-up, moccasin, court, sandal, boot, mule and
comfort. Many synthetic soling materials possess clog. All shoes are variations on these themes.
a degree of shock absorption. Patients can some- The history of footwear shows that styles re-
times relieve metatarsalgia by changing from invent themselves. Shoe styles tend to reflect con-
thin-soled shoes to shoes with thick soles with temporaneous expectations of society (Lawlor
good shock-absorption properties. 1996).
Figure 10.7 The seven basic shoe styles A. Lace-up B. Moccasin C. Court D. Sandal E. Boot F. Clog G. Mule.
the definition of a sensible shoe, which must are designed. It is better, therefore, to recommend
have a mechanism for holding the foot back in features to be found in a suitable shoe with an
the heel of the shoe. Without this fixation the foot
is allowed to slip forward into the toe space
causing friction on the sole and trauma to the
toes. Thus, there are two really important parts of
an ideal shoe: a band around the instep and cor-
responding pressure at the heel. These parts,
shown in Figure 10.8, should be firm and fit well.
The band around the instep prevents the foot
from sliding forward. This needs to be well up
the instep to be effective. This is counterbalanced
by pressure behind the heel to prevent the foot
from sliding back.
Support is often listed as being essential in a
good shoe, but a normal foot does not need to be
supported to function correctly or barefoot
walking would be impossible. A good shoe should Parts of the shoe Parts of the shoe
be firm enough to support itself and provide a that must be firm that must fit snugly
solid base from which to push off. Recommending to prevent the foot to prevent the foot
from sliding back from sliding forward
footwear is complicated by the constant changes
to styles and models marketed by different manu- Figure 10.8 The parts of a shoe needing to fit well to
facturers and the different uses for which shoes prevent forward or backward movement of the foot.
FOOTWEAR ASSESSMENT 255
Table 10.1 Points to look for in an ideal shoe but high heels became associated with fashion
• Laces with at least three eyelets
and style as early as the 16th century. High heels,
defined as those that place the foot in more than
Low, wide heel for good stability
slight equinus, are not suitable for everyday
Good width at the front of the shoe to prevent cramping
the toes
wear. In addition to the fact that they are nearly
always slip-oris, they alter the normal biome-
• Deep, reinforced toe box
chanics of the lower limb in walking. Habitual
• Firm stiffening round the heel
wear leads to permanent shortening of the calf
• Curved back for close fit around the heel muscles, barefoot walking is made uncomfort-
• Shaped topline, high enough up the instep for adequate able and in severe cases the heels may not be able
fixation
to touch the ground.
• Strong leather upper
Hard-wearing synthetic sole
Good fit
ASSESSMENT OF FOOTWEAR
• Good condition The assessment of footwear should not be seen as
a separate entity to be completed after other
aspects of the examination but should be inte-
explanation of why they are important. To assist grated into the global assessment. For example,
this task a list of points to look for in a suitable observation of patients walking in their shoes can
shoe is included in Table 10.1. often be achieved as they enter the clinic and
there are some checks of fit which should
be done before the shoes are removed. This
Unsuitable styles of footwear will ensure that the number of times the
Mules, clogs and court shoes, the styles on the shoes need to be removed and replaced is kept to
right of Figure 10.7, are unsuitable for regular a minimum. Table 10.2 lists the tests that should
wear as they have no means of securing the foot. be included in a simple footwear assessment and
The only way that mules stay on is by being
'gripped' by the toes. This can lead to toe defor- Table 10.2 The parts of a simple footwear assessment
mity. Slip-on shoes, especially court shoes, are and the stages at which they can be completed within the
global assessment
bought too short and inevitably cramp the toes as
the only way that they can stay on the foot is by Stage of Test Brief description
wedging the foot between the curved back of the assessment
heel and the toe puff. When tried on in the correct In shoes
size the foot slips forward into the toe space and Walking Observe gait
the heel lifts out of the shoe on walking, giving
Standing Observe stance
the impression that it is too big. Clogs or slip-on Check length Palpate end of longest toe
shoes that extend right up the instep will limit Check heel to Locate MTPJs in shoe
forward movement to some extent. A properly ball length
Check width Pinch upper over
fitting lace-up is always preferable (Fig. 10.8). metatarsal heads
In most shoes, even 'flat' ones, the heel is Check depth Palpate toes during flexion
raised slightly above the level of the ground, so Barefoot
that the foot is in slight equinus. Even a modest Walking Observe gait
height of heel will tend to throw the weight of the Sitting History
foot forward into the toe section unless it is Assess suitability of shoes
restricted by an adequate fastening. It is therefore Check wear marks
Examine inside of shoe
even more important for a high-heeled shoe to
Standing Observe stance
have a secure fastening. Raised heels are said to Note longest toe
have developed as a protection from dirty streets
256 SYSTEMS EXAMINATION
the stage at which each should be completed. have a major influence on the style of shoes
They are described in full below. Performing women are willing to purchase.
these checks routinely, as part of a set sequence,
will help to ensure that assessment of footwear is
Habits
completed without undue effort. It should be
remembered that hands should be washed Details of how often shoes are changed and
between examination of the footwear and the whether long periods are spent wearing slippers
foot. Patients attending for their first appoint- or sports shoes can also be important. For
ment should have been warned to bring a selec- example, a lady is unlikely to benefit from having
tion of their shoes, as new or 'best' shoes may not a pair of suitable shoes to go out in once a week
demonstrate the habitual wear pattern found in when she spends the rest of the week at home in
the shoes worn every day. There may therefore slippers.
be several pairs of shoes to examine.
Acquisition of footwear
History taking
Information about when, where and how often
Background information about the patient's patients buy their shoes can be useful: e.g. do
general footwear and purchasing habits is an they have their feet measured or visit a self-
essential part of the assessment of footwear. service shop? Whereas 40% of parents start off
having their children's feet measured, by the age
of 11 years only 15% of children have their feet
Financial circumstances
measured (Stevens 1995).
Before suggesting appropriate footwear, it is
important to ascertain the financial circum-
Independence
stances of the patient, as this will influence her
ability to follow the advice given. Women tend to No assessment of footwear would be complete
spend less per item of footwear than men but without noting the patient's ability to put on and
they change their footwear more frequently; take off her shoes or to do up and undo the
hence, in total, they spend more on footwear than fixation. Many adaptations to footwear and aids
men (British Footwear Association 1998). to assist independence are available and may
form a valuable part of treatment. Sources of
information are included in Further Reading.
Wardrobe
Questions regarding the number of shoes
owned and the number regularly worn may
Assessment of shoe fit
seem irrelevant but can add helpful informa- Shoe fit is always a compromise as the shape of
tion. This line of questioning may uncover that the foot is changing continually due to many
special shoes are worn at work and, therefore, different factors, some of which affect length
need examination in preference to shoes worn and some girth. The biggest factor affecting
only occasionally. There are specialist reinforced length is weightbearing and measurements of
shoes for work in dangerous environments, length should, therefore, never be made when
smart shoes may be needed for office work or the patient is sitting. Girth is affected by body
special shoes may be required for a specific weight but is also highly sensitive to both tem-
sporting activity. Advertising and the media perature and swelling. There is thus a tendency
influence women's attitudes towards purchas- for feet to be smaller in the morning than the
ing shoes (Reardon 1999). It is, therefore, impor- evening. Measurements taken during the
tant that the practitioner is familiar with current middle of the day will give the most representa-
styles within 'the high street' as these could tive results.
FOOTWEAR ASSESSMENT 257
Assessment of shoe fit is not an exact science: • With the patient standing in her shoes,
often observation and common sense are all that palpate the end of the longest toe through the
is required to decide whether shoes fit correctly. toe puff. This may not be possible if the toe
Sometimes a method of measuring fit is useful to puff is reinforced.
demonstrate to patients that their shoes are inad- • Sprinkle a little talcum powder into the shoe
equate. A well-fitting shoe should fit snugly and ask the patient to walk a few paces.
around the heel and the arch and allow free When the shoes are removed an outline of
movement of the toes. the toes can be seen printed in the powder on
This section includes a comprehensive list of the insole from which the gap can be
tests for different aspects of fit. It is not intended assessed. It may be difficult to see the result
that all the tests described should be included in of this test in footwear which extends high
each assessment. They are listed partly to up the instep (high-waisted).
demonstrate the range of potential tests, but also • Cut a thin strip of card the length of the foot
to allow selection of an appropriate test to suit and slide this into the shoe until it touches
the problems experienced by the patient. In most the tip. This should reveal a gap of about
cases the simplest test described will be adequate 12 mm between the inside of the heel and the
but, occasionally, when more accuracy is end of the strip of card (Fig. 10.9). This
required, the more complicated measurements method can be influenced by the shape of the
can be useful. toe puff and is therefore most effective in
The style of the shoe will to some extent dictate round-toed shoes. To minimise the error, keep
fit: e.g. a court or slip-on shoe is likely to be too the width of the card narrow and do not slide
small in length, width and depth. Additionally, it right to the end of very pointed-toed shoes.
the style of the front of the shoe can have a direct
Shoes that are too short will mould the toes
bearing on the fit in this region. Demonstration of
into the shape of the front of the shoe; shoes that
poor fit by some of the tests described may help
are pointed are likely to cause pressure lesions on
to convert the patient to sensible shoes.
the toes.
If shoes are really comfortable they are proba-
bly a good fit. Strangely, comfort is not as impor-
tant a factor as might be expected when shoes are
being purchased. Colour, style and heel height
may compete equally. People, particularly
women, seem to be tolerant of minor foot dis-
\
comfort and it is necessary to explain that ill-
fitting footwear may damage feet and that
o
comfort should be paramount when choice of
footwear is concerned.
,
, ,,
Length I
i
"
I
Correctly-fitting shoes should have a gap I
I
I
between the longest toe and the front of the shoe I
:<~~«{j(f>;a'.
.
~
Length of children's shoes. Children's shoes simple and one more accurate - are described
need a little more toe space than adults to allow below:
for growth. A gap of 20 mm between the longest
• With the patient standing in her shoes, feel
toe and the front of the shoe should be present in
for the metatarsophalangeal joint. If the bulge
new shoes, allowing 8-9 mm for growth before
of the joint is level with the bulge of the shoe,
new shoes are needed. If a child's shoe is worn
this measurement is correct.
out it is likely that it is too small, as it is usual for
• Measure the distance from the patient's heel
young feet to outgrow the shoe before it is worn
to both the first and fifth metatarsal heads.
out. It is also important to check for sock fit with
Flex the ball of the shoe and measure the
growing feet as these too can be rapidly out-
distance from the heel to the point at which
grown. Hosiery that is too small can cause as
the shoe bends both medially and laterally.
much damage as shoes that are too short.
The medial and lateral measurements from
the foot and the shoe should correspond.
Heel to ball length
Shoes with a heel to ball length that is too long
Correctly-fitting heel to ball length will ensure will put unnecessary pressure and strain on the
that the hinge of the shoe is correctly aligned metatarsophalangeal joints, particularly that of
with the ball of the foot, and that the widest part the hallux, as the foot will be trying to flex the
of the foot is in the widest part of the shoe. It shoe where it is still reinforced by the shank. If
varies according to the design of the last. the heel to ball length is too short, it will cause
Average heel to ball length will be adequate for fewer mechanical problems but will restrict toe
average feet, and will only need to be assessed if room (Fig. 10.10).
the toes are unusually short or long in relation
to the rest of the foot. Heel to ball length will be
Width
incorrect if too much room for growth is
allowed in children's shoes, when odd-sized Correct width is also important and should be
feet are not fitted with different-sized shoes or sufficient to allow the toes to rest flat on the
when extra long shoes are bought to fit wide insole without being compressed. Very few
feet. This important measurement should only fashion shoes are made in width fittings so
be assessed once the length of the shoes has fashion shoes are often bought either too narrow
been checked and found to be correct. Two tech- or a size longer than they should be, to benefit
niques for measuring heel to ball length - one from the corresponding increase in width. In a
Figure 10.10 Illustration of two feet with identical length but different heel to ball length and the result of fitting them both in
the same shoe.
FOOTWEAR ASSESSMENT 259
shoe fitter who will know what is currently insufficient wear where some wear should be
obtainable. expected.
Assessment of the fit of a patient's shoes Examination of the wear patterns of shoes
should be carried out on both feet even if the pre- will also reveal information about foot function.
senting problem is unilateral. A person's feet are Distortions of the uppers can indicate abnormal
commonly not identical in size and a pair of frontal plane motion during walking. The wear
shoes may fit neither foot adequately. Small dif- marks on the heel and sole will reflect the direc-
ferences in size can be managed by shoes which tion of the weightbearing pathway during the
fit the larger foot and adaptation for the shoe of gait cycle. Normal wear is the result of a smooth
the smaller foot. Differences of two sizes or more transfer of load from the heel to the forefoot.
will need odd-sized shoes, as the discrepancy in Some gait analysis equipment (Ch. 12) displays
heel to ball length will be too great. A list of sup- a centre of pressure line and it is logical to
pliers of odd-sized pairs can be found by con- assume that normal wear will occur along this
sulting organisations such as the Disabled Living path (Fig. 10.13).
Foundation (DLF) in the United Kingdom. Some The degree as well as the pattern of wear must
adaptations to help overcome the problem are be assessed, as shoes which are worn out or in
illustrated in leaflets available from the DLF and need of repair are unsuitable for regular wear.
the books suggested in Further Reading. One check of the degree of wear is to place the
If the assessment shows up any deficiency in shoe on a flat surface and gently touch the back,
fit and the patient is willing and able to buy new front and each side. The shoe should be stable
shoes, suggest a visit to a shoe shop with a and not rock when touched. If rocking is detected
trained shoe fitter and a good stock of different then the shoe will provide an unstable base for
fittings and last styles. Having feet measured walking and standing. Checking stance shod and
may be something many people associate only barefoot will confirm these observations.
with buying children's shoes. It is equally impor-
tant for adults to be measured, particularly those
Wear on the sale
with problem feet. Even specialist shops may
have difficulty fitting feet which are bigger, If the foot is functioning properly and is in a well-
wider or narrower than average. If a patient is fitting shoe the pressure on the sole of the shoe
having difficulty finding suitable shoes then spe-
cialist organisations like the Disabled Living
Foundation should be consulted for appropriate
manufacturers or stockists.
Wear marks
Assessment of the pattern of wear on the soles
and the uppers of patients' footwear can help to
confirm a diagnosis of foot pathology and may Centre of
also highlight deformity elsewhere, e.g. genu --+---- pressure line
valgum. The patterns are to some extent pre- under foot
dictable, given that the shoes enclose the foot and Areas showing
will mould to its shape. Well-defined deformities normal wear
give classic wear patterns. It is important to be
able to recognise the wear expected from a
normal foot in order to differentiate that which is
abnormal. Abnormal wear presents not only as Figure 10.13 The 'normal' pattern of wear on the sale and
an unusual pattern but also as excessive or the heel.
262 SYSTEMS EXAMINATION
should be even and no one part should wear out extending down the lateral border (Fig. 10.14).
excessively. It is normal, however, for signs of An everted forefoot will show excessive wear
wear to occur under the medial central forefoot along the inner aspect and an inverted forefoot
(Fig. 10.13). It is also normal for there to be a will be worn along the outer aspect.
slight curvature of the undersurface of the sole. Wear marks indicating a circular contact of the
An element of this is built into the shoe by incor- sole with the ground are caused when the
porating toe spring into the last (see Fig. 10.3), metatarsal area is being used as a pivot, e.g. any
and this is accentuated by normal toe-off in condition that makes use of the toes uncomfort-
walking. able. Examination of the sole will also reveal any
Any variation of the above will represent areas of abnormally high pressure, e.g. under a
abnormal sole wear. Some examples follow. single metatarsal head.
When the slight curvature on the undersurface of
the sole is not apparent, or is not symmetrical or
Wear on the heel
exaggerated, abnormal toe function is indicated.
This is often the case in patients with rheumatoid The normal wear on a heel (see Fig. 10.13)
arthritis who may have reduced toe function and spreads along the posterolateral border of the
a short stride. Insufficient wear on the posterior heel. Wear is not central, as might be expected,
part of the sole indicates a heel to ball length for several reasons: the entire calcaneus lies
which is too short and, when combined with towards the lateral side of the inside of the heel
excessive wear, at the tip of the sole, means that of the shoe; the weightbearing tubercle is lateral
the whole shoe is not long enough. Wear at the to the midline of the heel; and the calcaneum is
tip of the sole alone may indicate that the shoe inverted at heel contact.
has been made on a last designed without Excessive wear along the lateral margin of the
enough toe spring, but insufficient wear in this heel may indicate an inverted hindfoot, but this
area denotes lack of push-off. Excessive wear to pattern is also seen in genu varum. Similarly,
the sole of the shoe may indicate limited excessive wear on the inner aspect of the heel
dorsiflexion if it is towards the front of the sole, may indicate a valgus or everted hindfoot, but is
and pes cavus when it is across the tread without also seen in cases of genu valgum.
Figure 10.14 The pattern of wear seen in the shoe of a patient with pes cavus.
FOOTWEAR ASSESSMENT 263
A B
Figure 10.15 Crease marks on the upper A. Normal crease marks B. Crease marks with hallux rigidus.
264 SYSTEMS EXAMINATION
Examination of the inside of the shoe the most common observations, divided into
The assessment of wear should also include an good and less good aspects. Such a list could be
examination of the inside of the shoe. The wear used as a quick record of the examination by cir-
patterns inside are likely to mirror those found cling the appropriate shoe feature. The suitabil-
on the heel and sole. Additional features such as ity/ unsuitability would then be shown by the
creases, seams or rough areas and even nails column in which the circles had been made.
through the sole may be the cause of localised A shoe which was originally suitable may
lesions. The insock will often display a print of become unsuitable through age. Some shoe com-
the sole of the foot from which the areas taking ponents deteriorate over time, e.g. the insole,
greatest pressure can be observed. which may become cracked or hollowed.
Additionally, feet change shape with age and fit
may be compromised. A shoe may also be unsuit-
Other signs of wear
able if it is inappropriate for the conditions/situ-
The shoes of patients with diabetes mellitus may ation in which it is worn. A common example of
show a characteristic white deposit, sometimes this is found in patients with rheumatoid arthri-
accompanied by deterioration along the inner tis who, because of the difficulty of finding
sides. These signs of wear have been publicised footwear to fit, wear sandals all year round.
by the Shoe and Allied Trades Research
Association (SATRA) who found the white sub-
stance to be glucose and the deterioration due to Everyday shoes
contamination by urine. The preceding checks of suitability, fit and wear
will only be meaningful if they relate to the
Suitability patients' everyday shoes. Even if the shoes
assessed are representative they may be fairly
Table 10.4 lists the points that should be noted in new or have been recently repaired and there is a
the examination of shoe suitability, together with great deal of information to be gained from
examining more than one pair of shoes. New
patients should be routinely asked to bring
Table 10.4 Points to note in examination of shoe suitability
several pairs of footwear for examination. There
Points Good Bad are other occasions when it might be helpful to
see a selection of footwear, e.g. when assessing a
Style of shoes Lace-up, sandal, Court, mule, clog
boot, moccasin patient for orthoses. Another reason for asking to
Method of fixation Lace, buckle and Elastic, none see additional footwear is to overcome the possi-
bar, velcro bility that the shoes, which apparently conform
Heel height Flat High-heeled to the advice given, are being worn only for visits
Upper material Leather Synthetic to the clinic.
Sale material Synthetic, leather
Condition New, scuffed, worn Worn out
Sale wear Normal Abnormal
Hosiery
patterns Socks and stockings that are too small restrict the
Upper crease Normal Abnormal circulation to the foot and can do just as much
pattern
damage to the toes as shoes that do not fit.
Fit Length Good Too small/long
Width Good Too wide/narrow Hosiery fit should therefore be checked at the
Depth Good Too shallow/deep same time as shoe fit and this is particularly
Heel to ball Correct Too long/short important in children, where the foot is still
Flare Good Bad
growing. Socks and stockings may be outgrown,
Construction Welted, cemented, moccasin, moulded
have shrunk with inappropriate washing or
Type Dress, casual, sports, work
simply have been bought too small. The sizing of
FOOTWEAR ASSESSMENT 265
stretch socks can lead to confusion as the range of process, known as wicking, keeps the foot dry
sizes printed on the label indicates the range but will not take place if shoes are made of, or
from unstretched to full stretch. Socks will be lined with, synthetic material.
more comfortable and cause fewer compression
problems if the unstretched size corresponds to
SUMMARY
the shoe size.
The materials used in the manufacture of This chapter has described the factors which
hosiery can affect foot health. Socks made of should be included in an assessment of footwear.
natural fibres may be needed by patients with The reader should now be able to judge the suit-
skin conditions such as eczema, but a mixture of ability of footwear and whether it is contributing
natural fibres and synthetic substances is often to the foot problems experienced by the patient.
an advantage, as the synthetic material can help The ability to use footwear assessment to both
to keep the foot dry. Natural fibres absorb mois- the advantage of the patient and the practitioner
ture and remain damp. Synthetic fibres let the will come only with experience, but it is hoped
moisture pass through to an absorbent surface on that the importance of this often neglected aspect
the other side, for example a leather upper. This has been clearly demonstrated.
REFERENCES
British Footwear Association 1998 Footwear facts and Lawlor L 1996 Where will this shoe take you? A walk
figures, 1998 edition. British Footwear Association, through the history of footwear. Walker & Company
London McCourt F 2000 A problem of attribution in forensic
Frey C 1995 Pain and deformity in women's feet ... are podiatry. British Journal of Podiatry 13: 107-110
shoes the cause? Journal of Musculoskeletal Medicine 15: Reardon K 1999 Lowdown on the right shoe. The Times
35-38,43--46 Weekend 13 March: 5
Frey C, Thompson F, Smith J, Sanders M, Horstman H 1992 Stevens G 1995 Society news. Journal of Podiatric Medicine
American Orthopaedic Foot and Ankle Society women's 50: 10
shoe survey. Foot and Ankle International 2: 78-81
FURTHER READING
Hughes J R (ed) 1982 Footwear and footcare for children. Sources of information
Disabled Living Foundation, London
Hughes J R 1983 Footcare and footwear for adults. Disabled Disabled Living Foundation (DLF), 380-384 Harrow
Living Foundation, London Road, London W9 2HU
Hunt G C (ed) 1988 Physical therapy of the foot and ankle.
Churchill Livingstone, New York Independent Footwear Retailers Association, PO Box
247, London W4 SEX
Shoe and Allied Trades Research Association
(SATRA), Rockingham Road, Kettering, Northants
NN169JH
CHAPTER CONTENTS
Introduction 269
GENERATION OF X-RAYS
X-rays are generated by the passage of a high
voltage through a heated coiled tungsten wire
(the cathode) in a toughened glass tube contain-
ing a vacuum, producing free electrons in a
process known as thermionic emission. At the
269
270 LABORATORY AND HOSPITAL INVESTIGATIONS
other end of the tube is the anode, consisting of and is therefore far safer for the patient and oper-
a heavy metal disc, normally tungsten, embed- ator. The SI unit of radiation absorbed dose is the
ded in a copper bar, which rotates to absorb heat. gray (Cy).
When a high potential difference is applied
between the electrodes the electrons from the
cathode stream at high velocity towards the
The effects of radiation on tissue
anode (cathode rays) and bombard the tungsten All ionising radiations are harmful to living
target. If a positive nucleus of a target atom is tissue, and must be accorded the greatest
bombarded by fast-moving free negatively- respect. It is a firm principle that the advantage
charged electrons from another source a repul- to the patient of having a radiographic exami-
sion and braking effect (the bremsstrahlung nation should outweigh the associated radiation
process) takes place. The electrons decelerate hazard. Effects of radiation may be somatic or
and emit energy in the form of radiation and if genetic. Radiation suppresses the ability of cells
the energy levels are high enough the radiation to reproduce. The sensitivity to radiation is
is in the form of X-rays. The bombardment of related to oxygen saturation of the cells. Neural
atoms heavier than sodium, such as tungsten, by tissue is the least sensitive, and blood cells and
free electrons will produce a high energy wave bone marrow are the most easily damaged,
of X-rays in the range 10- 7-10-10 em, as well as leading to anaemia and leukaemia in severe
other charged particles known as alpha particles, cases of overexposure. The thyroid gland and
beta particles and gamma rays. The resulting the lens of the eye are also vulnerable. The
X-rays are focused as required by a light-beam gonads are radiosensitive and temporary or per-
diaphragm - lead shields, visually aligned on manent sterility, or even genetic mutations, can
the patient with a beam of light. be caused by the excessive irradiation of the
Radiation is able to penetrate dense objects for gonads of a person of reproductive age
a certain distance, dependent upon both the (Swallow et al 1986). However, the low level of
density of the object and the power of the radia- dosage received in most properly conducted
tion beam. X-rays produced by low voltages, radiographic examinations, and in particular
below 50 kV, will not penetrate tissue for any with the foot, means that there is absolutely
great distance and may be considered 'soft' minimal risk of any damage.
X-rays. Those produced by higher voltages pene-
trate for increasing distances and are known as
'hard' X-rays.
ORDERING AN X-RAY
When an X-ray beam passes through tissues, Any practitioner in the United Kingdom who
such as the foot, and strikes a sensitive film emul- wishes to clinically or physically direct Xvradia-
sion, it produces a chemical change and forms a tion must have core knowledge training as stipu-
negative image of the tissues, which may be lated in the Ionising Radiation (Medical
viewed once the film has been processed. The Exposure) Regulations 2000. The course, usually
most dense tissue, i.e. bone, is shown as white arranged by physicists, will make the practi-
and the less dense tissues are shown as increas- tioner aware of all the safety aspects and the code
ing shades of grey and black. In practice it takes of practice relating to the direction of radiation. If
quite a large amount of X-radiation to alter the the patient is referred by the practitioner to an X-
film: to reduce the patient dose, the film is nor- ray department the core knowledge training is
mally placed in a cassette containing rare earth not necessary as the radiologist is deemed to be
intensifying screens. These screens fluoresce clinically directing the examination.
when struck by relatively small amounts of radi- For an investigation to be of maximum use to
ation and it is the fluorescence that changes the the practitioner the reason for the referral, any
film. This reduces the radiation dosage required relevant clinical history, the information sought,
by up to 90%, depending on the type of screen, the views required and whether or not they
RADIOGRAPHIC ASSESSMENT 271
..
Figure 11.2 Dorsiplantar view shows a mild hallux
abductus deformity. Note also the bipartite medial sesamoid,
and additional sesamoid under the second and fifth
metatarsal heads.
Figure 11.4 Positioning for lateral view (weightbearing). A typical lateral view, giving a good outline of the talus, calcaneum
and medial column. Compare with Figure 11.16.
RADIOGRAPHIC ASSESSMENT 273
Figure 11.6 Anteroposterior view of ankle. This view clearly shows the lower ends of the tibia and fibula and outlines the
trochlear surface of the talus. In this case there is a history of an old avulsion fracture of the fibular malleolus and non-
union of a small fragment at the apex.
274 LABORATORY AND HOSPITAL INVESTIGATIONS
Figure 11.8 Axial view ofsesamoids. The sesamoids under the head ofthe first metatarsal are clearly seen, together with
the intersesamoidal ridge. In addition, there is a sesamoid underlying the fifth metatarsal head.
RADIOGRAPHIC ASSESSMENT 275
BASIC RADIOLOGICAL
ASSESSMENT
There is a vast amount of information that may
be deduced from the careful study of an X-ray.
Increased or decreased bone density, soft tissue
abnormalities, age, degenerative change, trauma,
metabolic disease, biomechanical abnormalities,
foreign bodies and surgical interventions will all
be reflected in the film. It takes much practice
and knowledge to detect some of the subtler
alterations in appearance. For this reason it can
help to adopt a system of assessment in order to
avoid missing important basic clues to a disorder.
A system which has found favour amongst some
is known as the ABCS of radiological assessment,
where:
A = Alignment and variations
B = Bone density
C = Cartilage
S = Soft tissue.
Alignment
In order to make judgements about the biome-
chanical features of a particular foot as seen on
X-ray it is important to decide how the picture
was taken. One cannot assess with accuracy any
osseous malalignment if the film was not taken
weightbearing, and preferably in normal angle
and base of gait. Since not many imaging
departments actually take films in this way, a
cautious approach should be adopted. How-
ever, one may certainly make some generalisa-
tions about the appearance of a 'normal' foot on
weightbearing dorsiplantar and lateral views. It
is sometimes useful to draw angles and refer-
ence points on acetate sheets overlying the
films. Angles quoted below should be consid-
ered as broad guidelines only.
In this section the commonly seen anatomical
variations, in particular accessory sesamoids,
will be discussed.
be measured against a bisection of the tarsus Further distally the metatarso cuneiform
(Fig. 11.12). The shift of the talus and lesser joints, the fifth metatarsocuboid joint and the
tarsus are somewhat reversed in a supinated intermetatarsal joints are visible, although
foot structure, although the talus clearly cannot superimposed. There is a notch present between
move very far laterally and there is a denser the first and second metatarsal bases, the
superimposition of the bones. metatarsocuneiform split, greater in some cases
The articular surface of the navicular with the than others. This may be related to the angle of
three cuneiforms should be clearly visible. It the distal surface of the medial cuneiform. The
should be possible to see the outlines of the base of the first metatarsal appears to have an
cuneiforms, but it can be difficult to see the facets additional transverse facet. This is in fact a
of all the intercuneiform joints due to superim- superimposition of the plantar aspect of the
position. In a case of osteoarthritic degeneration metatarsal base, which is cup-shaped.
the joints of the whole lesser tarsus can become The lesser four metatarsals are normally par-
indistinct. allel and virtually straight, with the fifth
metatarsal sometimes exhibiting a lateral
bowing, depending on the exact angle of the
X-ray beam. A longitudinal bisection may be
drawn of the second metatarsal and compared
to a bisection of the lesser tarsus. The resulting
angle, the metatarsus adduction angle, can be of
some value in determining whether or not the
condition of metatarsus adductus exists (Fig.
11.12). Some authorities believe that a normal
range would be 10-20°, with a higher figure
indicating that the condition is present. There
will be an increase of this angle in a supinated
foot and greater superimposition of the
metatarsal bases over each other.
Of great importance is the relationship
between the first metatarsal and the others.
Construction of longitudinal bisections of the
first and second metatarsals enables the metatar-
sus primus adducius angle to be measured
(Fig. 11.12). Most authorities consider that the
norm is 8-10°. Naturally, this angle increases
dramatically in cases of metatarsus primus
adductus, a component of a hallux abductoval-
gus deformity, and the intermetatarsal space
widens.
The first metatarsal sesamoids normally lie
approximately 0.5 em proximal to the articular
surface of the metatarsal head, approximately in
the midline, and should appear as two smooth
ovoid structures. They may be bipartite or multi-
partite. This does not necessarily indicate disease
Figure 11.12 Biomechanical evaluation of a DP view. or injury, although sesamoids can fracture like
Diagram to show: lesser tarsus abduction angle (A),
metatarsus adductus angle (B), metatarsus primus adductus any other bone. Since they underlie the
angle (C) and hallux abductus angle (D). metatarsal there is an increased depth of bone for
278 LABORATORY AND HOSPITAL INVESTIGATIONS
the X-ray to penetrate. As a result they appear portion of the cartilaginous surfaces in apposi-
more dense than the rest of the metatarsal. In a tion. The valgus rotation that occurs may be
case of developing hallux abductus, the clearly seen in advanced cases, with the plantar
sesamoids progressively move laterally, with the condyles of the proximal phalanx becoming pro-
lateral sesamoid eventually ending up in the gressively more visible. The resultant degenera-
interspace between the first and second tive changes will be discussed later.
metatarsals, the medial sesamoid following Deviation of the cartilaginous surface of the
closely behind. The sesamoidal position can be metatarsal can in some cases be identified and
plotted against the metatarsal bisection if quantified by construction of the proximal articu-
required. lar set angle (PASA). This angle has relevance in
The drawing of arcs from the intersection of the planning of surgical procedures for hallux
the metatarsal bisections allows the relative abductovalgus (Fig. 11.14). A deviation in
lengths of the first and second metatarsals to the shaft of the proximal phalanx of the hallux
be assessed, the metatarsal protrusion distance itself can be identified by drawing the distal
(Fig. 11.13). This latter measurement is generally articular set angle (DASA) (Fig. 11.15). This type
considered normal at ± 2 mm. of deformity is sometimes responsible for the
In the ideal foot the hallux articulates com- abduction deformity sometimes seen in a hallux
pletely with the metatarsal. If a bisection of the when the first metatarsophalangeal joint align-
shaft is drawn and compared to the metatarsal ment is normal.
bisection the hallux abduction angle can be mea- Occasionally, a hallux will have an interpha-
sured (see Fig. 11.12). The hallux may normally langeal joint abduction deformity which can lead
deviate laterally by a small amount, compensat- to the distal abduction deformity sometimes
ing in effect for the normal metatarsus primus referred to as 'terminal valgus'.
adductus angle. Less than 15° is generally con- The alignment of the digits may vary. Even the
sidered acceptable. In hallux abductus this angle most normal toes are not actually straight, but they
increases and the articulation becomes progres- should sit congruously on to the ends of the
sively less congruous until a partial lateral sub- metatarsals. However, abduction, adduction, sub-
luxation occurs, with only a relatively small luxation, dislocation and flexion deformities are
Xmm
Figure 11.13 Measurement of metatarsal protrusion Figure 11.14 Proximal articular set angle (PASA). Aline
distance. Bisections ofthe metatarsal shafts are extended representing the limits ofthe articular cartilage on the
proximally, and arcs are drawn to the articular surfaces. The metatarsal head is compared to a perpendicular to the
distance between the two arcs is measured. bisection ofthe metatarsal shaft.
RADIOGRAPHIC ASSESSMENT 279
Lateral view
A weightbearing lateral view will yield much
useful information (Fig. 11.16). The malleoli of
the tibia and fibula will be seen superimposed
DASA over the trochlear surface of the talus. The malle-
oli should be smooth in outline, as should the
trochlear surface. The talus should be domed.
Undue flattening or irregularity may be indica-
tive of degenerative disease.
The facets of the subtalar joint should be
clearly demarcated and the sustentaculum tali
and sinus tarsi readily apparent. The facets and
Figure 11.15 Distal articular set angle (DASA). A line the sinus tarsi become obscured in a pronated
representing the articular surface of the proximal phalanx is foot and more visible in a supinated one. The
compared to a perpendicular to the bisection of the calcaneum is inclined to the supporting surface,
phalangeal shaft.
and the calcaneal inclination angle can be easily
measured (Fig. 11.17). The normal angle will
exceedingly common. The superimposition of vary according to the midtarsal joint axes of
sometimes very small phalanges can sometimes motion for any particular foot: 0-10° would be
make it difficult to decide on the presence or considered low, 11-20° medium and 21-30°
absence of bony ankyloses or other pathologies. high. However, the measured angle will vary
Figure 11.16 Lateral view (weightbearing). In this pronated foot the talus is displaced medially and plantarly, obscuring the
facets of the subtalar joint. The cyma line has a marked anterior break, with the smooth curve being invisible, and a bisection
of the talar neck would clearly fall below the level of the first metatarsal shaft. The calcaneal inclination angle is low. Compare
this foot to that shown in Figure 11.4.
280 LABORATORY AND HOSPITAL INVESTIGATIONS
Figure 11.19 Accessory ossicles - os tibiale externum. In this case, os tibiale externum occurs bilaterally in a slightly
pronated foot. The ossicle on the right foot is bipartite.
Bone density
Bone is in a constant state of change: new bone
formation by osteoblasts normally being balanced
by the resorptive activity of osteoclasts. These
activities are governed by the endocrine systems,
and are also altered by chemical and vitamin
factors in the blood, by diet, by malabsorption
from the gut, by disease and repair processes and
by physical forces to which the bone is subjected.
The growth and maturation processes are
beyond the scope of this chapter, but are well
described in many standard textbooks, e.g.
Parsons (1980) and Kumar & Clark (1990).
An area of increased density to X-rays, which
will produce a whiter shadow on the film, is
known as increased radiopacity; decreased density,
which occurs at the menopause: 30% of post- there may be calcification of joint cartilages, chon-
menopausal women will suffer significant osteo- drocalcinosis, in long-standing cases.
porosis, which is largely preventable with Osteoporosis occurs on a local level following
replacement therapy. It is less well known that a period of disuse of a limb: e.g. after injury or
approximately 5% of men in middle age will also surgery when immobilisation has been
develop osteoporosis (National Osteoporosis employed; quite marked demineralisation can
Society 1993). sometimes be seen, temporarily, following a
Hypopituitarism reduces bone growth and pro- metatarsal osteotomy, which quickly reverses
duces short, slender bones with thin cortices. when stress and function return. Occasionally,
There are delays in epiphyseal fusion. there is an abnormal response to quite minor
Hyperactivity of the adrenal glands, or a pitu- injury, leading to the condition of reflex sympa-
itary adenoma, may cause the generalised osteo- thetic dystrophy. As well as swelling, pain and
porosis of Cushing's syndrome. There are around stiffness which are out of proportion to the
11 000 sufferers from Turner's syndrome in the UK, injury, there may be radiographic evidence of
who have undeveloped ovaries and are likely to irregular mottled osteoporosis distal to the
have osteoporosis. injury site. This radiographic appearance is
Hyperthyroidism, which could be due to exces- known as Sudeck's atrophy.
sive thyroid hormone replacement therapy, Autoimmune disease processes such as
increases the rate of bone remodelling. Faster rheumatoid arthritis produce specific bone
resorption than new bone formation occurs, density changes which will be dealt with later.
which may cause thinning of the cortices. Stress Finally, it is known that excessive smoking or
fractures can occur in the long bones. alcohol intake may playa part in osteoporosis.
Interference with vitamin 0 intake or one of
several disorders of vitamin D metabolism causes
Osteosclerosis
rickets in children, i.e. prior to epiphyseal closure,
and osteomalacia in adults. Malabsorption due to One may also see increased bone density on
intestinal disease or gastrectomy may be a factor. X-ray. Most commonly it is found in areas of
Sufferers from anorexia nervosa or bulimia higher stress, where the osteoblastic activity
should be considered at-risk patients for osteo- increases to cope with the forces. This will also be
porosis, as should ballet dancers and gymnasts observed around healing fracture sites. In these
who may deliberately starve themselves. In chil- cases the resulting bone will always be sclerotic
dren this leads to characteristic deformities of even after the resorptive osteoclastic activity.
wrists and legs, with enlargement and irregulari- Hypoparathyroidism, a deficiency of parathor-
ties of the epiphyseal plates, and generalised mone, results in blood calcium levels falling and
osteoporosis due to failure of the osteoid tissue to phosphate levels rising. The syndrome can result
mineralise. In the adult there is softening and in short lesser metatarsals, calcification in some
deformation of the bones, with diminished ligaments of the spine and in some cases
density. There may be evidence of stress fractures. increased sclerosis.
Hyperparathyroidism, due to hyperplasia of the Hypervitaminosis D can lead to increased distal
parathyroid glands (primary type), persistent metaphyseal calcification and calcium deposits in
stimulation due to low serum calcium levels (sec- the skin and periosteum.
ondary type) or an adenoma (tertiary type) or car- Paget's disease is a common disorder of
cinoma, will reduce bone density by resorption of unknown origin, although there may be inherited
calcium salts. Not all cases will show definite factors. There is speculation and research into a
osseous changes, but there may be subperiosteal low-grade viral involvement. It is secondary in
thinning of the long bone cortices, particularly the prevalence to osteoporosis and 0.5-1.0% of 45-54-
digits, and distal resorption. 'Brown tumours' year-olds and 10-20% of those over 85 will be
may be noted expanding the long bone shafts and affected. Males are more commonly affected than
RADIOGRAPHIC ASSESSMENT 285
females. Symptoms such as paraesthesia and pain 1-2 mm of blackness, which represents the carti-
are frequently related to nerve compression. The laginous surfaces. Careful examination may
disease causes excessive bone resorption fol- reveal the approximate edges of the cartilage sur-
lowed by haphazard new bone formation and faces. In a joint which is malaligned or commenc-
remodelling. Isolated bones or the entire skeleton ing a disease process one of the first signs will be
may be involved, and severe characteristic thick- changes in the cartilage space. This can usefully
ening and deformity may result. The foot is rarely be compared to similar joints elsewhere in the
involved except for the calcaneum. Although the foot. The space may become narrowed evenly or
bones are very enlarged and appear dense on X- unevenly, may become calcified and may eventu-
ray they are of poor quality; microfractures are ally disappear totally, for example in advanced
not uncommon. It should be remembered that osteoarthrosis, or may be increased in cases of
Paget's disease predisposes to an increased inci- joint effusion or early rheumatoid disease. These
dence of osteosarcoma and fibrosarcoma, conditions will be dealt with later under the head-
although less than 1% progress to a malignancy. ings of arthritis and rheumatoid disease.
Metastatic bone disease from primary carcino-
mata elsewhere, such as the breast, may show
Soft tissue
sclerotic deposits, although the majority of
metastases produce lytic changes. Secondary On a normal X-ray there will be very little soft
metastases are uncommon, but not unknown, in tissue evident although the outline of the foot
the foot. Some primary bone tumours also will be delineated. There will be no details else-
produce sclerotic changes, and these will be dealt where and any space-occupying lesion would
with separately. have to be diagnosed purely on bony malalign-
Osteopetrosis (Albers-Schonberg disease or ment in the same way as cartilage damage. For
marble bone disease) is a rare hereditary disorder example an intermetatarsal bursa may cause
causing thickening of the trabeculae in all the splaying of the adjacent metatarsals and proxi-
bones; in particular there may be dense bands in mal phalanges. It is important in the primary
the vertebrae. Although the bones are dense they assessment of the film to compare soft tissue
are more susceptible to shear forces and may thicknesses and densities with other sections of
fracture more easily. the feet. With a 'soft' X-ray taken at a lower
Increased fluorine ingestion (fluorosis) over power there will be progressively more soft
many years may result in the laying down of new tissue visible. If the X-ray has been particularly
bone inside the medullary cavity of long bones, requested for a suspected soft tissue lesion this
leading to a sclerotic appearance. There may also should be clearly stated on the request form. It is
be periosteal outgrowths. sometimes possible to see the shadow of a neo-
Epiphyseal, metaphyseal and diaphyseal dus- plasm such as a large ganglion (Fig. 11.22), but
plasias, which form a whole group of hereditary this cannot be relied on for diagnosis.
and congenital traits, may lead to many permu- Soft tissues can become more visible when
tations of growth disorders, some of which involved in disease processes. Long-standing dia-
involve increased bone density. betes may cause calcification of the small arteries,
which appear as small white 'worms', particu-
larly between the first and second metatarsals
Cartilage along the course of the dorsalis pedis artery.
Ordinarily one does not see cartilage on X-ray as Similar changes may be seen in cases of hyper-
it is radiolucent. The condition of cartilage really parathyroidism and arteriosclerosis. Other
has to be assessed by the relationship of the adja- tissues may have calcareous deposits, particu-
cent bones in a joint. For example, a healthy larly the muscles and tendons following injury, in
metatarsophalangeal joint will show smoothly which case the condition is known as myositis
outlined joint surfaces evenly separated by ossificans. All bursae are capable of undergoing
286 LABORATORY AND HOSPITAL INVESTIGATIONS
phate crystals which lead to intracapsular effu- and gives a fuzzy outline to the bone. The bone
sion, increased soft tissue density and increased will lose density and appear hazy. In time, a loose
joint space. Calcium salts may mimic gout in the body or sequestrum may be formed (Figs 11.25and
condition of calcinosis cutis, a collagen disease, 11.26). This can be passed to the surface by sinus
but the deposits, which are clearly visible, gener- formation, or it may eventually be reabsorbed or
ally occur well away from joint margins. remodelled. In some cases a remodelling of the
Normally, the periosteum is not visible unless cortex may produce a sclerotic osseous shell, an
pathological changes are occurring. The perios- involucrum, which encapsulates the sequestrum. If
teum may become elevated and visible due to treatment is inefficient a chronic walled-off
inflammation, infection or trauma and may in abscess containing debris and sometimes a
turn become calcified. sequestrum may form and can persist for years.
The condition of xanthoma tuberosum multiplex, Known as Brodie's abscess, this appears as a
believed to be endocrine in origin, can be respon- rarefied ovoid area and may particularly be seen
sible for large, benign, clearly delineated soft at the metaphyseal areas of long bones.
tissue masses which have a marked increase in
density. They can occur in relation to synovial Osteoarthritis
tendon sheaths and bursae in the foot and else-
where. The signs and symptoms of degenerative
osteoarthritis are well known. On X-ray the
RADIOLOGICAL ASSESSMENT OF
SPECIFIC PATHOLOGIES
Infection
It is important to recognise the development of
infection in bone on radiographic evidence as well
as by clinical presentation, although radiological
changes may not be present in the osseous struc-
tures for some time. The first signs are unlikely to
appear for 10 days or more. Infection may be
blood-borne, or a focus from elsewhere in the
body, or secondary to a direct entry wound such
as surgery or a compound fracture. Although
bone and joint infections can be due to diseases
such as tuberculosis (dramatically on the increase
worldwide), leprosy, syphilis or viral agents such
as smallpox, the most common infections are the
acute bacterial infections due to organisms such as
Staphylococcus aureus, Staphylococcus pyogenes,
Salmonella or Haemophilus influenzae. The infection
spreads firstly into the medullary bone but will
not cross the epiphyseal line. One of the first signs
is increased soft tissue density and swelling,
which should be readily apparent on X-ray.
Infection then passes through the cortex, and the
pus produced elevates and strips the periosteum. Figure 11.25 Osteomyelitis. Chronic osteomyelitis in this
neuropathic diabetic foot has destroyed much of the fifth
The first visible osseous change will often be the metatarsal and phalanges. Note the characteristic fuzzy
subperiosteal reaction, which lifts the periosteum outline of the elevated periosteum.
288 LABORATORY AND HOSPITAL INVESTIGATIONS
-----------------------_._-- ---------------------
Figure 11.26 Osteomyelitis. Almost complete destruction of the neck of the talus and all midtarsal bones, due to chronic
osteomyelitis.
• Comminuted fractures, in which there is Week 2-3 A fibrosis occurs in the initial blood clot and
calcification forms between the broken ends,
splintering or fragmentation. and may be visualised as a fuzzy plug of
• Impacted fractures, where one bone is driven tissue. The bone edges will be more blurred.
forcibly into the other. If the fracture is immobilised there will be
little or no extra callus formation. A fracture
• Avulsion fractures, where a chip of bone is that remains mobile will produce an
ripped away by fibrous attachment such as increased amount of calcified tissue in the
muscle or ligament. Such fractures can area which can be seen clearly on X-ray.
occur in similar sites to accessory ossicles. Week 3-8 Calcification in an immobilised fracture
The fifth metatarsal base is a common site should be completed. The fracture line will
disappear and remodelling of any excess
for a fracture and for os vesalianum, and bone will eventually, over a period of
care must be taken to differentiate between months, restore nearly normal, but slightly
them. thickened contours in the bone (Fig. 11.30).
A fracture which has not been immobilised,
• Pathological fractures, which may occur due to or in which the bone ends are not apposed,
osteoporosis or in cases of primary or or in a patient with poor circulation or
secondary neoplastic bone disease. disease processes, may continue to delayed
or non-union and exhibit osteoporotic
Certain parts of the foot are prone to specific changes with extra bone callus continuing to
form; the fracture line will remain evident.
types of fracture:
292 LABORATORY AND HOSPITAL INVESTIGATIONS
------------ - - - - - - - - - - - - - - - - -
A B
Figure 11.32 Osteochondroma. A dorsiplantar view (A) and an oblique view (B) of a subungual exostosis on the hallux,
secondary to trauma. These lesions usually have a cartilaginous cap, classifying them as osteochondromata.
the medulla, but does not always expand the The differential diagnosis should include
bone. Brodie's abscess.
Aneurysmal bone cyst. A sponge-like cyst with Synovial chondromatosis. This condition
blood-filled spaces and fibrous septa, this may occurs mainly in young or middle-aged males.
arise as the result of a vascular anomaly. It tends Multiple metaplastic cartilaginous bodies form
to occur in the age range 20-30 years and has within the synovial membranes around a joint,
equal sex distribution: 50% of the cases are in the usually the knee or shoulder but occasionally in
long bone metaphyses. There is a rarefied central the digits. Sometimes they will become true loose
area with a thin cortical shell and the cyst will bodies within the joint. Radiographic appearance
rapidly expand and destroy bone tissue. is of multiple small calcified opacities, accompa-
Osteoid osteoma. A most painful lesion which nied by joint effusion and increased soft tissue
occurs most often in the long bones of the density.
extremities, with over 65% incidence in the
femur and tibia. No bones are exempt, includ-
Malignant bone tumours
ing the feet: 75% of cases are in 5-20-year-old
patients, with a sex ratio of 2 : 1 male to female. Osteosarcoma. The commonest primary
Radiologically it exhibits an ovoid translucent malignant bone neoplasm, osteosarcoma
nidus up to 2 em in diameter surrounded by an accounts for 40%. It is not common in the foot,
area of sclerosis. In fact the sclerosis may be having a 50% incidence in the lower end of the
such that it masks the radiolucent area. The femur and the upper ends of the tibia and
patient may complain of severe pain at night. humerus. It may occur secondarily to Paget's
294 LABORATORY AND HOSPITAL INVESTIGATIONS
Upper
Lower
Figure 11.33 Multiple enchondromatosis. Note the expansiie, thin-walled lesions in the fourth and fifth metatarsal shafts (A).
The patient had similar lesions in the metacarpals of the left hand. The lesions were noted to have increased vascularity on
isotope bone scans (B).
disease. An X-ray may reveal radiating 'sunray' Chondrosarcomas. These tumours arise from
spicules of bone raising the periosteum, cartilaginous tissue and are second in frequency
although this is not particularly common, and a to osteosarcoma. Primary cases arise within the
mixture of lysis or sclerosis within the shaft of medulla, mainly in the long bones and ribs, with
the bone. A wedge of ossified tissue can form 10% of cases in the spine. Secondary cases arise
under the periosteum and is called Cadman's tri- from pre-existing cartilaginous pathology. The
angle. Osteosarcoma can occur, but rarely, in soft tumours occur mainly in the age range 50-70
tissues. Radiologically it shows soft tissue years, with a sex ratio of 2: 1 male to female.
swelling and patchy density. They are rare in the foot but have been noted in
RADIOGRAPHIC ASSESSMENT 295
the calcaneum. Radiologically they can be very are around the knee, followed in incidence by
varied in appearance, imitating other lesions, but the radius and ulna, but they have been
classically they produce expansile 'grape-like' observed in hands and feet. They are vascular
lesions, with a calcified periphery and multiple tumours, which on X-ray present as expanded
calcified central foci. Chondrosarcoma can occur translucent areas with a thin cortical rim.
in an 'extraosseous form' in soft tissues away Sometimes the cortex is breached but there is no
from bone. active new bone formation present and there
Fibrosarcomas. These tumours are less may be little periosteal reaction (Fig. 11.34).
common than osteosarcomas and occur primarily Differential diagnosis should include the
in the 40-60 age range. They are highly destructive aneurysmal bone cyst.
tumours, producing expansile 'motheaten' lesions Ewing's tumour. This is a primary tumour of
with slight periosteal reaction in the major long bone that accounts for 5% of primary bone
bones and pelvis: 50% of cases occur around the tumours. The age range is generally 5-30 years,
knee joint. with the majority of cases aged 10-20 years.
Giant cell tumours. These tumours, of which Initially there may only be minor porotic
about 15% are malignant, account for about 4% changes visible on X-ray, with early periosteal
of histologically identified tumours. They occur change and delicate spiculisation being sugges-
primarily in the age range 16-45 years. There is tive of osteomyelitis. These later changes cause
an equal sex distribution: 50% of the growths considerable tissue destruction, with a mottled
Figure 11.34 Giant cell tumour: a large vascular tumour affecting the lower end of the tibia.
296 LABORATORY AND HOSPITAL INVESTIGATIONS
Figure 11.35 CT scans of a tarsal coalition. This is the same case as in Figure 11.21 and shows bilateral talocalcaneal bars.
The image (A) is a single frame from a series of 12 taken as 5-mm 'slices' at right angles to the subtalar joint (B) (for
orientation purposes the talus is superior to the calcaneum).
298 LABORATORY AND HOSPITAL INVESTIGATIONS
Figure 11.36 CT scan, in the transverse plane, of a Figure 11.37 Magnetic resonance imaging. A single frame
comminuted calcaneal fracture with clearly shown intra- from a series of slices taken in the sagittal plane. The
articular fragments. healthy bone marrow and plantar fat pad show white, the
musculature is grey, and the tendons, notably the Achilles
tendon, clearly show as dark grey/black.
for assessing periosteal new bone formation, or generally known as a three-phase bone scan
bone fragments and fractures. (Table 11.2).
The most commonly used isotope is tech-
netium-99, derived from molybdenum. It is used
Nuclear medicine - isotope scanning because of its short half-life (approximately
6 hours). Other isotopes such as gallium are still
The technique of nuclear labelling is an old one,
used, but the trend is towards technetium. The
first used in the 1940s with isotopes such as
gamma rays emitted are detected by a gamma
strontium-87 and fluorine-18. It relies on the fact
camera positioned above and close to the
that an inflamed or pathologically active area of
patient. The radioactivity is converted into light
the skeleton has an increased blood flow and
bone activity. If a suitable radioisotope is
injected intravenously with a phosphate marker
Table 11.2 Isotope scanning: three-phase bone scan
it will ultimately be taken up by osteoblasts in
the bone. There is an immediate distribution Phase Process
into the bloodstream and early images, pro-
Phase 1 Images are taken every 5 s for 30 s,
duced by gamma-ray emissions, may be taken (flow study) giving an indication of blood perfusion
(phase 1 - early blood pool imaging). Further into the area
images are then taken of the blood flow into the Phase 2 Images taken when the area is fully
area (phase 2 - late blood pool imaging). (blood pool study) perfused
Normally the patient will then return 2-4 hours Phase 3 An image taken 3-4 hours later, giving
later for assessment of the uptake into the (metabolic study) an indication of the amount of isotope
tracer that remains bound to bone
bone (phase 3 - bone imaging). The technique is
RADIOGRAPHIC ASSESSMENT 299
-----------------------------------------------------------------------
Figure 11.40 Large synovial tumour (pigmented villonodular synovitis) which destroyed the second metatarsophalangeal
joint A. X-ray which shows the marked erosions and soft tissue swelling. The diagnosis was aided by the use of a
technetium-99 isotope bone scan. 81 shows the phase 2 late blood pool phase and 82 shows the phase 3 bone imaging,
both of which confirmed greatly increased osteoblastic uptake.
reflected by bone, and this limits usage to the interpretation of results requires a very skilled
examination of superficial soft tissues, e.g. exam- operator. The images are transient and, hence, very
ination for partial or complete rupture of the observer-dependent.
Achilles tendon or for plantar digital neuroma.
An extension of ultrasound is Doppler imaging,
SUMMARY
which can detect and measure blood flow and
direction in major arteries and veins. The small- Imaging techniques provide considerable infor-
est artery measurable in the foot would be dor- mation about many pathologies, but these tech-
salis pedis. The images are colour-based, with niques should only be requested to aid diagnosis
arteries appearing red and veins blue. Doppler and provide effective treatment. Plain X-rays will
imaging has obvious applications in vascular always have a major role in the diagnosis of foot
and diabetic departments. pathologies. However, the foot specialist must
Whereas ultrasound has the advantages of being keep abreast of technological developments such
relatively cheap, non-invasive and portable as CT scanning, MRI and nuclear isotope scan-
(modern machines can be used in a patient's home ning, which may become more accessible in the
if required), it is very labour-intensive and the future.
RADIOGRAPHIC ASSESSMENT 301
REFERENCES
Kumar P J, Clark M L (eds) 1990 Clinical medicine, 2nd edn. radiations arising from medical and dental use. HMSO,
Bailliere Tindall, London London
National Osteoporosis Society 1993 Menopause and Parsons V A 1980 Colour atlas of bone disease. Wolfe
osteoporosis therapy. GP manual. National Osteoporosis Medical Publications, London
Society, London Swallow R A, Naylor E, Roebuck E J, Whitley A S 1986
National Radiological Protection Board 1988 Guidance Clark's positioning in radiography, 11th edn. Heinemann,
notes for the protection of persons against ionising London, pp 89-107
FURTHER READING
Aird EGA 1988 Basic physics for medical imaging. Murray R 0, Jacobson H G, Stoker 0 J 1990 The radiology of
Heinemann, London skeletal disorders, 3rd edn. Churchill Livingstone,
Berquist T H 1990 Magnetic resonance imaging of the foot Edinburgh
and ankle. Seminars in Ultrasound, CT and MR 11(4): Pavlov H 1990 Imaging of the foot and ankle. Radiologic
327-345 Clinics of North America 28(5): 991-1017
British Institute of Radiology 1992 Pregnancy and work in Rogers L F 1982 Radiology of skeletal trauma, Vol 2, 3rd
diagnostic imaging. British Institute of Radiology, edn. Churchill Livingstone, Edinburgh, ch 22-23
London Root M L, Orien W P, Weed J H 1977 Clinical biomechanics,
Bushong S C 1997 Radiologic science for technologists, 6th Vols 1 and 2. Clinical Biomechanics Corporation, Los
edn. Mosby, St Louis Angeles, California
Gamble F 0, Yale I 1975 Clinical foot roentgenology, 2nd Taussig M J 1979 Processes in pathology. Blackwell Scientific
edn. Krieger, Basle Publications, Oxford
McKillop J H, Fogelman I 1991 Benign and malignant bone Warren M J, [effree M A, Wilson 0 J, MacLarnon J C 1990
disease. Clinician's guide to nuclear medicine. Churchill Computed tomography in suspected tarsal coalition. Acta
Livingstone, Edinburgh Orthopaedica Scandinavica 61(6): 554-557
CHAPTER CONTENTS
Introduction 303
Summary 316
INTRODUCTION
Gait analysis is the systematic analysis and
assessment of human locomotion. Gait is a very
complex activity and as such there are many dif-
ferent ways to analyse it. The use of gait analysis
combined with a thorough clinical orthopaedic
assessment (Ch. 8) are powerful tools for identi-
fying pathomechanical mechanisms, guiding
therapeutic interventions, making treatment
decisions and monitoring the outcome of inter-
ventions. However, the identification of cause
from effect is often difficult because of the highly
developed compensatory feedback which oper-
ates during the gait cycle and the occurrence of
more than one pathology at the same time.
Gross abnormalities, such as a patient with a
marked limp or a child who is a toe walker, are
relatively easy to identify. Minor variations
from the 'normal' cause more difficulty and are
harder to spot and describe in a meaningful
way. This is not surprising if one considers how
fast events occur during walking: it takes only
650 ms to complete one full gait cycle.
Practitioners are therefore increasingly looking
towards methods of investigating gait in a sys-
tematic way which provides accurate, repro-
ducible and quantitative data.
There is no single satisfactory method of
analysing and quantifying gait. Additionally, tech-
nological advances in this field are rapid, espe-
cially in the development of software to assist in
"The editors wish to acknowledge the work of Steve West. This chapter is based on his work
in the previous edition.
303
304 LABORATORY AND HOSPITAL INVESTIGATIONS
the interpretation and analysis of data collected a person walk up and down an area that allows
by more sophisticated systems. New systems are sufficient space for up to 10 steps, usually a cor-
continually being developed. The reader is there- ridor in the clinical setting. Any deviations from
fore recommended to review medical and engi- the assumed normal that are relevant are noted.
neering journals to keep abreast of developments. Observational gait analysis is best done by sys-
tematically concentrating on one body part at a
time, then another, and usually one limb at a
HOW CAN GAIT BE ANALYSED? time. With experience many gait deviations can
Gait can be analysed by observation or by a be observed. The difficulty of observing one
variety of methodologies which produce quanti- body part at a time is that multiple movements in
tative data: multiple segments are occurring concurrently
and need to be observed. Checklists, such as the
• temporal and spatial parameters
one provided in Table 12.1, are usually helpful to
• kinetics work through, especially when learning.
• accelerometers Traditionally, the approach is to observe the limb
• kinematics as it moves through the different periods of the
• electromyography
stance phase - heel contact, midstance, propul-
• energy expenditure
sion. Another approach (Pathokinesiology
• multisystems. Service 1993) is to divide gait into weight accep-
Clinically based gait analysis methods include tance (initial contact and loading response),
observation and simple quantitative methods that single limb support (period when body pro-
provide useful data. Observation of a patient's gresses over single limb, and swing limb
gait can be assisted by the use of video and tread- advancement (time when one limb is unloaded
mills. Simple quantitative measures can be and the other limb is loaded) and note variations
achieved from techniques using paper, pen, tape from normal during these phases. A standardisa-
measure and stop watch. Clinically based tion of the form to record gait analysis has been
methods are simple to use, can provide repeatable presented by Southerland (1996). The approach
data and are relatively easy and relatively quick has introduced a shorthand form of notation for
to interpret. They are also relatively low tech. recording during gait analysis referred to as
Laboratory methods are reliant on sophisti- GHORT (gait homunculus observed relational
cated and expensive equipment, which can be tabular). Readers are referred to Southerland
quite costly. Specialist knowledge is required to (1996) for detailed information.
use and interpret the data. Purpose-designed gait In clinical practice, the observational analysis of
facilities can provide an adjunct to the clinical gait is usually used after the history and physical
examination but are often used solely for examination of the patient in order to evaluate the
research purposes. presence of any abnormal function that may be
responsible for the patient's presenting complaint.
The subsequent more detailed static and non-
OBSERVATION OF GAIT
weightbearing biomechanical evaluation can be
Observational or visual gait analysis is the guided to particular areas of interest by the gait
analysis of a subject's gait without the use of analysis. Of importance at this stage of the clinical
any equipment and is one of the more useful evaluation is a consistency between the observed
and widely used clinical tools available to prac- gait and the findings of the biomechanical evalua-
titioners. The analysis of gait in this way is sub- tion. For example, if a lot of transverse plane
jective and needs a substantial understanding of motion of the midfoot is observed in stance during
normal gait (Inman et al 1981, Perry 1992, Rose the gait analysis, a similar increase in the trans-
& Gamble 1993). verse plane direction of motions at the subtalar
Observational gait analysis involves watching and midtarsal joints should generally be observed.
METHODS OF ANALYSING GAIT 305
Table 12.1 Practical observational gait analysis hinders sagittal plane observation. The tradi-
• Observe for amounts and timing of events tional teaching of clinical biomechanics places
• Look for asymmetry great importance on frontal plane compensation
Concentrate on one aspect at a time for different pathomechanical entities, which
Bisection of caicaneus and posterior aspect of leg is often
helpful encourages the use of observation of gait to
A mark on the medial side of the navicular is also helpful observe frontal plane motion of the posterior
• Be aware that many individuals may consciously or aspect of the calcaneus. The observation of the
subconsciously alter gait while being observed
At least an 8-10 metre walkway is desirable with provi- calcaneus in the frontal plane is easy, but is not
sion for watching subjects from behind/in front (frontal necessarily indicative of any abnormal or com-
plane) as well as from the side (sagittal plane) pensatory gait patterns. For example, any abnor-
• Patient should be wearing shorts
• Observe with and without shoes and with and without mal compensatory movement of the calcaneus in
orthoses the frontal plane is entirely dependent on the
range of motion of the joints of the rearfoot
Frontal plane observations:
Upper body: complex and the orientation of the assumed posi-
Head/eyes level or tilted? tion of the subtalar joint axis. If the axis is more
Shoulders level? vertical than the assumed normal, there will be
Height of finger tips
Symmetrical arm swing very little motion of the calcaneus in the frontal
Pelvis level or tilted? plane, with more in the transverse plane. If the
Lower limb: axis is more horizontal, there will be more
Position of knee
Q angle/patellar position motion in the frontal plane, which may not be
Timing of knee motion pathological. Observational gait analysis is also
Position of tibia limited by the ability to observe transverse plane
Timing of tibial rotation
Foot: motions and the difficulty to observe and inter-
Timing/amount of rearfoot motion pret motion in all three planes simultaneously as
Timing/amount of heel contact/off well as motion occurring simultaneously at
1iming/amount of midfoot motion
Transfer from low gear to high gear during propulsion several joints.
Angle and base of gait In a clinical setting in patients with pathology,
Abductory twist? the observation of gait requires them to walk for
Prominent extensor tendons (extensor substitution)
Clawing of digits (flexor stabilisation) some time, which can be fatiguing for them. The
endurance of the patient needs to be considered.
Sagittal plane observations: There is no permanent record from observa-
Upper body:
Forward or backward tilt tional gait analysis - no opportunity to review
Symmetrical arm swing the data at a later date. The analysis is very
Lower limb: dependent upon the skill and experience of the
Position/timing of hip joint motion
Position/timing of knee joint motion observer. All the data are subjective and qualita-
Position/timing of ankle joint motion tive. When one observes an individual standing
Foot: on both feet, it is impossible to predict whether
Timing/amount of heel lift
Timing/amount of midtarsal joint motion the load (distribution of force) under both feet is
Timing/amount of first metatarsophalangeal joint motion equal. This highlights the fundamental drawback
of observation of gait: you cannot observe forces
and the eye can be easily deceived. Reliability
There is a tendency in clinical practice to focus studies on observational gait analysis show it to
on frontal plane motion during the gait analysis be somewhat unreliable (Goodkin & Diller 1973,
when motion in the transverse and sagittal Krebs et al1985, Saleh & Murdoch 1985). Despite
planes are just as important to appreciate gait. these limitations observational gait analysis pro-
This primarily occurs for several reasons. Most vides a good overall impression of gait and
clinics only have long corridors available which requires no equipment. Experienced observers
facilitate the observation in the frontal plane but use observational gait analysis to make critical
306 LABORATORY AND HOSPITAL INVESTIGATIONS
judgements, assist in diagnosis and determine of slow-motion video and freeze-frame can
the outcomes of interventions such as foot enhance observational gait analysis. With good
orthoses. pause and slow-motion facilities the finer and
Treadmill. One of the most debated areas of subtle features of gait that would otherwise be
gait analysis relates to the length of walkway missed can be observed. This will be dependent
required in order to achieve 'normal' walking on the frequency of sampling: below 30 Hz would
patterns: 4-6 metres is considered appropriate. be unsuitable, 50 Hz is the minimum for slow
Many practitioners have heightened the debate walking and 100 Hz would be required for
by using treadmills rather than long walkways. running, or too much movement happens
If a treadmill is used, one must ensure that the between each sampling frame to make the infor-
subject has every opportunity to adapt to tread- mation of any use.
mill walking prior to analysis being undertaken. If two cameras and a video mixer are used, it
This usually requires at least 15 minutes of is possible to view gait in two body planes
walking on the treadmill. The more exposure to simultaneously on the same split screen elimi-
treadmills, the shorter the time recorded to accli- nating the problem of cross-plane interpretation.
matise and perform consistently (Tollafield Initially, many practitioners do find the two
1990). Clearly, older patients and those with views confusing. Videotapes can be archived for
medical conditions are likely to fatigue more subsequent viewing and the comparison of
quickly. No matter how sophisticated the system before and after gaits following an intervention.
is, subjects must feel relaxed and comfortable Recent advances in computing now allow the
when being observed. Most authorities now taping of gait (either the traditional videotape or
accept that in order to achieve this objective, the digital) to be viewed on a computer. Some
subject should be allowed to walk at his/her systems (e.g. 'Irim-Fit'P') allow the drawing and
own cadence rather than being artificially con- calculation of angles between segments, the gen-
strained by walking in time to a metronome or eration of gait analysis reports and the linking of
some other timing device. A forced gait is of no the recorded gait into the patient's computerised
value to a practitioner attempting to assess records.
walking patterns. Disadvantages to the use of videotaping gait
For visual observation, treadmills facilitate are that the rotational deviations in the trans-
closer inspection of the gait as well as easy obser- verse plane cannot be seen. Movements out of
vation of gait in the sagittal plane. Additionally, the plane of the camera can also distort joint
treadmills are relatively inexpensive. However, angle and influence interpretations: e.g. if sagittal
safety and balance of patients need to be para- plane knee motion is being observed, the angle
mount in their use. There are subtle differences may appear less than it really is due to internal
between overground and treadmill gait that need rotation of the limb. The analysis of the videotape
to be taken into consideration, especially during is still qualitative and has been shown to be only
the propulsive phase, as on the treadmill the moderately reliable (Eastlock et al 1991, Keenan
'ground' is moving. & Bach 1996), but it is an improvement on the
Video. Videotaping of a movement for analysis straight visual observation of gait.
(overground or on a treadmill) is an improvement
on the traditional gait analysis. Observational gait
analysis is limited by the speed that motions METHODS OF QUANTITATIVE GAIT
happen at, meaning that the more subtle motions ANALYSIS
cannot be observed in real time. Many move-
ments take place in a very short time period. It
Temporal and spatial parameters
has been observed that events that happen faster As gait is repetitive, the measurement of the tem-
than 83 ms 0/12 second) cannot be perceived by poral (time) and spatial (distance) parameters are
the human eye (Gage & Ounpuu 1989), so the use an aid to evaluating critical events that occur
METHODS OF ANALYSING GAIT 307
._-- ----------
during gait. These parameters include stride strides per 120 s. The velocity can be calculated
length, stride time, step length, step time, double by the following formula:
support time, mean walking velocity, cadence Velocity (m/ s) = stride length (m) x cadence
and the ratios of left to right of these parameters. (steps/min)/120
It also includes toe-out/toe-in angles and width The above parameters can be recorded with
of the walking base (base of gait). These parame- basic equipment and can provide valuable clini-
ters are useful as a measure of an individual's cal information (Kippen 1993). Poster paints,
functional ability to ambulate: for example, less talcum powder, chalk, plaster of Paris, carbon
time will be spent in single limb support if that paper and various coloured inks have been used
limb is painful. to obtain footprint impressions (Wilkinson &
Step length. This parameter is the distance Menz 1997). These footprint impressions provide
from initial heel strike of one foot to the heel a permanent record of the foot placements
strike of the opposite foot. during gait and can be used to calculate a variety
Cadence. This parameter is the number of of parameters, as indicated in Figure 12.1.
steps taken per unit time, usually per minute. For Foot switches can be used to determine tem-
practical purposes, practitioners tend to count poral parameters; these are inexpensive and
the number of steps taken during a period of simple to use. The switches are either of a com-
10-15 s. When measuring cadence it is important pression closing type or force sensitive type.
that subjects are told to walk at their normal They are typically used under the heel, first
walking speed and as naturally as possible. The metatarsal and fifth metatarsal incorporated
observation count starts once the subject is into an insole or strapped to the area of the foot.
walking at normal speed. To estimate average They are activated when a certain threshold of
cadence per minute the following formula pressure is applied. Foot switches can be used in
should be applied: combination with other systems, such as elec-
Cadence (steps per minute) = steps counted x tromyography, so that the timing of critical
60/time(s) events such as heel contact, forefoot contact,
Stride length. The distance between two suc- heel off and forefoot off can be determined in
cessive placements of the same foot, stride length relationship to other variables or parameters
will therefore consist of two step lengths; this being measured.
parameter is usually measured in metres. Gait mats (e.g. GaitRite™, GaitMat™) consist
The walking base. Also known as stride width, of a long strip of walking surface that has
the walking base is the distance between the feet, embedded in it an array of switches running
usually measured at the midpoint of the heel; it is along the length and width of the mat. As sub-
recorded in millimetres. jects walk on the mat, the switches close and
Toe-out and toe-in. These parameters are a open, allowing the computer to calculate the
measure of foot position in relation to the line of timing of each switch. As the geometry of the
forward progression. It has been shown that mat is known, many of the temporal and spatial
foot position in relation to the line of forward parameters of gait, such as cadence, timing of
progression constantly changes during gait. To single and double support duration and stride
produce an 'average' the position the foot length, can be determined. These systems have
adopts for 10 steps is recorded and the mean is the advantage of being relatively low cost and
calculated. are portable.
The velocity of walking. This parameter, mea- The measurement of temporal and spatial
sured in metres per second, is the distance parameters can highlight pathology and changes
covered by the body in a given time in a particu- associated with disease or rehabilitation. Patients
lar direction. The mean velocity can be calculated such as those with rheumatoid arthritis,
as the product of cadence and stride length. The Parkinson's disease or paralysis will all show
cadence is measured in half strides per 60 s or full significant deviations from 'normal' parameters,
308 LABORATORY AND HOSPITAL INVESTIGATIONS
Kinetics of gait
This is the study and measurement of forces and
moments exerted on the body that influence
movement. Of direct relevance to the practitioner
is the recording of forces at the foot/floor inter-
face, measured, for example, via force platforms.
Lesion patterns give an indication of the site of
excess stresses but quantitative information
cannot be gained by observation (Duckworth et
aI1985). Consequently, some method of examin-
ing the plantar load distribution must be
employed.
Many authors use the terms 'force', 'load' and
'pressure' interchangeably. This practice is to be
discouraged. It is worth defining these terms and
others used in biomechanics (the study of the
effect of mechanical laws on the locomotor
system) from the outset.
Force. As defined by Newton's second law of
motion, Force is mass multiplied by acceleration.
Base of gait This law means that any time a force is applied to
an object, the object accelerates. Since accelera-
tion is the change in velocity divided by the
change in time, a force applied to an object will
produce a change in the object's velocity. Force
can therefore be considered as change in momen-
tum divided by change in time. Force is a vector
quantity, having both magnitude and direction.
Pressure. Pressure is force divided by area: the
'cOJo
larger the area the lower the pressure. This unit
'0
Q) has important implications when comparing dif-
Ol
c ferent measurement systems for measuring pres-
«
sure under the foot. For example, systems which
have large discrete element sizes may not be able
Figure 12.1 Spatial parameters that can be measured
to measure the true pressure under a small area
using a simple walkway, of the foot.
Researchers and practitioners are interested in
the interaction between the foot and shoe. The
e.g. short stride length, slow or fast cadence. fundamental questions being asked are:
However, it must be recognised that assessment • Is there a correlation between the loading
of these parameters on their own is not sufficient characteristics of the shod and unshod foot?
for a comprehensive overview of gait. Spatial and • What happens at the foot/ shoe interface?
temporal parameters vary during walking and • Is there a correlation between the loading
from one period of walking to another. characteristics measured at the shoe/floor
Consequently, it is important to view the data interface and those at the foot/floor interface?
with caution and to obtain a mean average for • Are the effects of foot orthoses influenced by
any parameter. the type of footwear?
METHODS OF ANALYSING GAIT 309
the light image into the lens of the video camera. their study it was found that the paper showed
The pattern observed shows the areas of little viscoelasticity, tackiness or other hystere-
increased light intensity with pressure. The sis-like effects and no evidence of saturation
video output can be captured via a frame over the pressure range studied. Hysteresis is
grabber and then manipulated and analysed by the lag between the release of stress and the ces-
software (Fig. 12.3). The pedobarograph is a sation of strain in materials subjected to tension
non-portable system that requires a raised or magnetism.
walkway into which it can be placed. The images This work highlighted the need for careful
produced provide high spatial resolution in con- interpretation of the data. The systems
tinuous greyscale or 16 colour zones. employed to measure load have within them
The pedobarograph has been well docu- characteristics that can affect the data. For
mented using both dynamic and static data example, the characteristics of the foil, when
(Betts & Duckworth 1978, Betts et al 1980b, measuring static loads, could provide loading
Hughes et al 1990, Minns & Craxford 1984). In data that was too high or too low because of the
most of these studies authors have used com- response time and hysteresis of the material. The
puter imaging techniques to zone the greyscale recovery time and recovery characteristics of the
images and enhance them with colour. Several material, once it has been loaded and unloaded,
investigations have been undertaken to establish is especially important when investigating
the effects of different foil characteristics on the dynamic loading. In the early pedobarograph
light intensity emitted. One study by Betts et al studies not only was the material slow to recover
(l980b) suggested that photographic paper with from loading but it also became tacky and
a pearl finish would be a suitable foil for cali- tended to stick to the glass surface even when
brated dynamic foot pressure measurements. In unloaded. This gave a false loading as a result of
Foil
Shielding
Light source
Force transducers
Mirror
Camera
the foil characteristics. The pedobarograph ing a hard copy print. The system provides
system can be calibrated and can measure pres- detailed numerical and graphical data on the
sures to 25 kg/ em? (2.45 MPa). forces applied to the foot (Fig. 12.4). The system
Recordings have been made of both static and has poor spatial resolution and does not analyse
dynamic loading with feet considered to be discrete pressures on the plantar surface of the
normal and abnormal. It has been stated that the foot. However, it should be noted that it can be
distribution of load between the sole of the foot calibrated and has been used to calibrate other
and a supporting surface can reveal information force measurement systems.
about both the structure and the function of the
foot (Lord 1981). As mentioned previously it is
Musgrave footprint
desirable to investigate the way in which the
plantar surface of the foot bears and transmits The Musgrave footprint is a computer-based
loads. system that can be used for the measurement of
plantar foot pressures. The footplate is a low-
profile plate which uses Interlink force sensitive
Force plates
resistors (FSRs) between aluminium plates. The
Force plates allow the measurement of vertical plates are often used in pairs to provide data of
and shear forces and centre of force application
under the foot. Force plates (e.g. Kistler'P',
AMTFM, Bertec'?') are fixed to the ground and LEFT RIGHT
are used to measure the ground reaction forces
exerted as the patient walks on to the plate
during gait. The plates normally need to be set in 10
both a temporal and spatial nature. The system is Insole pressure measurement systems have
interfaced through a standard PC and is therefore become commercially available, e.g. the German
relatively portable. Emed system, the Italian Orthomat and F-Scan.
The Musgrave plate can be calibrated and can The Emed system belongs to a class of devices
record pressures up to 15 kg/ em- (14.4 MPa). It characterised as matrix mats. In these devices,
produces data which can be displayed graphi- the individual sensors are formed electronically
cally, numerically or visually. The data presenta- at the intersection of rows and columns of
tion is clear and easy to interpret. Young et al conductive material (Nicol & Henning 1978).
(1993) undertook a comparative trial of the The F-Scan insole system consists of a printed
system against a pedobarograph and found that insole approximately 300 mm long, 105 mm
the Musgrave plate was unable to measure pres- wide across the forefoot, 70 mm wide across the
sures above 15 kg/ cm-. Such pressures have fre- heel and 0.02 mm thick. The insole is a multi-
quently been observed under the metatarsal layer, piezoresistive, screen-printed sensor sand-
heads of diabetic patients. The work concluded wiched in a moisture-resistant coating. The
that in low-pressure areas such as the heel the layers are held together by small glue spots at a
Musgrave footprint could provide comparable repeat distance of 1 cm square. This allows the
results to the pedobarograph. sensor insole to be cut to fit any size of
The Musgrave footprint tends to illustrate ver- shoe down to an adult size 4, providing care is
tical force as pressure values and cannot differ- taken not to cut through any required silver
entiate high shear force values. Callosity under connecting tracts.
the foot may not show high values unless the The ink tracts provide multiple sensors of
load under the foot has a long duration of contact identical characteristics. The sensors relay data
with the pressure platform. (Fig. 12.5) via silver tracts which are banded
together to exit the foot on the lateral aspect and
insert into a small, lightweight signal processing
In-shoe force measurement
unit worn by the subject just above the lateral
Many methods have been developed for record- malleolus. The data are presented to the practi-
ing foot loading while the foot is shod. tioner via a screen and/ or a printer supplying a
Piezoelectric discs have been attached to the one-to-one sized printout. The data presentation
plantar surface of the foot to record the different and collection is achieved via a user-friendly pro-
effect of heel height on forefoot loading gramme using windows and graphic display
(Schwartz & Heath 1947). Capacitive pressure keys that allows for several alternative data
transducers have been stuck to the sole of the display modes.
foot to record peak pressures in predetermined The insole sensors do not show a linear rela-
areas during gait in patients affected with tionship between resistance and pressure; algo-
Hansen's disease (Bauman & Brand 1963). rithms in the software are used to assign levels
Strain gauge transducers have been attached to to pressure. Since this is not linear, different
the forefoot and hindfoot of the sole of the shoe ranges can be achieved for high or low pres-
to record the total floor reaction. By this method sures. The insoles have a range from 0.57 kg/ em?
it was possible to record the heel and sole forces (56 kPa) to 8.85 kg/ em? (868 kPa). The insole unit
separately (Miyasaki & Iwakura 1978). An insole may be sensitive to temperature and moisture
for recording plantar pressures was developed changes. However, well-controlled protocols
by Lereim & Serek-Hanssen (1973) in which may be able to reduce this characteristic.
miniature transducers were accurately posi- Repeatable data collection runs are achievable
tioned against the sole of the foot by the use of X- provided that the sensors are undamaged. Most
rays. These were then incorporated into a PVC investigations use each insole unit for a
insole to be worn in the shoe. New insoles had to maximum of five data collection runs or approx-
be made for each subject. imately 40 gait cycles. The sensor has been
METHODS OF ANALYSING GAIT 313
Accelerometers
The use of accelerometers in gait analysis has
generally been confined to the measurement of
impact forces such as those seen at heel strike.
Much work has been undertaken by sports
footwear manufacturers in the quest for the ideal
10 mm
shock-attenuating insole unit. The 'shock meter'
: .--11--: 10 mm
system has been used to investigate shock waves
transmitted during gait (Johnson 1990). A few
experiments have been undertaken using
accelerometers mounted on pins and then
screwed directly into the bones of volunteers,
-.11
lmm ~ l. .
although this method is clinically unacceptable.
Accelerometers have been used to measure accel-
eration of body parts during motion (Morris
1973). Accelerometers have been used in research
Figure 12.5 Diagrammatic representation of F-Scan.
but in clinical practice they may not be of much
value (Collins & Whittle 1989).
Kinematics
shown to exhibit significant decay after this
(Rose et al 1992). Unpublished work suggests Kinematics describes angular movement and dis-
that the sensor, if laminated with a thin backing placement of joints and the body throughout
material, produces valid and reliable data space. There are a variety of ways in which these
throughout its working load range for 200 gait data can be measured directly and indirectly.
cycles. The sensors have shown failure with
respect to total breakdown of the silver relay
Direct method
tracks, and loss of individual sensors as a result
of marked creasing or cutting. It has also been Direct measurement can be achieved by using
noted that sensors can be permanently switched goniometers (Chao 1980). These measure
on, registering maximum loads. This is thought joint angle changes. The use of goniometers
to be as a result of sensor damage during cutting is becoming increasingly common, especially
the insole to fit shoes. Software modifications in electrogoniometers and flexible goniometers
the future may allow investigators to delete 'hot' (Fig. 12.6). Electrogoniometers (e.g. Biometric'Y)
sensors prior to data analysis. are electromechanical devices that span a joint,
314 LABORATORY AND HOSPITAL INVESTIGATIONS
Indirect methods
sions. The joint centres are calculated using these usmg surface or indwelling electrodes.
segmental coordinate systems. From the joint Indwelling electrodes are more definitive than
centres, anatomically aligned coordinate systems surface electrodes in terms of sampling activity
are constructed and used to calculate joints angle from a particular muscle. These electrodes are
during walking trials. also required for analysis of deep muscle activity,
To minimise errors, systems need to be cali- e.g. in the deep posterior compartment of the
brated prior to use. The placement of markers on calf. A major problem with this sort of electrode
the skin relative to osseous landmarks is crucial if is that it causes intramuscular bleeding and may
models that have been developed for various displace during muscle contraction (Kadaba et al
systems are to be used with any reproducibility 1985). The use of surface electrodes is clinically
and if subjects are to be evaluated on different more viable as they are non-invasive and less
days or if different subjects are to be compared variable than indwelling electrodes. These elec-
with each other. Movement of the skin marker trodes are generally used to provide gross infor-
over osseous landmarks also needs to be taken ma.tion about the activity of muscle groups
into account during the modelling of gait or the (Wmter 1990) and are therefore less selective.
evaluation of an intervention. There is also an increased risk of 'cross-
As well as calculating and providing graphs of talk' - picking up activity from other muscles
kinematics, software computes the kinetic vari- that are not directly under investigation. The
ables of the net joint moments, forces and powers EMG is therefore commonly used to identify
based upon the kinematics and ground reaction gross phasic muscle activity prior to the fitting of
force from the force platform. orthoses designed to affect muscle activity, or for
Electromagnetic tracking systems. These preoperative planning prior to tendon transfer or
systems (e.g. Polhemusl''", Skill 'Iechnologies'P', lengthening. For routine clinical practice the
Flock of Birds'[") are beginning to be used more system is of little value.
frequently and are not dissimilar in the informa-
tion they provide to the video-based gait analysis
Energy expenditure
systems, but use electromagnetic sensors to track
the motion of a 'marker' attached to the skin in Patients who exhibit gross changes in their gait
three dimensions. They avoid the need for are likely to use more energy than patients with
cameras and the use of multiple markers on each an efficient gait pattern. This is not surprising
segment. since the structure and function of the locomo-
316 LABORATORY AND HOSPITAL INVESTIGATIONS
tor system is designed to be energy-efficient in this sort of assessment is not routinely under-
terms of its ability both to store and use energy taken in the clinic.
(Ch. 8). The determination of energy expendi-
ture in gait has been undertaken since the
Multisystems
1950s. Many investigations have looked at
normal and abnormal gaits in terms of energy Several developments are currently under way
cost. Estimation of the energy cost of walking to provide multiple linked data. These systems
usually involves the measurement of oxygen may well provide data from energy consump-
consumption (Inman et a11981) or calculation of tion studies with gait and force plate studies. In
potential and kinetic energy levels of body seg- some gait laboratories additional information
ments from their motions and masses from EMG is also simultaneously presented.
(Quanbury et aI1975). The difficulty with these systems is that they
A commercially available device called Caltrac tend to cause information overload of the prac-
measures the total number of calories used by titioner.
subjects during walking. An alternative
approach is to monitor heart rates as an indica-
SUMMARY
tion of energy expenditure during activity (Rose
et aI1989). In this method the 'physiological cost Gait analysis is a complex task. The collection and
index' (PCl) is calculated as an estimate of energy analysis of quantitative data can aid observation
used. The following formula is used: of gait. One of the main problems with these
PCI = (heart rate walking - heart rate resting) / methods is the difficulty in establishing what is
velocity normal. Gait may alter with every step a person
where heart rate is in beats/min and velocity is takes; as a result, repeatability is a major problem.
in m/min, or beats and velocity are per second. The practitioner must also be wary of highly tech-
This is probably more useful in clinical practice nical equipment which will provide complex data
than the measurement of oxygen consumption that prove difficult to interpret and require con-
and carbon dioxide production during activity. siderable computer power or time.
The measurement of oxygen consumption In the research field, quantitative analysis of
requires an analysis of the subject's exhaled air. gait is making a contribution to our understand-
Normally this requires the use of a Douglas bag, ing of the complexities of gait. In particular,
which allows the respiratory quotient to be cal- research into gait is improving our knowledge of
culated. Exercise is generally undertaken on a its components and is also being used to design
treadmill. Since the equipment required is bulky, and evaluate therapeutic interventions.
REFERENCES
Bauman J H, Brand P W 1963 Measurement of pressure Chao E Y S 1980 Justification of triaxial goniometer for the
between foot and shoe. Lancet 3: 629-632 measurement of joint rotation. Journal of Biomechanics
Betts R P, Duckworth T 1978 A device for measuring plantar 13: 989-1006
pressures under the sole of the foot. Engineering in Chodera J 1960 Pedobarograph: apparatus for visual display
Medicine 7(4): 223-228 of pressures between contacting surfaces of irregular
Betts R P, Franks C 1, Duckworth T, Burke J 1980a Static and shape. C25 Patent, 104 514 30d
dynamic foot pressure measurements in clinical Collins J J, Whittle M W 1989 Impulsive forces during
orthopaedics. Journal of Medical and Biological walking and their clinical implications. Clinical
Computing 18: 674-684 Biomechanics 4: 179-187
Betts R P, Franks C I, Duckworth T 1980b Analysis of Duckworth T, Boulton A J M, Betts R P, Franks C 1, Ward J D
pressure and load under the foot. Part 2: Quantitation of 1985 Plantar pressure measurements and the prevention
the dynamic distribution. Clinical Physical Physiological of ulceration in the diabetic foot. Anatomical Record
Measurement 1(2): 113-124 59:481-490
METHODS OF ANALYSING GAIT 317
Introduction 319
Microbiology 320
Indicationsfor microbiology 320
Laboratory tests
Sampling techniques 320
Identification of microorganisms 325 A. Percivall
Urinalysis 328 1. Reilly
Indications for urinalysis 328
Collection of the urine specimen 328
Clinical assessment 328
Laboratory assessment 330
Bloodanalysis 331
Indicationsfor blood analysis 331
Collection of the blood sample 332
Haematology 332
Biochemistry 334
Serology 335
disease. Predictive values of positive test results caused by bacteria. Some viral infections of the
give a measure of the frequency of the disease foot do occur: the main protagonist is the human
amongst all patients who test positive for that papilloma virus (HPV), which gives rise to
disease. The efficiency of a test indicates the per- plantar warts or verrucae.
centage of patients correctly diagnosed with a As with other forms of laboratory testing,
particular pathology. microbiological testing should only be consid-
Some of the tests can be undertaken in the ered when it is likely to serve a useful purpose.
clinic (near patient testing) but most require the The circumstances where it is applicable are:
use of laboratory services. Because of the expense
• when the results of testing are likely to
and possible inconvenience caused by some of
influence the choice of treatment and result
the tests it is important that they are only used
in more effective treatment for the patient
where appropriate.
• if the results will help identify sources of
infection that need to be traced.
MICROBIOLOGY
Indications for microbiology Sampling techniques
Practitioners often request microbiological analy- Specimen types
sis to determine which particular organism is
Specimens may be divided into two groups:
causing an obvious infection. However, the
those from normally sterile sites and those con-
process can often be wasteful of both time and
taining a normal resident flora. The differentia-
resources. Organisms found and identified in the
tion is important since samples taken from
laboratory usually fall into two categories: they
normally sterile sites need to be inoculated into
either reflect the normal microbial flora or they
enrichment media. The media provides nutrients
fall outside this group and may be considered
that will allow rapid growth (or amplification) of
pathogens. It must be remembered that some
the organisms so that enough will be available
normally resident organisms have the propensity
for identification. Specimens taken from sites
to cause disease when found in abnormal sites.
which have resident flora will, in contrast, need
Conversely, just because a normal resident
to be inoculated into media containing selective
organism has been isolated at an abnormal site, it
agents which will suppress the growth of any
may not be the causative agent of the disease as
commensal organisms that might mask a poten-
commensals often contaminate samples sent to
tial pathogen.
the laboratory. Further, the distinction between a
Ideally, when microbiological information is
pathogenic organism and a non-pathogen is
needed, an appropriate specimen is taken from
often imprecise, e.g. where a person is a 'carrier'
the correct site. The specimen is transported
of a disease. This has led to the adoption of two
immediately to the laboratory where it is
basic rules:
processed quickly using the best tests, which are
• Never without good reason dismiss a then correctly reported; these results are returned
microbe as a contaminant because it is not an to the originator where they can be properly inter-
'accepted' pathogen. preted at a time when the information is relevant.
• Never without good reason accept a microbe Thus, it is important that the results of the work
as the necessary cause of a disease merely done in the laboratory are a true reflection of that
because it is an 'accepted' pathogen. specimen. Reasons for failure to report an organ-
ism originally present in a specimen include:
Microorganisms are classified, biologically,
into four main groups: viruses, protozoa, bacteria • a delay in examination
and fungi. In podiatry, with the exception of • the amount of specimen examined is
some superficial mycoses, most infections are insufficient
LABORATORY TESTS 321
• the amount of medium into which the chances of providing meaningful results.
specimen is inoculated is insufficient Many techniques may not work reliably if
• the medium used for inoculation is of insufficient material is provided.
doubtful quality or unsuitable for the growth • If at all possible, samples should be taken
of the organism present prior to the commencement of antibiotic
• the incubation time of the inoculated medium is therapy. A drug may suppress a pathogen
too short or the wrong conditions are provided sufficiently to thwart isolation and
• too few colonies are examined or the identification, without actually working well
organism is not recognised. enough to allow the patient to recover.
• It is often desirable for practitioners to wait for
It is imperative to use reputable laboratories the initial results from the laboratory before
that employ strict internal standards and where starting antibiotic therapy. The results will
reagents and media are performance-tested allow practitioners to choose a narrow-
using standard organisms. If this procedure is spectrum drug that they can be confident will
adhered to, failure to report pathogens often rests do the job. However, if a life-threatening
with the sampling technique employed by the infection is suspected, a broad-spectrum
requesting practitioner. Good-quality specimens antibiotic should be prescribed without delay.
are obtained following certain guidelines: • Specimens taken for microbiological analysis
are by their very nature likely to contain
• The sample should be taken from the actual
pathogenic organisms and therefore should
site where an infection has been diagnosed
be treated with care.
or is suspected.
• Good documentation is vital to ensure that
• Skin should not be cleaned with an antiseptic
samples are not mixed up, lost or subjected to
prior to taking the sample.
inappropriate tests.
• Strict aseptic technique must be followed in
• It is vital that there is dialogue between the
order to reduce the risk of the sample
practitioner taking the sample and the
becoming contaminated by the
laboratory staff. For more unusual organisms
microbiological flora of either the patient or
the microbiologist may be able to provide
the person taking the sample.
advice about the most appropriate methods
• Many pathogenic microorganisms are
of sampling and transportation.
surprisingly delicate. Unless special
• In order to be effective the laboratory requires
measures are taken they do not survive for
good clinical information about the patient.
long away from the body. This means it is
The site of the suspected infection must be
often vital that specimens are transported to
stated. The symptoms should be included on
the laboratory without delay.
the clinical history section. Is there anything in
• If some delay in transporting specimens to
the patient's history or in the clinical features
the laboratory is anticipated, it is important
(colour of pus, cellulitis) that might provide a
that steps are taken to prevent significant
clue as to the type of organism that is causing
growth of contaminating normal flora
the problem? It is important to note recent
organisms. These organisms grow at room
treatment with antibiotics for the reason given
temperature and can swamp the genuine
above. Without this sort of detailed
pathogen. Suppression is normally achieved
information, valuable time and resources may
by refrigeration of samples or inclusion of an
be wasted in inappropriate analyses.
inhibitor in the transport medium.
• It is important that sufficient sample is
Apparatus for obtaining specimens
supplied so that the laboratory may use
different methods for culture and analysis of Containers. Strong leak-proof sterile contain-
the sample and thereby maximise their ers of adequate size, conforming to the relevant
322 LABORATORY AND HOSPITAL INVESTIGATIONS
British Standards specification, must be used to Once the sample has been obtained it should
transport specimens from source to laboratory. be sent directly to the laboratory. Accom-
These British Standards pay attention to min- panying the sample will be a laboratory request
imising the health hazard from leakage, aerosol form. Accurate information will enable the lab-
formation or spread of airborne particles when oratory staff to carry out the most appropriate
opening containers holding specimens. tests and investigations quickly and thus
Containers range from 6 ml 'bijou' bottles, with provide the clinician with the results without
screw caps suitable for body fluids, trans- delay. Laboratory request forms vary, but it is
port media and biological cultures, to large important that the following information is
300 ml bottles suitable for early morning urine included:
samples and sanitary specimens. Whatever con-
• The patient's name.
tainer is used, it must be clearly labelled in
• The ward name or place where the sample
indelible ink with sufficient space for name,
was taken.
address, date and nature of specimen together
• The patient's date of birth - resident flora
with the time the specimen was taken. The label
change with age and it is therefore helpful to
should have a water-resistant back.
the laboratory staff in their investigations.
Swabs. Bacteriological swabs are often made
• Date of admission to hospital - useful for
from a pledget of Dacron (Terylene) attached to
infection control staff to monitor nosocomial
the end of a holder made from wood, plastic or
infection.
metal, the whole of which is sterilised before use.
• Site of infection - be as specific as possible, it
Cotton wool pledgets can be used, but they may
will help laboratory staff distinguish
release lipoproteins, which can harm some fas-
commensals from pathogenic flora.
tidious bacteria. Swabs are the collection instru-
• Antibiotic therapy - even small amounts of
ment of choice where microbial contamination or
antibiotic inhibit the growth of micro-
infection is suspected. Swabs complete and ready
organisms in the laboratory.
sterilised with or without transport media are
• Date and time of collection of the specimen -
available commercially.
microorganisms survive or multiply at
varying rates and, thus, this information is
Collection of samples important when the sample is cultured.
Wounds and mucosal surfaces. If a large • Specimen type and investigation requested -
quantity of pus is present this may be drained remember most swabs look the same once in
and sent to the laboratory; otherwise, a swab the laboratory, therefore state clearly what the
should be taken. Great care should be taken to specimen is. State whether the sample is for
avoid contamination with the normal flora from microculture and sensitivity, for virology or
surrounding healthy tissue. It is important that serology.
a sample is taken from the base of the wound. If • Biohazard status - if suspected, then the
it is taken from the superficial edges, the flora of sample should not only be marked as such
the adjacent skin could contaminate it. Swabs but should be transported in double-wrapped
are placed into tubes containing a semi-solid specimen bags.
transport medium, which prevents them from
drying out. Laboratory examination
Skin. For mycological (fungal) investigations,
nail clippings or skin scrapings from the edge of When samples containing suspected bacterial or
the lesion, taken with a blunt scalpel, can be fungal pathogens are sent to the laboratory, the
placed in either a purpose-designed packet most appropriate methods for investigation will
which has a black inner surface to help identify be carried out. The methods used fall into the fol-
the sample, or a clean, dry plastic container. lowing categories:
LABORATORY TESTS 323
------------------------------------------------------
Figure 13.1 Bacteria classified by staining, shape and use of oxygen A. Gram-positive B. Gram-negative.
that suppress or kill all but a few types of bacteria or the production of coloration in
(known) organisms. dermatophyte test medium which
• Indicator media - routine media with the incorporates an indicator that detects the
addition of substances which change the rise in pH as the culture grows.
appearance of the media when a particular
organism grows on it: for example, Culture media can be used in either of two
haemolysis of red blood cells by haemolytic forms: liquid or solid. The solid form is prepared
LABORATORY TESTS 325
from liquid media with the addition of agar in presence of spores, etc. Hanging drop mounts of
concentrations of 1-4%. Liquid media or 'broths' living organisms are examined for motility and
are used, for instance, in the routine culture of special techniques can be applied for the exami-
pure cultures, sterility testing and anaerobic nation of capsules and £lagellae.
culture but suffer from the disadvantage that Staining reaction. The Gram stain is the
mixed cultures cannot be separated. The use of most important of the staining reactions and, in
solid media facilitates this process and mixed conjunction with the morphology, is often
cultures can be separated to allow isolation of enough to narrow the field considerably.
individual colonies. Staining with malachite green will show the
bacterial spores in Bacillus and Clostridium spp.,
Identification of microorganisms the position of which in the cell can determine
the species.
Bacteria
Cultural characteristics. The size, shape and
It is first necessary to isolate the microorganism colour of colonies on solid media are sometimes
in pure culture before carrying out identification helpful in diagnosis but are not sufficiently stable
tests. This is usually achieved by streaking or enough to be of routine value. However, the
spreading the initial inoculum on the surface of ability of an organism to grow on different
solid selective media to produce isolated colonies media, including the stimulatory effects of added
of the desired organism. A colony is then selected substances such as glucose, whole blood or
and may need subculturing in routine or serum, can be significant, i.e. the degree of
enriched media to restore normal growth before haemolysis of blood incorporated into the media
examination. Table 13.1 lists the types of bacterial is used to differentiate streptococci. Alpha-
pathogens found in the lower limb. haemolytic streptococci such as Streptococcus
The process of identification is normally done pneumoniae produce colonies which are sur-
in the following way: rounded by a green ring, whereas Streptococcus
Morphology. Stained microscopic mounts are pyogenes, a beta-haemolytic bacterium that is
examined for size, shape, cell aggregates, the responsible for human throat infections, grows
Bacteria Features
Staphylococcus aureus Gram-positive, aerobic coccus. Most frequent cause of foot infections. Able to form an
enzyme which coagulates citrated plasma: therefore the infection tends to remain
localised. Responsible for boils, carbuncles, septic toes and osteomyelitis.
Steptococcus pyogenes Gram-positive, aerobic or anaerobic coccus. All strains are beta-haemolytic. Produce
enzymes which help break down surrounding connective tissue and thus aid its
spread. May lead to cellulitis, lymphangitis and lymphadenitis and may be the prime
organism responsible for necrotising fasciitis.
Pseudomonas aeruginosa Gram-negative, aerobic bacillus. Gives rise to blue-green pus and produces a pungent
odour. May be found in paronychia alongside Candida albicans.
Escherichia coli Gram-negative, aerobic bacillus usually found in the gut. May be present in mixed
infections and also is found alongside Candida albicans in paronychia.
Klebsiella spp. Gram-negative, aerobic bacillus found in the gut. May be present in mixed wound
infections.
Proteus spp. Gram-negative, aerobic bacillus found in the gut. May be present in mixed wound
infections.
Corynebacterium minutissimum Gram-positive, aerobic bacillus responsible for erythrasma and pitted keratolysis.
Clostridium welchii Gram-positive, anaerobic bacillus responsible for gas gangrene.
326 LABORATORY AND HOSPITAL INVESTIGATIONS
with a clear ring around it where the blood cells Sensitivity testing. Once the identification of
have been completely lysed. These characteristics an organism has been made, the susceptibility of
of colony growth of bacteria are accompanied by the organism is often predictable. However, not
observations of the optimum temperature and all organisms have predictable resistance pat-
pH ranges for growth and any pigment that may terns and, thus, testing for sensitivity to particu-
be produced. The gaseous requirements of lar antibiotics is required. Perhaps the most
organisms can also be diagnostic. Some bacteria common method used to test antibiotic sensitiv-
are obligate aerobes (e.g, Bordeiella), but others ity is disc diffusion. A Petri dish is inoculated to
(e.g. Pseudomonas aeruginoeai, which usually produce a lawn of the test organism and an
utilise molecular oxygen, are capable of utilising antibiotic-impregnated disc containing a range of
nitrate if cultured anaerobically. Anaerobes are antibiotics at concentrations comparable with
either facultative, i.e. they can grow either aero- therapeutic plasma levels is placed on the surface
bically or anaerobically, or obligate. Other factors of the lawn.
such as the ability to grow in the presence of Inhibition of growth around the disc indicates
antibiotics, bile salts and high salt concentration the organism is sensitive to the antibiotic.
should also be noted. Although this test indicates sensitivity of the
Biochemical reactions. The ability of organ- organism, it does not show the lowest concen-
isms to utilise particular substrates with a tration (minimum inhibitory concentration,
detectable end product, such as sugars, is a MIC) at which the antibiotic will inhibit growth
widely tested function. A range of these bio- of the microorganism. Although a relationship
chemical tests are available, including fermenta- between MIC and successful outcome of antimi-
tion patterns, catalase, oxidase and nitrate crobial chemotherapy cannot be clearly estab-
production, and are, perhaps, the most useful lished, it is considered the most useful guide to
aids to identification. For example, if a positive the efficacy of antimicrobial therapy. Several
identification of Gram-positive cocci has been methods of obtaining the MIC are available, and
made, a catalase test can be done to aid further recently commercial test strips of paper with
diagnosis. Staphylococci and streptococci are antibiotic incorporated along its length in
both commonly found cocci. Staphylococci are increasing concentration have simplified the
catalase-positive and are able to produce test. These test strips are put on a lawn inocu-
bubbles of oxygen when incubated with hydro- lum of the test organism and the point at which
gen peroxide. Streptococci, which are catalase- the growth meets the test strip corresponds
negative, do not react in this way and no oxygen to the MIC (Fig. 13.2). From these figures the
is produced. This may help identify, say, a minimum bactericidal concentration (MBC) can
colony of staphylococci but does not help with be determined; this is defined as the lowest con-
identification of the species within the genus. A centration that prevents growth after subculture
mannitol fermentation test may be able to deter- to an antibiotic-free medium. These figures
mine if the colony consists of Staphylococcus are required where accuracy of dose is impor-
aureus or Staph. epidermidis, since Staph. aureus tant, e.g. in treating the immunocompromised
tests positive, whereas Staph. epidermidis does patient.
not. Ready-made kits for multiple biochemical Serological and bacteriophage testing. It is
analyses are freely available commercially to often possible to identify bacteria by determining
enable complex tests to be carried out simulta- their antigenic composition. This can be achieved
neously with remarkable accuracy. All help to by incorporating suspensions of the organism in
build a pattern of the metabolic activity of the a series of standardised solutions of purified anti-
organism, which - together with the informa- bodies. Where agglutination occurs, it can be
tion gained from microscopic and cultural inferred that the organism possesses a specific
examination - may be sufficient to identify the antigen against which that antibody was origi-
organism. nally prepared. Bacteriophages are also highly
LABORATORY TESTS 327
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Viruses
specific in their lytic action of bacteria. Thus,
stock preparations of known phages can be used Unlike bacteria and fungi, viruses cannot be
in a similar way to antisera, allowing precise grown on artificial media and usually require
identification of variants within species, e.g. tissue culture, chick embryo culture or inocula-
staphylococci. tion into laboratory animals. Much work is in
Animal tests. The identification of pathogenic progress to simplify viral identification. The
organisms may require the use of animal inocu- processes are complex and outside the scope of
lation but is only of value if the inoculum pro- this chapter.
duces highly specific symptoms or lesions in the Although newer techniques for the detection
sensitive laboratory animal. and identification of microorganisms, such as
detection of antigens, antibodies and polymerase
chain reaction studies, help in the overall arma-
Fungi
mentarium available to the practitioner, culture
Fungal infection is a common manifestation in still remains the gold standard against which all
podiatric practice and is usually diagnosed on its these newer techniques are measured. The best
Fungus Features
Trichophyton rubrum Affects skin and nails. 85% of cases of onychomycosis thought to be due to T. rubrum.
Can affect skin and hair in a number of ways. Diffuse dry scaling tinea on the soles is
usually due to T. rubrum.
Trichophyton mentagrophytes Affects skin and nails. Can cause a range of skin responses but is especially associated
with vesicle eruption. 12% of cases of onychomycosis due to T. mentagrophytes.
Epidermophyton f1occosum Affects skin in a variety of ways but is especially associated with vesicle eruption.
Rarely causes onychomycosis.
Scopulariopsis brevicaulis Secondary pathogen. Produces a dark green-black discoloration.
Candida spp. A yeast of which Candida albicans is the most common. Affects skin and nails. In nails
is often responsible for paronychia.
328 LABORATORY AND HOSPITAL INVESTIGATIONS
non-culture tests have specificities and sensitivi- consequences for the lower limb. Renal and
ties in the order of only 85-90%, even in the hepatic diseases may have serious systemic
hands of experienced staff. repercussions, which complicate diagnosis and
It should always be remembered that because affect the treatment of lower limb problems.
of the skill and costs involved in culturing and Urinalysis is particularly useful in the preopera-
carrying out the exacting tests to identify organ- tive assessment of patients to screen for illnesses
isms, the practitioner must take care to ensure which may complicate or contraindicate elective
that correctly taken specimens are sent to the lab- procedures. Screening for a urinary tract infec-
oratory. This will help speed the result and thus tion (UTI) or the presence of bacteria in urine can
allow appropriate, efficient and, more impor- also identify those patients at increased risk of
tantly, effective treatment to be delivered to the developing postoperative wound infections.
patient.
Collection of the urine specimen
URINALYSIS
Urine specimens can be classified as a first-
The kidneys play an important role in the main- voided morning, random or timed sample. The
tenance of homeostasis, one of their functions first-voided morning specimen is the most con-
being the excretion of waste and foreign sub- centrated of the day, and is the most specific for
stances through the formation of urine. Water nitrates and proteins. The random specimen is
accounts for 95% of the total volume of urine; the the most convenient for patients to collect and is
remaining 5% consists of electrolytes, cellular the most commonly used specimen. Timed spec-
metabolites and exogenous substances such as imens are combinations of urine voided over a
the excretion products of drugs. The amount of specific length of time and are more applicable to
fluid drunk and the amount lost through perspi- the hospital environment.
ration, respiration and defecation modify the Proper collection and prompt examination of
amount of urine produced. The average daily urine is important for accurate analysis. The use
output of urine for an adult is 1200 ml. of clean collecting vessels will minimise bacterial
If a disease alters the body's metabolism or and chemical contamination. The patient is
kidney function, traces of substances not nor- usually asked to provide a midstream specimen
mally present (or normal constituents in abnor- of urine (MSU), which should be less than 4
mal amounts) may appear in the urine. Many hours old at the time of testing. To collect the
early disease states can be detected by urinalysis specimen, the patient should be instructed to first
before they become clinically obvious and it gently cleanse the opening to their urethra with
therefore plays a useful role in the assessment of water and begin to urinate into the toilet, subse-
patients. Assessment of a patient's urine can be quently inserting a clean container into the
made both in the clinic and in the laboratory. urinary stream to collect the sample. The con-
Testing is non-invasive and cost-effective, and tainer is removed from the urine stream and the
urine specimens are easily obtained. Clinical act of voiding completed.
assessment is commonly performed, allowing
the practitioner to obtain information about the
health status of their patient rapidly. Clinical assessment
Physical examination of urine
Indications for urinalysis
Colour. Urine should be examined under good
Urinalysis may be used as an aid in the diagnosis lighting against a white background. Normally,
of renal disease, hepatic disease and diabetes the colour of urine is yellow owing to a pigment
mellitus, all of which have relevance to the podi- called urochrome. The colour becomes deeper
atrist. Diabetes mellitus can have widespread with increasing concentration, such as in the first
LABORATORY TESTS 329
proteinuria or infection. Decreased values are confirms a UTI and also requires further analysis
seen in diabetes insipidus, pyelonephritis and to identify the infecting organism.
glomerulonephritis. A fixed value may indicate
renal failure.
Laboratory assessment
Blood. Haematuria is the presence of red
blood cells (RBCs) in the urine. In microscopic Microscopy
haematuria, the urine appears normal to the
A small amount of the collected specimen is cen-
naked eye, but examination under a microscope
trifuged at 5000 rpm for 5 minutes and the sedi-
shows a high number of RBCs. Gross haematuria
ment resuspended in a few drops of urine and
can be seen with the naked eye. Most of the
mounted on a glass slide:
causes of haematuria are not serious: e.g. exercise
may cause haematuria for 24 hours and blood is • Erythrocytes: more than 5 erythrocytes per
often found in the urine of menstruating females. high power field is abnormal.
However, the condition can be associated with • Leucocytes: more than 5 leucocytes per high
serious renal or urological disease and/ or UTI. A power field may indicate bacterial infection
positive result will require a medical opinion. or renal disease.
pH. Normal urine is slightly acidic, with a pH • Epithelial cells: derived from the cellular lining
of 5-6. Values are lowest after an overnight fast of the genitourinary (GU) tract, small
and highest after meals. Strongly acid urine numbers of epithelial cells may be found in
may indicate starvation or uncontrolled dia- urine. A large number is an abnormal finding.
betes mellitus. Recheck the glucose and ketone • Casts: casts result from the precipitation of
test results if this is the case. Very high (alkaline) protein, cells and debris inside the renal
values suggest infection and warrant further tubules. They are so named because their
investigation. shape represents a 'cast' of the lumen of a
Protein. Normal urine contains small amounts tubule. Hyaline casts are formed from
of albumin and globulin, not normally detectable Tamm-Horsfal protein and may be found in
by the reagent strip. A negative result does not normal patients but are more frequently seen
therefore rule out abnormal proteinuria. A posi- in sufferers of hypertension, congestive heart
tive result indicates renal disease, UTI or hyper- failure or renal disease. Granular casts are
tension and requires confirmation. composed of protein and tubular cells and
Urobilinogen. Although normally present in indicate renal tubular disease. Red cell casts
urine, elevated levels of urobilinogen indicate suggest disease associated with bleeding and
liver abnormalities or haemolytic anaemia. A white cell casts are an indicator of acute
positive result requires an urgent medical pyelonephritis.
opinion. • Crystals: crystals may be found in patients
Nitrite. The presence of nitrites requires their with urinary stones but are found in the
conversion from nitrates by Gram-negative bac- urine of normal patients as well. Formation
teria. A negative test does not rule out infection of crystals varies with the pH; urate crystals
since Gram-positive cocci will not produce can be found in acid urine and phosphate
nitrites, and note that the urine must also be crystals can be found in alkaline urine.
retained in the bladder for several hours to allow Cystine crystals are found in patients with
the reaction to take place. A positive result cystinuria and oxalate crystals may be
confirms a UTI and requires further analysis. present in patients with oxalate stones.
Leucocytes. The presence of leucocytes and
other components of pus in the urine, pyuria, is an
Culture
indication of bladder or renal infection. A negative
result where clinical symptoms are present would A urine culture is used to estimate the number
require microscopy and culture. A positive result of bacteria present in urine and to identify the
LABORATORY TESTS 331
• Normally, more than 99% of the formed of a stained blood film. Many abnormalities in
elements are RBCs. The percentage of total RBC morphology can be seen. Anisocytosis is
blood volume occupied by the RBCs is called excessive variation in the size of RBCs, poikilocy-
the packed cell volume (PCV) or haematocrit, tosis is excessive variation in their shape, sphero-
expressed as the percentage of total blood cytosis demonstrates round RBCs, and the RBCs
volume packed by centrifuge in a given of sickle-cell disease are long and bent.
volume. The PCV is reduced in all types of The differential WBC count is a reflection of
anaemia; a haematocrit measurement of less 100 WBCs that are morphologically examined in
than 30% is probably detrimental to surgical a peripheral smear. The numbers of different
intervention. types of WBCs are expressed as a percentage of
• The haemoglobin concentration reflects the the whole (see Table 13.4). A left shift denotes a
oxygen-carrying capacity of the blood. It is decrease in neutrophil segmentation, which is a
reduced in all forms of anaemia and is sign of increased turnover and demand for
increased in polycythaemia. WBCs most commonly seen in acute bacterial
• RBC indices are arithmetic ratios derived infections.
from the RBC count, PCV and haemoglobin
Inflammatory tests
concentration. The most useful of these ratios
is the MCV, which is a measurement of the • ESR: the ESR is the rate of fall of RBCs in a
haematocrit divided by the RBC count. It is column of blood. The ESR increases with age
low, less than 82 fl, with microcytic anaemia and is higher in females than in males. A
and greater than 100 fl with megaloblastic raised ESR reflects an increase in the plasma
anaemia. The mean cell haemoglobin (MCH) concentration of proteins and is indicative of
is the haemoglobin concentration divided by diseases associated with malignancy,
the RBC count; the mean cell haemoglobin infections and inflammations.
concentration (MCHC) is the haemoglobin • Plasma viscosity is used by some laboratories
concentration divided by the PCv. instead of an ESR. As with the ESR, the level
• The WBC count can be decreased of viscosity is dependent on the concentration
(leucopenia) or increased (leucocytosis). of proteins, but is the same in males and
Leucopenia can result from a viral infection, females, and increases only slightly with age.
ingestion of certain drugs (especially • C-reactive protein (CRP) is synthesised in the
antineoplastics) and radiation. Leucocytosis liver and can be detected in the blood within
can result from acute bacterial infection, 6 hours of an inflammatory response. This
leukaemia, acute haemorrhage and tissue test is also replacing the ESR.
necrosis.
• The platelet count provides quantification of Clotting studies
thrombocytopenia but gives no indication of
platelet function. • The prothrombin time (PT) determines the
• The reticulocyte count measures those early amount of prothrombin in the blood. Test
forms of RBC with inclusion fragments of the reagents are added to a sample and the time
endoplasmic reticulum. The count quantifies taken for the blood to clot noted. It provides
the rate of erythropoiesis: increased numbers a laboratory measurement of the extrinsic
of reticulocytes reflect increased formations blood coagulation pathway. The PT is
of RBCs, as seen in haemorrhage or prolonged by deficiencies in fibrinogen,
haemolysis; a low number suggests prothrombin and factors V, VII and X but
nutritional deficiency or leukaemia. remains normal in patients with haemophilia
A and B, or platelet deficiencies. It is
The blood film. Details of individual blood cell commonly used to monitor patients taking
types are obtained from microscopic examination warfarin.
334 LABORATORY AND HOSPITAL INVESTIGATIONS
• The activated partial thromboplastin time nous constituent of urine. In pathologies that
(APTT) provides a laboratory measurement affect renal function, its serum concentration
of the intrinsic blood coagulation pathway rises. Azotaemia is defined as increased nitroge-
and is the best single screen for disorders of nous substances in the blood and is charac-
coagulation. The APTT is prolonged by terised by a blood urea nitrogen (BUN) level
deficiencies in fibrinogen, prothrombin and greater than 20 mg/100 ml. The BUN: creatinine
factors V, VIII, IX, X and XII, and in patients ratio is 10: 1 in normal individuals; in patients
with haemophilia A and B, or platelet with acute renal failure both BUN and creati-
deficiencies. nine levels rise and the ratio may be unchanged.
• The thrombin time (TT) measures the The BUN level alone is increased in patients
clotting (fibrin formation) time of a sample with renal disease, gastrointestinal haemor-
of blood following the addition of a small rhage or increased protein metabolism.
amount of thrombin. The most common The BUN level is decreased in patients with
cause of a prolonged TT is the presence of severe cirrhosis, inadequate protein intake or in
heparin. pregnancy.
• The bleeding time is the time required for The concentration of creatinine in the serum has
cessation of bleeding from a small skin a linear relationship to glomerular filtration,
puncture, usually of the ear lobe. As the making it a more sensitive indicator of renal
droplets of blood escape, touching the wound disease than BUN. Creatinine levels rise in
with filter paper blots them. When paper no patients with renal disease, gigantism, acromegaly
longer stains, the bleeding has stopped. It is a and increased dietary intake from roasted meats.
standard assay that measures the The normal range for uric acid is 3.5-7.2 mg/ dl
effectiveness of platelet plug formation. The for males and 2.6-6.0 mg/ dl for females.
bleeding time is increased if platelet function Elevated serum uric acid is not a reliable diag-
is abnormal, e.g. patients who are suspected nostic test for gout. However, acute gout never
of having a qualitative platelet disorder such occurs in patients who have a serum uric acid
as von Willebrand's disease or patients on level in the lower half of the normal range. The
aspirin therapy. test can give rise to false negatives and positives.
In the first few attacks, when it is often difficult to
diagnose, the serum acid level is often below the
Biochemistry
higher level. Serum uric acid levels can be
Arterial blood gas studies are the best single deter- helpful in monitoring treatment.
mination of lung function, referring to the deter- Sodium levels are increased in patients with
mination of arterial oxygen and carbon dioxide dehydration, primary aldosteronism, Cushing's
tensions and the pH. Indications for blood gas syndrome and with some diuretic drugs. Sodium
studies include the assessment of preoperative levels are decreased in fluid retention (seen in
lung function, documentation of pulmonary congestive heart failure), with unreplaced body
disease and continuing assessments of cardiopul- fluid loss (vomiting, diarrhoea) and in Addison's
monary diseases. Serum chemistry assays useful in disease. Sodium is the principal cation of extra-
the diagnosis or monitoring of many metabolic, cellular fluid.
renal and fluid/ electrolyte abnormalities are given Potassium levels may be increased (>5.5 mmol/I)
in the following paragraphs. in patients with renal failure, mineralocorticoid
Urea and creatinine are dependent on the deficiency, acidosis, massive tissue necrosis
kidney for excretion: therefore, their measure- and with high-dose penicillin (hyperkalaemia).
ment is an index of renal function. Urea, an Hypokalaemia may occur in patients with chronic
end product of protein metabolism, is synthe- diarrhoea, primary/secondary aldosteronism,
sised in the liver, and is the principal nitroge- Cushing's syndrome or with diuretic drugs.
LABORATORY TESTS 335
-"--------"----------------
• where tissue has an abnormal appearance Table 13.6 Tissues which can be removed from the foot
for histological analysis
and malignancy is suspected
• where the lesion fails to heal, e.g. inclusion Epithelial Keratinised stratified epithelial
cyst, pyogenic granuloma (Plate 29). tissue (skin)
Stratified cuboidal epithelium
(sweat glands/secretory function)
Sampling techniques Multicellular exocrine glands:
The range of tissues from the lower limb that can - coiled tubular eccrine and
apocrine (sweat)
be removed for histological analysis can be found - branched acinar holocrine
in Table 13.6. Various methods can be used to (sebaceous)
remove tissue or fluid for investigation. The tech- Connective Mesenchymal found in adult tissue
nique used will depend upon the site and the below skin and blood vessels
amount that needs to be removed. A wide range Loose areolar: subcutaneous layer
of investigations can be performed on tissues of skin and blood vessels, nerves
associated with fibroblasts,
taken from the body. Samples should be collected macrophages, mast cells and
in such a way as to pre-empt the method to be various fibres
used. The practitioner should therefore decide at Adipose: under weightbearing
the outset what investigations are required. surfaces, joints and bone marrow
Appropriate collection and storage techniques Dense collagenous: common to
are vital to preserve the sample. fascia, aponeuroses, tendons,
ligaments
Most techniques require local analgesia. In the
Elastic and reticular: less abundant
case of tissue it is generally advisable to remove in feet
a section of surrounding healthy tissue as well as
Hyaline and fibrocartilage:
the abnormal tissue; this allows the pathologist chondrocytic cells associated with
to make comparisons between normal and joints, especially distal metatarsal
abnormal tissue. ends, fibrocartilage
submetatarsals, between bones
Sources for histological diagnoses can be and tendons
either tissue or cell preparations. Tissues can be Osseous (bone): made of compact
obtained by biopsy (shave, punch, needle or (outer), cancellous (inner) and
excision), from resected organs (partial or com- cellular components associated
with regeneration
plete) or via autopsy. Cell preparations include
fluid aspirates, smears, brushings and fine Muscle Skeletal: striated, contractile form
attached between bones; mainly
needle aspirates. In podiatric practice it is pri- intrinsic form in feet in four layers
marily tissues that are sampled and sent to Nerve Cell body and axons
histopathology. Some examples of biopsy are
Neuroglia: found at sites of tumours
given below.
Synovial membranes Loose connective tissue: line
structures and secrete synovial
fluid, tendon lining, bursae, do not
Biopsy contain epithelial cells
Shave. A shave biopsy can be achieved by Tissue repair Stroma: supporting connective
introducing an endoscope into the body. This tissue restoration; active repair or
scar tissue due to fibroblasts or
procedure is used when it is necessary to remove keloid (overactivity)
a piece of tissue from a deep structure, e.g. syn- Scab/fibrin plug: sealing wound
ovial membrane from a joint.
Granuloma: active repair tissue
Punch. A punch biopsy (incisional biopsy)
involves the removal of a small section of abnor-
mal tissue. The procedure is not as extensive as tions such as deep infection. A punch, which con-
excisional biopsy but is still open to complica- sists of a cylinder with a sharp, fine cutting edge,
LABORATORY TESTS 337
is used. The punch is pushed through epithelial down to muscle, ligaments and tendon will
tissue and a small section of epithelial and/or require careful repair. Ganglion formation must
connective tissue is removed. A trephine is a be removed in total as it has a high recurrence
similar instrument to a punch, but much more rate. The gelatinous mass is difficult to retrieve.
sturdy. It is used for punching holes in bone. In The thin translucent membrane should be
these cases a larger access hole is necessary. Bone included wherever possible. Thicker mem-
samples should, wherever possible, have clear branes suggest that they have undergone longer
radiographs attached to assist the determination periods of deep trauma.
of the general appearance of the lesion. The Complete. Whole parts, such as amputated
advantage of punch biopsy lies in the small area feet, toes and excised rays, can be sent to the
of tissue removed. Normal tissue is not usually pathology department. Analysis of whole
included. The depth of tissue sampling will anatomy takes a good deal longer due to the time
depend upon the pressure applied. Punch biopsy required to separate and fixate tissues. Bone
is likely to be used where large areas have been needs to undergo a decalcification process.
affected and treatment cannot be undertaken at
the same time. Unlike excisional biopsy it is
Transportation and storage
purely a diagnostic procedure. When skin biopsy
is performed it is essential to create an unobtru- Laboratory personnel will discuss the best mode
sive scar. In the foot, tissue around digits may of collection to ensure that an appropriate sample
require a section of bone to be removed in order for testing is achieved. Specimens labelled urgent
to achieve closure. A surgeon specialising in feet are unwelcome unless requested during surgery
should be consulted to reduce the risk of where a quick result is necessary, e.g. in the case
ischaemia. of a suspected malignancy, so that appropriate
Needle. Aspiration is the technique used to treatment can be performed concomitantly. Even
withdraw fluids from the body, e.g. synovial small samples will take 24 hours to fix before the
fluid. Examination of synovial fluid can be very tissue can be usefully analysed.
useful when examining for the presence of uric All specimens should be clearly marked with
acid crystals (gout), infection or bleeding into a the patient's name, hospital number, site and the
joint space. Where uric acid crystals are sus- date/time that the sample was taken. A full
pected the sample of synovial fluid should be history of the patient is essential. High-risk cases
placed in absolute alcohol or placed directly on should be identified with a separate 'high risk'
to a slide. Bursae can be aspirated. This usually label. The specimen should be sealed in a plastic
leads to a temporary relief of symptoms. bag, the request form remaining outside.
As with microbiological samples, damage can
be sustained by using an incorrect method of
Resected organs
transportation. Most tissue samples are placed
Partial. Partial resection or excisional biopsy in a screw-cap container containing normal
involves the removal of all the abnormal tissue buffered formalin (NBF) solution. Formalin
plus a section of the surrounding normal tissue. itself constitutes a hazard, especially if spilt on
This procedure permits examination of the living tissue. Samples for frozen section should
abnormal tissue as well as, hopefully, providing be transported dry. They will be damaged if
treatment at the same time. It is a surgical they come into contact with formalin. Frozen
technique which requires high standards of sectioning provides rapid results, usually
asepsis. A scalpel is used to incise and then within 5-10 minutes, and is used where results
dissect the abnormal tissue and some surround- are urgently required: often when the patient is
ing normal tissue from the site. Haemostasis still on the operating table, when the result of
should be carefully performed to prevent the test will decide the course of action to be
unnecessary complications. Tissue from skin taken.
338 LABORATORY AND HOSPITALINVESTIGATIONS
Tests and interpretation of results Nerves fall under this category. They can show
marked changes, involving abnormal blood
These fall into several categories depending vessels, as in the case of neuromata. Nerve con-
upon the nature of the lesion and/or suspected duction tests may provide evidence of damage
pathology. Slides of tissue are produced for prior to surgical investigation in the foot.
microscopy. Often, staining techniques are used
in order to show up changes more distinctively.
SUMMARY
The main purpose of histological examination
is to assess whether the tissue or fluid sample This chapter has covered the indications for the
differs from what is normal. Abnormal cellular use of a range of near-patient and laboratory-
findings, e.g. changes to the nucleus, may indi- based tests, appropriate sampling techniques, the
cate malignant changes. Chronic inflammation principles of testing and interpretation of results.
may be evident because of the presence of lym- Emphasis has been placed on starting with the
phocytes, plasma cells and macrophages. simplest tests prior to using more specific and
Abnormal findings may relate to the presence of sophisticated tests.
giant cells, a characteristic feature produced by The use of laboratory tests can never replace
foreign bodies. This is a common feature in the good interview and assessment techniques. Tests
foot. should be used economically and wisely, should
Scarring and inflammatory changes may tether cause no harm to the patient and above all
down tissue, which can account for some pain should be used to support treatment, confirm
syndromes in both fore and hind parts of the foot. diagnosis or rule out a suspected malignancy.
These syndromes are difficult to diagnose accu- Results should be acted upon in order to ensure
rately other than by exploratory procedures. that effective treatment is provided.
FURTHER READING
Axford J 1996 Medicine. Blackwell Science, Oxford Philpott-Howard J 1996 Microbiology. In: Hooper J,
Bayer Diagnostics Urinalysis - the inside information McCreanor G, Marshall W, Myers P (eds) Primary care
Blandy J 1998 Lecture notes on urology, 5th edn. Blackwell and laboratory medicine. ACB Venture Publications,
Science, Oxford London
Hanno P M, Wein A J 1994 Clinical manual of urology. Quinn G 1995 Laboratory blood tests in podiatry. British
McGraw-Hill, New York Journal of Podiatric Medicine and Surgery 7(2): 24-27
Hoffbrand A V, Pettit J E 1993 Essential haematology. Robinson S H, Reich P R 1993 Haematology, 3rd edn. Little,
Blackwell Scientific, Oxford Brown and Company, Boston
Karlowicz K A 1995 Urological nursing - principles and Stokes E J, Ridgeway G L, Wren M W D 1993 Clinical
practice. W B Saunders, Philadelphia microbiology, 7th edn. Edward Arnold, UK
Kumar P, Clark M 1998 Clinical medicine, 4th edn. Tortora G J, Grabowski S R 2000 Principles of anatomy and
W B Saunders, Philadelphia physiology, 9th edn. John Wiley and Sons, New York
CHAPTER CONTENTS
Introduction 341
341
342 SPECIFIC CLIENT GROUPS
To achieve optimal compliance with young • Do the parentis) and child converse or sit
children it is sometimes necessary to use distrac- close together?
tion tactics: use of toys, humour and constant • Do the parents assist the child in removing
banter can be helpful. clothes?
• Do the parents appear caring, neutral or
angry towards the child?
Interviewing • Does the child appear confident or cling to
A number of cognitive aspects about children are the parentis)?
worthy of consideration as they can influence the A flexible approach to questioning may be nec-
interview process: essary in cases of difficult children. If the child is
uncooperative, do not hesitate to temporarily
• limited attention span abandon the examination or reschedule the
• influenced by immediate events appointment for a time when the child is less
• limited experience (black and white) tired or irritable. Advise the parents to bring
• egocentric along items such as personal toys to create a com-
• non-conceptual. petitive distraction while being examined.
It is important to build a rapport with both Some children do not want to cooperate. In this
the child and parents and not to alienate or case use positive statements (i.e, stand up, walk
talk down to the child. This helps develop the straight, stand on your toes) and be firm. Avoid
cooperation of the child to examination and giving the child a chance to be oppositional and
compliance of both child and parentis) to the don't be afraid to utilise the 'white coat' syn-
treatment plan. Questions should be relevant drome. Remember the practitioner's role is to
and posed using a diplomatic approach, and help the child, not to be liked.
all explanations should be clear. One aspect of paediatric management is an
It may be easier to interview the parent while ability to handle the parents (Meadow 1992).
the child is playing. Watching the child at play Always enquire specifically about the parents'
allows evaluation of motor coordination and concerns. Explain about the cause and treatment
posture. Toys should be available to facilitate this using plain language and avoid promoting
informal assessment. Sometimes young children parental anxiety by mentioning all complica-
will perceive direct questioning by a stranger as tions. Furthermore, avoid the use of terms that
threatening, and so playing with the child first might invoke unnecessary parental anxiety (e.g.
may put him at ease. Making the most of the chronic, progressive, delay, tumour, spastic).
child's natural clothing vanity is another ploy the While it is wise to avoid raising expectations of
practitioner can use to relax the child. treatment one should always end the consulta-
It is important that during any assessment the tion on a positive note.
child is chaperoned. The latter point cannot be
ignored these days, when children may misin- History taking
terpret the nature of examination if left alone
In order to obtain a relevant history a structured
with the practitioner. It may be useful to ask
systematic approach should be adopted. This
parents to dress the child in easy-to-remove
will reduce the possibility of omitting relevant
clothing so that the process of undressing does
information. In addition to the general questions
not add to the patient's anxiety. Another person
regarding the presenting problem and medical
who is present - parent, nurse or care assistant-
history (Chs 3 and 5), particular attention should
can bear witness to events.
be paid to the following areas:
Parental dynamics can also influence the
success of the consultation. The practitioner • perinatal history (pregnancy and delivery)
should be aware of: • neonatal history
THE PAEDIATRIC PATIENT 345
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• result of 8 month hearing test the child walking, sitting, playing and how they
• ability to comprehend and obey simple interact with their parents.
commands. When assessing children, the focus is usually
on the locomotor system. In most children a brief
Family history vascular, neurological and skin assessment will
suffice. Further detailed examination should be
Family history of problems can provide vital performed in cases where the presenting
information about the cause and the prognosis of problem, history taking or brief assessment indi-
the complaint. Are there other siblings with a cates the presence of a significant problem. Tests
similar problem? It is helpful to ascertain any should only be used in order to clarify an other-
family traits. These can usefully be represented wise unclear diagnosis.
by constructing a pedigree chart. In genetically Those parts of the examination process which
determined conditions, e.g. immune deficiency are of particular relevance to the examination of
states, neurodegenerative disease or muscular the child are noted below.
dystrophy, enquiries about second- and third-
degree relatives may be indicated.
Neurological assessment
Previous consultations or advice Neurological assessment implies motor and
This should be noted as it may affect the parent's sensory evaluation. In the UK all neonates are
perceptions of the outcome of the child's foot examined by a paediatrician after delivery; mid-
problem. It must be stressed that the majority of wives and health visitors undertake follow-up
paediatric problems are usually normal develop- tests during the early years of development. Most
mental variations, rarely requiring anything neurological abnormalities will be detected
more than explanation and reassurance. during this stage. Reflexes are an important
method for determining normal muscle develop-
ment and innervation in the neonate. Certain
Examination involuntary (primitive) reflexes disappear after
Once a clear history has been taken, the child is 1 year of age. Reflexes present during the first
examined. The younger the child, the more expe- year of life are summarised in Table 14.2. The
dient the process needs to be. It is important to formal neurological examination of an infant will
do easy/fun tests first. Tests which may be per- include an evaluation of the primitive reflexes,
ceived by the child as threatening (e.g. hip exam- muscle tone/power, coordination (hand/eye) and
ination) can be left until last. Sometimes it can posture in relation to development. Neurolog-
help to examine a sibling or parent first to put the ical examination of the child should emphasise
child at ease. The examination should consider evaluation of superficial!deep reflexes, muscle
the following points: tone/power (stand on tiptoes/heels) and coordi-
nation (heel-to-toe walking, balancing on one leg,
• observation of gait and posture hopping).
• general walking capability All practitioners should be mindful of skeletal
• symmetry of body and gait abnormalities which indicate a neuro-
• obvious deformity muscular disorder, e.g. Charcot-Marie-Tooth
• muscle bulk and wasting disease (Case history 14.1), Duchenne's muscular
• joint motion dystrophy and Friedreich's ataxia. In some cases
• vascular and skin quality late walking may be due to neurological dys-
• footwear. function undetected at birth or developmental
First impressions are useful and the practi- hip dysplasia. Neurological tests should be
tioner should start with a general observation of carried out if an abnormality is suspected (Ch. 7).
THE PAEDIATRIC PATIENT 347
Reflex Descriptor
Oral reflex If a finger is placed in a baby's mouth, the baby will automatically suck and swallow. Failure to suck
may indicate a cerebral problem later leading to motor dysfunction in the lower limb
Mora reflex This reflex (startle reflex) disappears by 5 months. The infant is held in a supine position with one hand
supporting the head and neck. By sudden slight dropping of examiner's hand supporting head a
response is elicited. The normal response is for the baby to spread his arms away from his chest with
hands open and fingers spread apart followed by a movement of the arms towards the centre of his
chest as if in an embrace. The legs are flexed. Failure to respond suggests weakness. Asymmetry may
indicate lower spinal lesion if one leg affected. Hyperactivity suggests CNS infection and reverse Mora.
Where the baby extends limbs with external rotation, this indicates basal ganglia disease
Grasp reflex Palmar or plantar response up to 9 months. An object is placed in the palm and the fingers
automatically flex to grip the object. The foot would be similarly stimulated in the area behind the toes.
Failure to respond suggests CNS weakness, depending upon symmetry of reflex
Plantar reflex This is achieved by firmly stroking the lateral sale of the baby's foot and extending the movement
across the ball of the foot. A normal response in a child under 1 year is extension of the hallux.
An abnormal response indicates dysfunction of the upper motor neurones
Placing and If you touch the anterior aspect of either upper or lower limb (anterior tibia) against the edge of
stepping/walking an examination couch the child will lift the limb to place the foot/hand onto the surface of the couch.
reflex Alternatively, place the dorsum of the foot beneath the table top to attain the same response. This
occurs in the newborn up to about 4 weeks of age. If the baby is gently held above a surface with the
sales lightly contacting the surface this will elicit a stepping/walking motion. This response is present
until 8 weeks of age. Absence may indicate brain damage
Tonic neck reflex When the baby is supine and not crying, the head will be turned to one side and the arm on the same
side will be extended. The other knee will often be flexed. In normal babies, passive rotation of the
head will increase upper body muscle tone on the side to which the head is turned. This reflex is
present up to 3 months
Patellar and ankle Results should be similar to normal adult
tendon reflex
Gait analysis
Observation of the child's posture and gait on
entering the clinic enables the practitioner to gain
a general impression of lower limb function. It is
useful to observe the child shod so as to evaluate
the effect of the footwear on lower limb mechan-
ics. The choice of footwear may be unsuitable and
advice may be needed. The child should also be
observed unshod wearing underclothes in order
to assess the position of the lower limb, especially
the knees. First, decide whether the child's gait
style is appropriate for their age. As with all
patients it is important to observe the child's gait
from head to toe, taking note of any signs of asym-
metry of posture. The head should be level in the
frontal and transverse planes. In very young chil-
dren the head is positioned slightly ahead of the
body and may tilt downwards in the sagittal plane
to improve forward momentum as the child
chases their centre of gravity. Symmetry of facial
features and head size should also be evaluated.
The shoulders should be aligned and a child over
6 years should have symmetry of arm position
(same distance from the body) and symmetrical
arm swing. In static stance the arms should hang
level; if they appear uneven when fingers are
Figure 14.1 An 11-year-old boy had suffered cerebral
straightened this may suggest a corresponding palsy following an infection. Ankle equinus with spasticity
shoulder drop. If shoulders are level and there is has affected the right side of his body.
no evidence of scoliosis then anisomelia of the
arms may be indicated. If one arm is held close to
the body in a flexed posture neurological assess- Equinus may be apparent during gait; in chil-
ment is indicated to rule out an an upper motor dren up to 4 years it is not uncommon to observe
neurone lesion (UMNL), e.g. hemiparesis or cere- toe-walking. Abnormal in-toeing (common) or
bral palsy (Fig. 14.1). out-toeing should be noted. Evidence of a limp
Asymmetry at the level of the pelvis during needs further investigation (see later section on
walking may indicate pathology associated limping) and the presence of a scissoring gait,
with a scoliosis or a limb-length discrepancy. indicative of spastic adductors, warrants closer
Weightbearing and non-weightbearing examina- neurological examination.
tion should be performed on the spine to confirm
a tentative diagnosis. Gluteal muscle weakness or
Weightbearing assessment
paralysis associated with hip disorders will cause
a distinct lateral lurch in gait (Trendelenburg gait) Spine. It is important to check the spine for
as the fulcrum for the muscle is lost. shape, deformity and movement. Check for
THE PAEDIATRIC PATIENT 349
•
especially scoliosis. Scoliosis is a frontal plane
deformity but can show signs of vertebral rota-
tion, causing a kyphotic or humped appearance
in the sagittal plane. Progressive thoracolumbar
problems can impair pulmonary function and in
time cause strain on respiration. • Meninqocel
Marked scoliosis in children, especially where
epiphyseal growth remains, must be considered
potentially progressive. These patients should be
~
sent for a specialist opinion. Lordosis is increased
forward curvature in the sagittal plane, which Meninqornyelocel
commonly affects the lumbar vertebrae. This
varies between races, Afro-Caribbeans having a
larger lordotic curvature than Asians and
Caucasians. Early walkers also appear to have an
increased lumbar lordosis but this is due to a pro-
truding abdomen.
Hips. The Trendelenburg sign may be useful in Figure 14.2 A. Normal development of the neural tube
detecting hip weakness. The Trendelenburg test and spine. B. Classification of spinal dysfunction.
Figure 14.3 Hair tuft at the base of the spine seen with spina bifida occulta.
350 SPECIFIC CLIENT GROUPS
-----------
is a measure of normal muscle action between bered to avoid damaging the blood supply to the
the pelvis and greater trochanter (gluteus femoral head. At birth the head of the femur lies
medius). If the mechanism fails, it is deemed pos- superficially in the acetabulum, which gives the
itive (Ch. 8). appearance that the thigh is externally rotated on
the pelvis. As the child develops, the head of the
femur goes deeper into the acetabulum, which in
Non-weightbearing assessment
turn allows the limb to internally rotate. In a
Young children may be best examined on a normal neonate there is a ratio of 2: 1 external to
parent's lap. The lower limb is examined for pain internal hip rotation. With development, the
and swelling, obvious deformity and signs of amount of external rotation reduces as the
weakness. Both limbs should appear the same amount of internal rotation increases, to the point
regarding position, muscle bulk and tone. On where a normal adult value shows equal internal
examination there should be symmetry in ranges and external rotation of 45° in each direction.
and direction of joint motion on each side. When undertaking formal hip examination it is
Ranges of motion change with development; important to evaluate flexion/ extension, abduc-
however, quality of motion should be smooth tion/ adduction and internal!external rotation
and unhindered. The temperature of the limb in both hip-flexed and hip-extended positions
should be warm and the limbs should be exam- (Ch. 8). This should be followed by assessment of
ined for dislocations, fractures, soft-tissue lumps hamstring tightness (Fig. 14.4). Comparison of
and enlargement of bony areas. Bring the legs the lengths of the tibiae and femurs can be per-
together and visually estimate the limb lengths at formed using the Allis/skyline test (see Ch. 8). A
the level of the malleoli. discrepancy of limb length in an infant may be
Pelvis and hips. Altered function of the gluteal indicative of hip dislocation.
muscles due to hip dysplasia will cause a change In the neonate, ligamentous laxity may be
in the shape of the buttocks. As a result the present, together with instability of the hip. This
gluteal fat folds will not appear level ('anchor is associated with circulating maternal hormones.
sign'). The central crease forms the central anchor Correct technique in hip examination is para-
with the two base lines along the buttocks as the mount so as to prevent iatrogenic dislocation or
bottom of the anchor. If the base lines are not avascular necrosis of the femoral head. Nerves
level this implies asymmetry. When performing lying posterior to the hip joint, particularly the
tests on the hips of children, it must be remem- sciatic nerve, are subject to trauma in posterior
Figure 14.4 To determine hamstring tightness, lay the child supine, flex the hip to 90° and attempt to extend the knee to 90°.
THE PAEDIATRIC PATIENT 351
hip dislocation. Damage to the nerve may lead to The child should be observed from the side for
motor and sensory loss. genu recurvatum (hyperextension). This defor-
Knees. During childhood the knee undergoes mity occurs in the sagittal plane. In very early
a swing in the frontal plane from varus to valgus childhood, genu recurvatum may be present but
and then back towards neutral (Beeson 1999). should reduce with development as the knee lig-
Normal physiological bow legs (genu va rum) aments tighten. If reduction does not occur the
(Fig. 14.5) will present between birth and 2 years patient should be tested for ligamentous laxity
of age. Physiological genu valgum (knock knees) (Harris & Beeson 1998a).
is commonly seen between the ages of 3 and The range of transverse plane motion in the
5 years (Salenius & Vankka 1975). At 4 years of knee should be equal in both directions and be
age girls tend to be more knock-kneed than boys minimal by the age of 4 years. In the newborn
(Heath & Staheli 1993). Physiological genu 20-30° of total motion may be available
valgum is generally outgrown by the age of 8 (Kilmartin 1988). The amount of rotation of the
years (Beeson 1999). Some authors consider that tibia on the femur should reduce by 10° at
a second episode of genu valgum may occur 3 years of age and at 6 years of age should show
between 12 and 14 years of age (LaPorta 1973); minimal movement.
this is mainly seen in girls due to the pubertal Patellae. The position of these large sesamoids
effects of growth (Cahuzac et al1995). should be noted. Are they facing forward,
Knee position can be assessed with the child inwards or outwards? The patellae may be up to
either lying supine or standing. In the supine 30° externally rotated at birth. In young children
position the child's knees or ankles are pushed it is considered normal for the patellae to be
together with the legs parallel to the examina- externally rotated, but by 4 years of age the patel-
tion couch. The distance between the medial lae should face forwards. The position of the
femoral condyles of the knees and medial malle- patellae is dependent upon normal hip develop-
oli of the ankles can then be measured with a ment. The change of direction of motion (DaM)
tape measure. and range of motion (ROM) at the hip, femoral
torsion and reduction of external position of the
femoral head allow the patellae to face anteriorly.
These changes may continue until 10 years of age
and may give rise to an abnormal foot position.
Tibia-fibular segment. The tibiae should
appear symmetrical. Signs of excessive frontal
plane bowing should be noted and conditions
such as Blount's disease and rickets ruled out.
The calf muscles should be assessed for tone,
bulk and symmetry. Exaggerated lateral calf
muscles with forward facing patellae may
suggest medial genicular position.
The tibia and fibula twist with normal devel-
opment. At birth it will be apparent that the
malleoli are on the same level in the frontal
plane. As development ensues, the distal end of
the tibia twists externally (tibial torsion). The
lateral malleolus moves to a more posterior posi-
tion. There is axial rotation of the tibia and fibula
as well as twisting within the bone itself.
Malleolar position will reach an adult value
Figure 14.5 16-month-old girl with tibia vara of both legs. around 6 years of age with a position of 13-18°
352 SPECIFIC CLIENT GROUPS
correct length, width and depth. Often parents applied over the lesser trochanter with the
present their children to clinic because they are middle finger of each hand over the greater
concerned about excessive shoe wear. It is impor- trochanter. The femoral head is gently dislocated
tant to determine whether the shoe wear is by moving the pressure on the hand backwards.
normal or abnormal. In making this decision it is Consequent release of pressure allows the head
important to establish how long the shoes are to slip back into position. A positive result indi-
worn each day, the level and type of activity the cates that the hips are unstable due to ligamen-
child engages in and the types of material the tous laxity. The test becomes less useful as the
shoe is constructed from. Wear marks may be child becomes older (Valmassy 1993). The
misleading: i.e. heavy toebox wear associated wisdom of this manoeuvre is questionable, as
with a child using the foot as a bicycle break can the potential for avascular necrosis or neurolog-
be confused with a child who drags his foot due ical damage is increased by intentionally dislo-
to a hemiparesis. cating the hip joint.
It is important to communicate findings Palmen's sign. This is similar to Barlow's test
directly with the child, as they may be undertak- and performed in the same manner. It is a
ing activities at day nursery that their parents are provocative test for a subluxable (but not dislo-
unaware of. Assessment of footwear is consid- eatable) hip. If the hip is subluxable, the exam-
ered in detail in Chapter 10. iner feels a give (but not a clunk) as the femoral
head is displaced partially out of the acetabulum
(Harris 1997).
CONDITIONS AFFECTING THE Ortolani's manoeuvre. This is performed by
LOWER LIMB OF CHILDREN flexing the hips to 90 The middle fingers are
0
•
up and down along the lateral side of the ala pressed against the femur. The degree to which
(Harris 1997). squatting is restricted will indicate the severity of
the condition.
Anterior knee pain can occur during adoles-
Knee pain in the child
cence (more common in females). It is a recalci-
Complaints of significant, persistent knee pain trant problem which, in a minority of cases, can
are relatively uncommon in children and be disabling. The pain will be most intense
usually they present with a limp or refusal to during or after vigorous activity, although kneel-
walk. The clinical history should attempt to ing or sitting with a flexed knee for long periods
localise the pain, determine what activities exac- ('cinema seat' sign) may also incite discomfort. A
erbate the pain and what treatment has been high 'Q' angle (see Ch. 8) has been implicated as
provided to date. It is also useful to assess the a precipitating factor. Internal femoral rotation,
psychosocial dynamics of the child and his external tibial rotation and genu valgum are
family. All children between the ages of 5 and 15 known to increase this angle.
years presenting with knee pain must also be At certain stages of development an increased
evaluated for ipsilateral hip disorders (Davids 'Q' angle will be normal when physiological
1996). A structured approach to knee assess- knee valgus is present. The 'Q' angle should
ment is essential (Ch. 8). A number of specific reduce to 15° by 6 years of age.
knee tests are indicated in children: Osteochondroses causing knee pain. Intra-
Patella compression test. With the patient articular knee pain due to osteochondritis disse-
lying supine and the knee extended, the practi- cans, characterised by primary necrosis of
tioner compresses the patella against the femoral subchondral bone, will cause pain over the
condyles. If performed too vigorously it will lateral side of the medial femoral condyle.
cause pain, even in the normal knee. A more sen- Osgood-Schlatter's disease is a traction
sitive approach of gradually loading the kneecap apophysitis affecting the tibial tubercle and is
is preferred and is less distressing for the patient. associated with patellar tendon strain. It pre-
Medial facet tenderness test. The patella is dis- dominantly affects males between 10 and 14
placed medially and the practitioner palpates the years of age. Pain is anterior and below the knee.
posterior medial surface. Performing this test It is made worse by strenuous activity.
also determines whether there is any tightness of Examination demonstrates the presence of a
the lateral capsule tending to pull the patella lat- prominent and tender tibial tubercle and quadri-
erally, increasing shearing forces on the posterior ceps wasting may be visible. Extending the leg
facets, which may damage the articular cartilage. against resistance exacerbates the symptoms.
Quadriceps muscle bulk evaluation. The patient Radiographs may show fragmentation of the
is asked to contract the quadriceps muscle group; tibial tuberosity at the tendon insertion.
the bulk of the vastus medialis muscle is
assessed. Loss of muscle bulk can occur with
Abnormal frontal plane configuration
chronic pain or poor mechanical function of the
of the knee
knee.
Muscle function. Quadriceps muscle strength Parental concern about knock knees or bow legs
and hamstring flexibility should also be assessed. is a common presenting complaint.
The 90: 90 test will determine hamstring tight-
ness which, when present, will tend to flex the
Genu varum
knee and increase patellofemoral compression.
Squatting test. The patient is asked to stand on Genu varum is normally present from birth until
both feet and then crouch down. Patients with 2 years of age. If a child presents with bow legs at
severe pain will express discomfort; as the knee 3-4 years of age, further investigation and treat-
flexes the posterior surface of the patella is com- ment may be necessary. A distance of more than
THE PAEDIATRIC PATIENT 355
Scm between the knees, at any age, is cause for Genu valgum
concern and necessitates further investigation
Genu valgum is normally present between 3-5
(Sharrard 1976). Rickets and Blount's disease are
years of age and 12-14 years of age. In severe
two conditions predisposing to genu vara with
unremitting cases radiological examination
tibial vara.
should be used to rule out developmental or
Rickets. Rickets will present as genu varum as
metabolic abnormalities of the epiphyses.
well as anterior bowing at the junction of the
Surgical correction may have to be considered,
middle and lower one-third of the tibia. Swelling
although this is rare. Unilateral knock knee
of the wrists and ankles and bossing of the
should be investigated as it is almost always a
cranium is also seen in rickets. Radiological
pathological defect of the epiphysis associated
investigation will show the epiphyses to be
with either trauma, osteomyelitis, tumour or
widened and irregular, whereas the metaphyses
developmental bone disturbance.
will appear 'cupped'.
Excessive subtalar joint pronation of the foot
Biochemical tests are performed to determine
has been associated with genu valgum, as it
levels of vitamin 0, calcium and phosphate,
throws body weight medial to the central axis of
which may be reduced due to dietary deficiency,
the foot and hence tends to force the foot into
malabsorption, renal disease or hypophosphatasia.
pronation. Conversely, excessive varus deformity
If biochemical tests prove normal, Blount's
of the forefoot may create frontal plane movement
disease may be suspected.
of the knee, in order to bring the entire forefoot
Blount's disease. This is a condition affecting
into ground contact. Genu valgum will result.
the growth of the medial upper tibial epiphysis.
Cessation of the growth plate causes the tibia to
develop a lateral varus tilt. This condition has an
Popliteal angle in children
estimated incidence of 0.05 per 1000 live births
and is due to the lateral side of the growth plate The popliteal angle is defined as the angle of the
expanding faster than the medial side. Blount's tibia to the femur when the hip is flexed and knee
disease is thought to be a combination of obesity extended. Evaluation of the popliteal angle is
and marked physiological bowing. This will used to assess hamstring tightness in healthy chil-
have the effect of compressing the medial side of dren and hamstring contracture in cerebral palsy
the growth plate, which causes further bowing of (Katz et al 1992). It is also used as an indicator of
the tibia. The lateral epiphysis continues to gestational age in infants. The mean angle in new-
expand as pressure is released. The medial epi- borns is reported to be 27° and reduces to zero by
physis will appear fragmented on X-ray. Blount's age 11 months (Reade et aI1984).
disease may appear at any time between the ages Hamstring, and more specifically medial ham-
of 18 months and 4 years. Referral for treatment string, shortening is a common cause of asym-
should be initiated as the condition will invari- metrical hip motion and subsequent in-toeing.
ably progress without treatment. In the infant, Diagnosis is made by flexing the hip to 90° and
Blount's disease is often severe with both knees then attempting to extend the knee using the
affected. Arrest of the medial growth plate may 90: 90 test (see Fig. 14.4). In children under 10
also affect older children, aged between 6 and 13, years, less than 70% extension is unsatisfactory.
in whom the deformity is usually unilateral and Quality of motion is also evaluated while per-
less severe than the infantile variety, though no forming the 90: 90 test. If the hamstrings resist
less certain to progress without treatment. the final 30° of motion it is usual for the child to
Unilateral tibia vara can contribute to limb- experience discomfort, which indicates an abnor-
length discrepancy. mal tightness. The medial hamstring tension can
Trauma, infection (McRae 1997) and fluorosis be tested by internally rotating the flexed upper
(Tachdjian 1972) can also result in marked genic- thigh while gradually extending the knee. If,
ular bowing. with internal rotation of the thigh, knee extension
356 SPECIFIC CLIENT GROUPS
is limited and uncomfortable, then the medial adducted feet in the presence of a forward-
hamstring is the principal cause of the complaint. looking patella occur in cases of internal genicu-
Children with tight hamstrings can assume a lar position (knee), internal tibial torsion (leg)
normal angle and base of stance; however, during and metatarsus adductus (forefoot).
gait, as the knee extends just prior to heel contact, Following gait analysis, the ranges of motion
the tight medial hamstring will abruptly rotate at the hip and knee joint and the position of the
the leg internally. Such cases will also demon- transmalleolar axis and forefoot should be
strate a windmilling style of running, the lower assessed. The range of hip rotation is assessed
leg being circumducted during the late swing with the knee and hip extended: the leg is
phase of running in order to 'short-cut' around brought to the neutral position where the patella
the extended knee position. Growing pains are is facing directly upwards (parallel with the
common in such in-toers, Hamstrings should frontal plane). While viewing the patella, the leg
therefore be tested in any child complaining of is internally and then externally rotated and the
persistent nocturnal leg pains. degree of rotation estimated. In children of less
than 4 years, an excessive internal range of hip
motion is considered abnormal and will often
In-toeing problems
explain an in-toeing style of gait. In children
In-toeing is often a cause for parental or grand- older than 4, asymmetry of motion may be
parental concern because the child doesn't walk significant.
like his peers. Children themselves may not be A common finding on hip examination of the
unduly affected, unless their gait pattern causes in-toeing child is an increased internal range of
tripping. It is important to establish exactly what hip motion but reduced external range of
the family's worries are, because resolving those motion. In such cases there is obviously
fears provides an important goal of treatment. sufficient range of external motion to allow
Sometimes, the concern is related to the child normal walking; however, the child continues to
tripping or a pronated foot. walk in-toed because it is easier to do so. The
Thirty percent of children in-toe at the age of 4, parents should be told that the child is simply
but the condition persists in only 4% of adults walking along the line of least tension. Most
(Svenningsen et al 1990). It was once thought to children who present with internal femoral
cause osteoarthrosis of the hip and poor sporting position grow out of the condition. While inter-
ability (Alvik 1960), but it has subsequently been nal rotation falls from about 60° at age 4 to
shown to be unimportant in osteoarthrosis of the under 40° in the adult, decreasing 2-3° per year
hip (Hubbard et aI1988), while the sporting per- (Staheli 1993), external rotation remains at a
formance of women with internal femoral posi- constant 40° from 4 years of age to adulthood.
tion has been found to be equivalent to normal The net result is loss of total rotation with age
controls (Staheli et aI1977). and less internal bias to gait.
Resolution of the in-toeing gait usually occurs
between the ages of 4 and 11 (Fabry et al 1973,
Tibial torsion and internal genicular position
Thackeray & Beeson 1996a, 1996b). Management
of in-toeing depends upon the level at which the Clinical diagnosis of internal tibial torsion is
abnormality originates. made by measuring the transmalleolar axis,
Assessment starts with gait analysis. The key which is formed between the midpoints of the
to accurate diagnosis is the position of the medial and lateral malleoli and the frontal plane.
patella. In the in-toeing child, the patella will The transmalleolar axis increases during the first
either point in the direction of progression or it few years of life from 2-4° at birth to 10-20° in
will be internally rotated or 'squinting'. A squint- the adult. Many complex methods have been
ing patella indicates that the cause of the gait described for measuring tibial torsion (Reikeras
defect is proximal to the knee joint. Severely & Hoiseth 1989). A quick clinical estimation is
THE PAEDIATRIC PATIENT 357
Figure 14.9 A C-shaped curvature of the lateral border of the foot is the hallmark of metatarsus adductus. This 2-year-old
boy responded poorly to treatment as the deformity was quite rigid. The early management of metatarsus adductus is
desirable.
THE PAEDIATRIC PATIENT 359
that it is easier to correct a clubfoot deformity in 'Flatfoot' is a common term used by health care
the first few days of life than after even a few professionals and lay people alike. 'Excessive
weeks (Ponsetti 1992). pronation of the foot' is a more accurate term
Assessment of the clubfoot should address the because, as well as a lowered medial longitudinal
relative severity of each of the four components of arch, the flat foot may also present the following
the condition. The plantarflexed first metatarsal clinical signs (Fig. 14.11):
component is critical but usually yields well to
• calcaneal eversion
manipulative correction. The equinus and inver-
• bulging of the talus (talonavicular joint
sion components of the rearfoot and the adduc-
subluxation)
tion of the forefoot at the talonavicular joint are
• abduction of the forefoot
more resistant to correction (Ponsetti 1996).
• 'too many toes sign'
Internal tibial torsion may also occur with club-
• 'C' -shaped lateral border.
foot and must be also be corrected.
No matter how effective initial treatment, club- Helbing's sign, described as a bowing of the
foot will always result in shortening of the foot, calcaneal tendon as it inserts into the calcaneus,
reduced calf muscle circumference and reduced can sometimes be associated with excessive
ankle and subtalar joint motion. Medial displace- pronation. Helbing's sign is not always reliable
ment of the navicular and abduction of the talus because in some cases of excessive pronation it is
on the calcaneus may also persist. In less well not seen. This is so when the foot maximally
corrected clubfeet, poor gait and abnormal fore- pronates from a supinated position associated
foot loading results in plantar callus and shoe- with rearfoot varus. Pronation can occur using
fitting difficulties. The Ilizarov technique has the available range of subtalar joint motion, but
been used for the correction of persistent defor- the calcaneus may still remain in a relatively
mities (Wallander et aI1996). inverted position. This is commonly referred to as
'partially compensated rearfoot varus'. Marked
eversion of the calcaneus will inevitably lower
Flat feet
the medial longitudinal arch. With calcaneal ever-
Flatfoot is one of the most common conditions sion there will also be abduction of the distal end
seen in paediatric podiatry clinics. There is no of the calcaneus, allowing the talus to assume a
universally accepted definition for flatfoot. more adducted and plantarflexed position which
Morley (1957) suggested that children under can be seen clinically as medial bulging in the
5 years of age appeared to have flat feet because area of the talonavicular joint. Once congruency
the medial longitudinal arch was filled with fat. is lost at the talonavicular joint, progressive sub-
Radiological studies of toddlers' feet have luxation of the joint follows. As the talus ad ducts,
subsequently proved Morley wrong. All children the forefoot will assume an abducted position rel-
under 5 years have a depressed medial ative to the adducted rearfoot. This abnormality
longitudinal arch because of the low calcaneal will manifest clinically as the 'too many toes
inclination angle and the underdeveloped sign'. When a normal foot is observed from the
sustentaculum tali. It is only with external rear, it is possible to see the fifth and sometimes
torsion of the tibia, in the first 5 years of life, that the fourth toe. In a pronated foot the third toe
the calcaneus begins to assume its normal 20° may be seen as well. The lateral border of the foot
angle of inclination and the medial longitudinal will be C-shaped with the concavity of the 'C'
arch becomes apparent. However, in the neonate, overlying the calcaneocuboid joint.
fat deposits are retained for a short period and The aforementioned clinical signs associated
tend to be quite marked on the dorsum of the with excessive pronation will occur with varying
foot. This fat distribution does contribute to an degrees of severity. In some cases the only abnor-
immature foot shape, which disappears quite mality will be a lowering of the medial longitu-
rapidly after the first 12 months. dinal arch: all other signs will be absent. Such
THE PAEDIATRIC PATIENT 361
Figure 14.11 A 10-year-old boy with moderate pronation. Calcaneal eversion, medial talonavicular bulging and forefoot
abduction characterise excessive subtalar joint pronation associated with forefoot varus of both feet.
feet are not a cause for concern; indeed, a study of normal values should be used to determine
of 295 Israeli army recruits undergoing basic which children were abnormal and required
training found that the incidence of stress frac- treatment. However, in practice, Staheli's normal
tures was reduced in individuals with low- limits have proved to be very wide. Moreover,
arched feet (Giladi et aI1985). the height of the arch alone is not a reliable indi-
When evaluating the child's pronated foot the cator of excessive pronation of the foot as the
practitioner must consider other risk factors that arch is not flat in every pronated foot. Some
may affect the foot in its overall development
(Napolitano et al 2000). These contributing
factors may influence the treatment plan. The AlB 2.0
risk factors include: 1.8
1.6
• obesity
1.4
• ligamentous laxity
1.2
• hypotonia (Down's syndrome)
1.0
• rotational deformities
.8
• frontal plane tibial deformities
.6
• equinus
.4
• tarsal coalitions.
.2
Objective assessment of the pronated (flat) foot o
is vital in order to measure how the patient's foot 0 2 4 6 8 10 12 1415-19 30's 50's 70+
is changing with the passage of time or indeed
how it is responding to treatment. Staheli et al Figure 14.12 Staheli's table of normal arch index values.
The mean value for the arch index and two standard
(1987) developed the arch index as an indicator deviations for each of the 21 age groups. The solid line
of foot pronation (Fig. 14.12). The narrowest shows the mean changes with age; the shaded area shows
point of the arch width was divided by the the normal ranges. The actual values for each age group
are represented by solid circles for the mean and open
widest point of the heel width to give an arch circles for two standard deviations. (Reproduced by kind
index value. Staheli recommended that his graph permission of the Journal of Bone and Joint Surgery.)
362 SPECIFIC CLIENT GROUPS
patients will present with calcaneal eversion and discomfort where the foot is excessively
talonavicular bulging, but the medial longitudi- pronated. This is because the excessive prona-
nal arch may still be apparent. tory movement of the foot causes the muscle to
Rose's valgus index (Rose et al 1985) takes into work aphasically, leading to overuse. In many
account the eversion of the foot relative to the leg cases, such leg pain may be written off as
and can be used in conjunction with Staheli's untreatable 'growing pains'. The condition is,
index to obtain more valid information about the however, very responsive to conservative
degree of pronation (Fig. 14.13). Rose's technique orthotic treatment.
measures the displacement of the medial malleo- Whereas the young patient's foot may be
lus relative to the weightbearing surface of the severely pronated, it usually remains quite
heel. The more the foot pronates, the greater the flexible, as demonstrated by the hallux dorsi-
medial displacement of the malleoli. flexion (Jack's test) and tiptoe-standing tests. This
The Rose and Staheli indices should be used to invokes the windlass mechanism associated with
determine objectively foot position and arch the plantar aponeurosis, affording a rise in arch
height. Footprints should be repeated once height where the foot is flexible (Case history
yearly in an attempt to identify change. The deci- 14.3). This test is negative for rigid flat feet. In a
sion as to which children require treatment rigid pronated foot the arch will not rise upon
should be based upon an assessment of the mag- dorsiflexion of the hallux; neither will the rear-
nitude of their symptoms, family history and the foot invert when the individual stands on tiptoes.
footprint indices. The swivel test, where the child is asked to turn
The patient with excessive pronation may their upper body in stance and look over one
suffer from chronic low-grade discomfort in the shoulder while the foot on that side is observed,
medial longitudinal arch, talonavicular area, or can be useful. If the foot demonstrates a supina-
leg muscle pain, or even all three. The tibialis tion movement with arch rise, this signifies a
anterior muscle is particularly prone to causing flexible foot. The supination resistance test can
also be used. With the child weightbearing, the
examiner places two fingers on the plantar aspect
of the navicular and pushes up. If arch rise is
observed with this manoeuvre a flexible foot is
indicated. All of these tests are used to demon-
strate whether the tarsus is flexible or not.
r---
I Case history 14.3 I
Two brothers age 8 and 10 years presented with
excessively pronated feet in relaxed calcaneal stance
with severe talonavicular bUlging. Both boys
experienced foot fatigue bythe end of the day and
pain in the styloid process. Their gaitwas excessively
abducted and apropulsive. Jack's test and the tiptoe
test were positive, demonstrating a flexible flat foot.
The posterior tibial tendon was anteriorly displaced
Figure 14.13 Rose's valgus index. Footprints to show overthe medial malleoli, rendering itan inefficient
diagnostic features A. The orientation ofthe heel oval, in invertor and plantarflexor ofthe foot. The peroneal
this case pointing towards the second toe B. The medial muscles werecontracted. Both boysdemonstrated 6
pressure pattern which is commonly found in flat foot on the Beighton scale.
C. To show the measurements for calculation ofthe valgus ConclusIon: A diagnosis of severe flexible flatfoot
index, which equals 1/ 2 AB - AC x 1DDIAB where A and B primarily caused by malposition of posterior tibial
are vertically beneath each malleolus and C is the centre of tendon and tightness ofperoneal muscles and
the heel print. (Reproduced by kind permission ofthe aggravated by ligamentous laxity.
Journal of Bone and Joint Surgery.)
THE PAEDIATRIC PATIENT 363
measured. An angle in excess of the normal the patient's records, this can provide a visual
9° is known to be the forerunner of clinically indication of the effectiveness of treatment.
apparent hallux valgus (Kilmartin et al 1994). Because hallux valgus is usually a bilateral con-
• Osteophytic thickening of the first dition, both feet can be assessed in this manner
metatarsophalangeal joint. Visible thickening even if at first only one foot is affected.
of the joint indicates hypertrophy of the
metatarsal head caused by loss of congruency
Lesser toe deformity
of the joint and subsequent early
degeneration of the joint surface. The following lesser toe deformities are common
• A strong family history of the complaint. A cause for parental concern:
family history of hallux valgus, while not
• adductovarus third, fourth, fifth toes
confirming diagnosis, must arouse suspicion.
• dorsiflexed second toe
When hallux valgus is present in the child,
• overriding fifth toe
family history may also indicate the likely
• underriding third and fourth toes.
prognosis for the child. A history of severe
deformity affecting siblings, parents and Although the abnormal position is often real
grandparents is very significant. enough, the condition may be quite benign. It is
essential that the practitioner applies the follow-
Hypermobility may be a predisposing factor ing criteria to determine which lesser toe prob-
for juvenile hallux valgus; therefore, the screen- lems require treatment:
ing of all children with hypermobility for hallux
valgus would be beneficial (Harris & Beeson • Is weightbearing on the apex of the toe
1988b). rather than the soft plantar pulp? Apical
Pain is not usually a feature of hallux valgus weightbearing may lead to the development
until the deformity is more advanced. Pain can of painful corns and callus.
be associated with footwear irritation of the skin • Is the malposition of one toe likely to influence
overlying the medial eminence. Because of the the position of an adjacent, otherwise normal
progressive nature of hallux valgus, once the toe? For example, a dorsiflexed second toe will
diagnosis is made, assessment and review is lead to loss of buttress effect on the hallux,
likely to be a long-term commitment for both which will predispose to hallux valgus.
patient and practitioner. Dorsoplantar weight- • Is the malpositioned toe likely to be irritated
bearing radiographs will allow accurate assess- by footwear or cause footwear-fitting problems?
ment of the following: • Is the type of toe deformity likely to respond
to conservative or surgical treatment?
• first metatarsophalangeal joint space
• hallux valgus angle Transverse and frontal plane deformities are
• first-second intermetatarsal angle resistant to conservative treatment, whereas
• medial eminence sagittal plane deformities and even the sagittal
• osteophytic development plane component of complex digital deformities
• sesamoid position. respond more favourably to conservative treat-
ment. In children older than 9, conservative treat-
Radiographic changes are likely to be very ment becomes progressively less effective. In
subtle in the short term. Three yearly X-ray infants younger than 2, corrective devices are
reviews are therefore indicated. Objective clinical poorly tolerated and technically difficult to make
assessment can be made by taking a digital because of the size of the toes.
goniometer measurement of the first metatarso- If treatment is indicated, conservative treat-
phalangeal joint angle. This value should be ment should always be attempted first. Response
recorded after drawing around the weightbear- to treatment may be monitored using a Harris &
ing foot on a blank sheet of paper. When stored in Beath mat. The child should be asked to step on
THE PAEDIATRIC PATIENT 365
-----------
and then off the mat. Digital purchase will be be misleading. Conversely, an innocuous inci-
recorded by the mat. A Musgrave pressure dent associated with minimal trauma may frac-
system can also provide useful information. ture a pre-existing unicameral bone cyst of the
Apical weightbearing by the digits will be calcaneus or bone weakened by a tumour.
recorded as a very small area of digital contact, A number of specific questions should be con-
whereas adductovarus will often appear as the sidered (Table 14.4).
lateral side of the digit in contact with the mat. In Limping after vigorous activity may be the
overriding digits, toe purchase with the ground first clue to an impending stress fracture. Rather
will be absent. Following treatment, the foot than limp, the child may refuse to walk or stand
printing procedure should be repeated. and ask to be carried.
Drawing around the toes on blank paper, If pain is associated with the limp, its exact
photocopying the undersurface of the foot while location and pattern should be explored with the
supporting the child's weight, or photograph- child. The pattern of referred pain in children
ing the digits will also facilitate objective assess- appears to be stronger than in adults (e.g. pain
ment of treatment success. referred to the knee due to medial hip problems
such as slipped capital femoral epiphysis (SCFE)
or osteoid osteoma). The character of the pain
Causes of limping in children may be helpful, such as the constant pain from an
expanding tumour or infection versus pain
The painful limb / foot in the child is a cause for related to joint motion. Conditions which lead to
concern. Limping is abnormal, and few parents demineralisation of bone frequently cause gener-
tolerate the problem for long before seeking alised pain, particularly in the weightbearing
medical help. The child who limps presents a bones. Lower extremity pain and limping may be
diagnostic problem, as there are numerous con- the first signs of systemic illness such as juvenile
ditions that may result in limping (Table 14.3). It idiopathic arthritis (JIA), leukaemia, Gaucher's
is the practitioner's role to determine the likely disease or chronic renal disease.
cause. The age of the patient will make certain diag-
First, localise the problem in terms of anatom- noses more suspect:
ical structure. Careful systematic evaluation
from the pelvis distally will help. Next, deter-
• developmental dislocation of the hip in the
mine the cause, e.g. trauma. In young children
young child
physical signs rather than subjective symptoms
• Perthes' disease or toxic synovitis of the hip
will playa major role in determining aetiology.
in 5-7 year olds (more common in males than
Communication is limited and so true clinical females on a 6:1 ratio)
acumen is demanded. Thorough questioning of
• Kohler's oseteochondritis of the navicular
the parents is crucial. It is easy to be led to false (5-12 year olds)
conclusions, since pain may be influenced by
• heel pain (Sever's traction apophysitis) in
psychological factors, subjectivity and referred 9-12 year olds
pain (from the hip to the knee).
• SCFE or anterior knee pain in young
adolescents 02-15 years age).
History
Osteochondroses such as Perthes', Kohler's,
To arrive at a correct diagnosis it is paramount and Freiberg's diseases are a group of disorders
that a detailed history is obtained. The exact cir- associated with trauma and altered vascular
cumstances surrounding the onset and duration supply to bone (DeValentine 1992) which com-
of the limp must be carefully and sympatheti- monly cause limping in children. Other examples
cally explored. An episode of trauma is fre- of osteochondroses affecting the foot are given in
quently blamed as the cause of the limp, but may Table 14.3.
366 SPECIFIC CLIENT GROUPS
Nervous system
CNS Cerebral tumour
Cerebral palsy
Spina bifida
Spinal muscular atrophy
Back Trauma
Acute appendicitis
Herniated nucleus pulposus (slipped disc)
Scheuermann's disease of the spine (osteochondritis of spine)
Spondylolisthesis (forward displacement of vertebra on one distal to it)
Ankle/foot Fracture/sprai n
Rickets (ankle)
Osteomyelitis (calcaneus)
Unicameral bone cyst (calcaneus)
Sever's disease (traction apophysitis)
Osteochondroses - Mouchet's or Diaz/K6hler's/ Buschke's/Freiberg'slTreve's disease
Haglund's disease (osteochondrosis of accessory navicular)
Iselin's disease (traction apophysitis)
Accessory navicular - type II (Romanowski & Barrington 1991)
Tarsal coalition
Embedded foreign body in foot
Verruca
Onychocryptosis
Subungual exostosis
Table 14.4 Questions the practitioner should consider ination may be required to exclude knee pathol-
when assessing a child with a limp
ogy. Measurement of limb lengths is important,
• Is the limp constant or intermittent? as limb shortening may be an early sign of a dis-
• Is the limp only present in the morning, at the end of the located hip. Cutaneous changes should not be
day when the child is fatigued or is it present throughout overlooked. Extra skin folds, cafe au lait spots,
the day? erythema or heat may provide an excellent clue
• What is the posture of the lower extremity when the child
is limping?
to diagnosis.
• What is the effect of climbing stairs or running? A complete neurological examination includ-
Did the limp start following vigorous activity? ing evaluation of muscle function and strength
is important. A neurological abnormality is fre-
quently the underlying cause of many difficult
to diagnose limp problems (e.g. the child with
Physical examination
early Charcot-Marie-Tooth disease who pre-
Gait assessment should be preferably under- sents with a mild cavus foot and toe clawing).
taken unassisted by the parent. The uncoopera- Subtle variations in neurological function may
tive child is best assessed when he thinks the only be noticeable with weightbearing or fol-
examination is finished. Stiffness or limitation of lowing vigorous activity. The Trendelenburg
motion of a single joint forces the surrounding test (ability to stand on one foot) is a valuable
joints to compensate by increased movements. clue to limb stability. Most normal children over
This results in an irregular or jerky gait, such as 4 years of age can sustain this position for a
the forward thrust of the pelvis with a stiff hip or minimum of 30 seconds. Less time (a delayed
hiking the pelvis to swing through a stiff knee. Trendelenburg) may suggest weakness of
Positional change may occur, such as external the hip abductors or hip instability associated
rotation of the foot to accommodate a stiff ankle with acetabular dysplasia. Weakness of a
and limited dorsiflexion or external rotation of specific muscle is usually due to a local problem
the entire limb in SCFE. Sometimes it is helpful to (e.g. quadriceps atrophy accompanying a knee
accentuate the limp by asking the child to walk complaint), whereas weakness of muscle groups
on his toes or heels. Listening to the gait can be is usually associated with primary muscle dis-
informative: the slapping of the foot in drop foot, eases, systemic illness or neurological problems
the scraping sound of spastic gait or the quick (Hensinger 1986).
soft steps of an antalgic gait. Inspecting the shoes Certain limping patterns are characteristically
for abnormal wear is useful: increased toe wear associated with weakness of specific muscles.
in toe walkers, destruction of the medial shoe Tightness or spasticity of the muscles and poor
counter in severe abnormal pronation. voluntary control are good clues to mild cerebral
A non-weightbearing evaluation will help to palsy. Similarly, running accentuates the flexion
clarify initial impressions about the limp. Joints and posturing of the upper limb in a child with
should be examined individually and compared mild spastic hemiplegia. Rupture of the calcaneal
to the contralateral side and with expected tendon will lead to drop foot; Thompson's test
normal values, in particular observation for should be performed (Ch. 8). Hamstring inflexi-
joint stiffness, limited motion or guarding. bility can result in a flexed knee gait with abrupt
Marked changes to joint angle measurements internal rotation of the leg at heel strike, particu-
indicate disease or injury and should not be larly if the medial hamstrings are tight. Limited
attributed to immaturity. Joint stiffness fre- straight leg raising can be associated with ham-
quently accompanies synovial swelling and/ or string inflexibility, but also other causes such as
joint effusion as seen in JIA, whereas laxity of a discitis or spondylolysis and spondylolisthesis
joint generally points to a ligamentous problem. need to be excluded (Fields 1981). These usually
In the hip, telescoping or pistoning are the give rise to back pain, which radiates laterally
classic signs of dislocation. A formal knee exam- into the buttocks.
368 SPECIFIC CLIENT GROUPS
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FURTHER READING
Berkow R (ed) 1987 The Merck manual, 15th edn. Merck Behrman R E, Vaughan V C 1987 Nelson textbook of
Sharp & Dohme Research Laboratories pediatrics, 13th edn. W B Saunders, Philadelphia
THE PAEDIATRIC PATIENT 371
Drennan J 1992 The child's foot and ankle. Ravens Press, Pollak M 1993 Textbook of developmental paediatrics.
New York Churchill Livingstone, Edinburgh
Ferrari J 1998 A review of the foot deformities seen in Sharrard M D 1979 Paediatric orthopaedics and fractures,
juvenile chronic arthritis. The Foot 8(4): 193-196 Vols I and II, 2nd edn. Blackwell Scientific, London
Illingworth R S 1990 The development of the infant and Sheridan M D 1980 From birth to five years. Children's
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extremity. Futura, New York Thomson P (ed) 1993 Introduction to podopaediatrics.
W B Saunders, London
CHAPTER CONTENTS
Introduction 373
GUIDING PRINCIPLES
As with other areas of assessment it is essential to
take an accurate history and perform a detailed
examination. The majority of sports injuries seen
by the podiatrist are chronic in nature due to
overuse: they represent a diagnostic challenge
due to the long injury period and compensation
mechanisms which may have occurred as a result
373
374 SPECIFIC CLIENT GROUPS
of the injury. Both of these factors can make it it is imperative to know the anatomical struc-
difficult to confirm the diagnosis of the injury tures of the region in order to make an accurate
and ascertain its aetiological factors. diagnosis. After observing the area for
The history and examination should be aimed inflammation, erythema, ecchymosis, structural
at both diagnosing the injury and determining defects and malalignment the practitioner
the presence or absence of intrinsic (personal) should physically examine the area. The
and extrinsic (environmental) risk factors associ- purpose of the physical examination is to iden-
ated with the injury. The identification of intrin- tify, isolate and then stress individual anatomi-
sic and extrinsic risk factors can assist in making cal structures to try and reproduce the patient's
the diagnosis and guiding the management plan. symptoms. This should help enable the practi-
It is important to gain as much information as tioner to identify whether the pathology is iso-
possible about the injury. Information on the lated to a specific tendon, ligament, bone, joint,
duration, nature, frequency and intensity of muscle or nerve. A summary of the assessment
symptoms must be gained along with details of process is given in Figure 15.1.
the injury mechanism, aggravating factors and
previous treatment.
Clinical examination of the patient, which
ROLE OF THE SPORTS PODIATRIST
should include the whole musculoskeletal The podiatrist may be part of an interdisciplinary
system, with a specific focus on the lower limbs sports medicine team, a multidisciplinary sports
and the injury site, should follow the standard medicine team or working as a sole practitioner.
examination protocol of observation, palpation Central members of a sports medicine team are
and movement. When turning to the injury site likely to include a sports physician, orthopaedic
Extrinsic factors
Sport, equipment, Extrinsic factors
Equipment, sport
surface, training errors,
environment
i ,. ! technique
Medical history
( HISTORY
Social history
Drug history t ~
Injury observation
Swelling,
(0 IFFERENTIAL
DIAGNOSIS
malalignment,
ecchymosis, etc
Injury history
Location, duration,
mechanism,
Pain profile, +/- factors, I
previous treatment DEFINITIVE )
r DIAGNOSIS Injury assessment
Identify, isolate and
stress injured structure
Specialist
investigations
surgeon, physiotherapist and podiatrist. Other overcome these potential shortcomings and to
members of the team may include a general prac- be able to offer the patient more beneficial treat-
titioner (GP), radiologist, osteopath, chiropractor, ment plans. If such a network does not exist the
podiatric surgeon, masseur, and professionals practitioner may be required to provide treat-
from the sports science disciplines such as an ment and advice using mechanical, physical
exercise physiologist, sports psychologist, and and pharmacological modalities as well as
nutritionist. Working in such a team is of obvious giving advice on appropriate training sched-
benefit to both practitioner and patient. The ules. Although this may not affect the treatment
patient is likely to be treated more holistically, outcome, the practitioner must be aware of his
with appropriate intervention more readily avail- limitations and refer to other practitioners
able. For the practitioner there should be assis- where necessary.
tance in making an accurate diagnosis and being
able to treat more of the aetiological factors of the
ASSESSMENT ENVIRONMENT
injury (Case history 15.1).
Working as a sole practitioner is often more The practitioner may assess and treat the injured
challenging. Assistance in making an accurate athlete in a variety of different environments: the
diagnosis through interdisciplinary discussion majority are likely to be in a clinic or private
or access to specialist investigations such as practice setting, whereas practitioners involved
magnetic resonance imaging (MRD bone scans with sports clubs will often see athletes in what-
and intracompartmental pressure tests may not ever medical facilities are available at the club
be available. It is important to develop a referral ground or stadium. Some athletes may require
network with other health care practitioners to assessment and treatment at the side of a pitch or
track during an event. In each situation there will
obviously be time, space and equipment limita-
----- - - - -----_._-
~~----~
tions. A methodical, well-planned and logical
Case history 15_1 approach to the assessment will assist the practi-
- - - - - - - - . - - - - - - - - - - - - - ----1
tioner in whichever environment he is treating
A 19-year-old female, elite cross-country runner with
pain in her medial longitudinal arch was referred, by
the athlete.
her coach, to a multidisciplinary sports medicine As with any biomechanical examination it is
team. The pain had been present for 4 weeks and important to have an area to observe the
was gradually getting worse. The pain was centred
around the navicular and the insertion of the posterior
athlete's gait. There should be a minimum of
tibialis tendon was both prominent and painful. Base 5 m of uninterrupted non-carpeted surface. A
line X-rays were negative for a navicular stress flat bed couch is essential for a number of tests
fracture but demonstrated a type 2 os tibialis
externum. A magnetic resonance imaging (MRI) scan
where the athlete must be able to lie fully prone,
was requested by the sports physician to examine the supine or on their side. There should be plenty
health of the tibialis posterior tendon and determine of space on either side of the couch for the prac-
the presence of a stress fracture. The scan confirmed
a navicular stress fracture and healthy tendon. She
titioner to undertake an assessment of the knee,
was treated with a short leg cast for 6 weeks followed thigh, hips and lower back. Tape, padding and
by prophylactic orthoses to reduce pronatory temporary orthoses are useful adjuncts to diag-
compression forces on the navicular. She was also
identified as being oligomenorrhoeic with only four
nosis and should be available in all working
menstrual cycles per year. This is known to be a risk environments.
factor for stress fractures (Tomten et al 1998). She It is important that the athlete wear clothing
was subsequently referred for dual energy X-ray
absorptiometry (DEXA) scanning of her pelvis, spine
that permits an accurate examination. Shorts must
and foot, which demonstrated reduced bone mineral be worn to allow assessment of the knees and
density. She was therefore referred to a observation of leg alignment and muscle bulk. It
gynaecologist and sports nutritionist to address these
imbalances. Three years on she is still competing at
may be of benefit to have spare shorts of different
an elite level and has had no further stress fractures. sizes available for patients who do not bring their
own. Jumpers and jackets should be removed to
376 SPECIFIC CLIENT GROUPS
assess the spine, hips and shoulder position. Table 15.1 Intrinsic and extrinsic risk factors associated
with sports injuries
Assessment of the athletes' footwear is essential.
This should involve both the sports footwear and Intrinsic risk factor Extrinsic risk factor
general footwear, as either or both can contribute
Age Sporting equipment
to overuse injuries. Athletes should be advised to
bring their sports shoes to all consultations. Gender Exercise surface
The use of gait analysis equipment can be of Previous injury Sporting activity
great benefit in assessing the sports patient. The Structural alignment Sport position
most commonly used equipment is a treadmill, Flexibility Training errors
with or without the use of a video camera. More Physical fitness Warm up and stretching
specialist equipment such as force platforms, in- Physical build Environmental factors
shoe pressure systems and digitised video gait Psychological factors
analysis are discussed in detail in Chapter 12. Systemic disease
Specialist equipment can be very useful when
assessing more complex sports injury cases or
when treating professional athletes. These
systems can: Intrinsic risk factors
• aid the diagnosis Age
• identify sporting technique
The age of an athlete can affect both the type of
• assist in treatment planning
injury that may occur and the healing mecha-
• help explain injury mechanisms to the
nisms that follow. Younger and older athletes
patient.
tend to be more injury prone for a variety of
Although the cost would prohibit most practi- reasons. There is generally less muscle mass and
tioners from purchasing such equipment it muscle strength in both of these groups com-
would be beneficial to identify where patients pared with older adolescents and young adults.
can be referred for this type of analysis. This can result in greater injury risk both in
contact and endurance sports. Less protective
sports equipment is available for children than
INJURY RISK FACTORS adults, which can lead to greater injury risk from
The aetiology of both acute and chronic injuries ground reaction forces and physical contact. The
is undoubtedly multifactorial. To simplify this quality of coaches in children's teams is often
process, risk factors are divided into intrinsic lower than their adult counterparts, which may
and extrinsic causes. Intrinsic risk factors are cause injury due to improper training and coach-
those that are personal and are either biological ing supervision (Dalton 1992).
or psychosocial characteristics that predispose In children of all ages fractures are more
the individual to injury. Intrinsic risk common than ligamentous disruptions. Even the
factors account for up to 40-60% of all running location of fractures varies with the age of
injuries (Cavanagh & Kram 1990, James et al the child. Adolescents tend to have fractures in the
1978). Extrinsic risk factors are independent of physeal areas, whereas preadolescents have more
the person and are related to the type of sport- fractures in the diaphysis (Cantu & Micheli 1991).
ing activity and the sporting environment. Certain bony injuries, such as the osteochondri-
Extrinsic risk factors account for up to 80% tides, can only occur in the young athlete. Also
of running injuries (McKenzie et aI1985). Of all traction apophysitis of the calcaneus (Sever's
risk factors for overuse injuries training errors disease), the fifth metatarsal (Iselin's disease), and
are the most common and may account 60% of of the tibial tubercle (Osgood-Schlatter's disease)
the cases (Hreljac et al 2000). Table 15.1 lists the only occur in children and adolescents, although
intrinsic and extrinsic risk factors to injury. rarely the symptoms may persist into adulthood
ASSESSMENT OF THE SPORTS PATIENT 377
._--------------_._-- .._---_._--_._---_._-_ .. _ - - _ . _ - - - - - - - - - - - _ . _ - _ . -
in the case of Osgood-Schlatter's disease. Both boys are twice as likely to be injured as girls
traction apophysites in the young athlete and (Bruns & Maffulli 2000). This is in contrast to
musculotendinous injuries in the older athlete studies involving military personnel where injury
have been linked with reduced flexibility. It is rates among female recruits are between two and
known that reduced flexibility is more common in four times higher than their male counterparts
both groups (Anderson & Burke 1994, Gerrard (Jones et a11988, Ross & Woodward 1994).
1993). Assessment of flexibility is therefore a key Perhaps of more significance than injury rates
area when examining both children and older ath- are the differences in the types of injury seen
letes with sports injuries. between males and females. Certain injuries are
Musculotendinous injuries are the commonest associated with certain sporting activities. An
injury in the older athlete (over 40 years). This is example of this is posterior ankle impingement,
due to a number of cellular changes which occur which is most commonly seen in females partic-
with increasing age. Changes in collagen cross- ipating in either dance or gymnastics. Pain from
linking cause an increase in tendon stiffness and existing structural deformity or natural align-
reduce the elasticity of the tendon. This can result ment may also occur in the female athlete.
in a muscle being subject to earlier and prolonged Hallux valgus is far more common in females
loading in a movement cycle and being unable to and the joint or prominence can become painful
undergo normal stretching, resulting in damage due to the increased ground reaction and fric-
to the musculotendinous unit. The diameter, tional forces of sporting activity. A valgus align-
density and cellularity of the collagen fibrils are ment of the knee is more common in females,
also diminished with advancing age, which and this can increase the strain on the medial
results in reduced muscle mass and strength. soft tissue structures of the knee during sport
Finally, the blood supply to tendons reduces with involving excessive knee flexion and rotation,
age, resulting in an increased risk of tendonitis, e.g. medial collateral ligament injuries in skiing.
tendonosis or rupture (Strocchi et aI1991). Patellofemoral syndrome is undoubtedly more
Overuse injuries in the older athlete may also common in females than males and this is prob-
develop due to a delayed physiological response ably due to a wider pelvis decreasing the
to exercise. When a person starts an exercise pro- mechanical efficiency and altering the muscle
gramme there are gradual positive changes to the mechanics of the patellofemoral joint.
cardiovascular, neurological, endocrine and mus- The incidence of stress fractures has also been
culoskeletal systems. As a person becomes fitter reported to be higher in females. Early studies
the muscles become stronger and there is an showed the female incidence to be 10 times
increase in bone density. These normal adaptive greater than men (Protzman & Griffis 1977).
changes are delayed in the older athlete and may Although more recent studies have not shown
cause musculotendinous injuries if the athlete such a significant difference between the sexes it
increases their training volume too quickly. is generally accepted that female athletes are
more prone to stress fracture than males, espe-
cially in the military. There are three common
Gender
aetiological factors which may be responsible for
Physiological differences between the sexes result this greater relative risk of stress fracture. These
in differences in athletic performance. For compar- interlinking factors are known as the female
ative body sizes women have a reduced cardiac athlete triad or unhappy triad and are usually
output, blood volume, vital capacity and mean present in combination:
muscle mass when compared to males. Whether • amenorrhoea or menstrual irregularities (less
this increases the risk of injury in female athletes is than five menses per year)
uncertain. Studies involving civilian populations • osteoporosis (due to menstrual abnormalities,
have not shown significant differences in injury hormonal imbalance, calcium deficiency or
rates between the sexes; except in children where malnutrition)
378 SPECIFIC CLIENT GROUPS
------'-'--'-'--
assessment should include examination of the • muscle weakness (vastus medialis, gluteus
joints, muscles and osseous alignment (Ch. 8). medius, medial retinacula of the knee)
The majority of podiatric interventions in sports • patella malalignment or hypermobility (in
injuries are related to the assessment and treat- frontal, transverse or sagittal plane)
ment of structural alignment and function that • patella maltracking (during flexion and
has caused or contributed to the injury. extension)
Chronic or overuse sports injuries are usually • excessive subtalar joint pronation
due to the presence of one or both of the follow- • frontal plane malalignment of the knee or
ing situations: tibia.
• normal structure and function but inadequate The presence or absence of these factors should
preparation or excessive demands placed on assist the practitioner in identifying the aetiolog-
the tissues ical factors and planning the most effective
• abnormal structure and function with relatively treatment (Witvrouw et al 2000).
normal demands placed on the tissues. Asymmetries between limbs may represent the
obvious cause of a unilateral overuse injury.
Although this is a rather simplistic view, it
However, it is important to consider the role of
can be seen to be true in the majority of cases. If
other factors such as the type of activity, exercise
we consider two runners with patellofemoral syn-
surface, unilateral trauma and injury history.
drome: runner A runs over 100 miles/week,
Any of these factors may cause a unilateral
running every day; runner Bruns 20 miles/week,
injury. If structural asymmetry is identified, then
running 3 times per week with 4 rest days. Apart
the practitioner must determine a biomechanical
from their injuries, they are both healthy and have
mechanism by which the asymmetry could have
taken 6 months to get to this weekly mileage. It
caused the overuse injury. If we consider stress
should be clear that runner A is doing too much,
fractures as an example, there is a strong associa-
too soon, and too frequently:
tion between stress fractures and limb-length
• running 100 miles/week will often result in inequality (Brukner et al 1999). Stress fractures
injury tend to occur in the longer limb, and the greater
• a running volume of 100 miles/week in just the inequality the greater the incidence (Friberg
6 months has not allowed the tissues to 1982). The reasons for this are thought to be due
undergo the normal adaptive processes to the biomechanical consequences of the limb-
required to meet these demands length difference, which results in a longer stance
• running every day does not allow adequate phase, skeletal realignment, greater osseous
recovery time for the tissues, resulting in torsion and increased muscle activity of the
injury. longer limb.
Other aetiological factors may also be present
in runner A, but treatment will fail unless the Flexibility
errors of the training schedule are addressed. In
the case of runner B, the aetiology of his injury Hypermobility due to increased muscle flexibil-
is likely to be due to abnormal structure and ity and ligamentous laxity has been associated
function which has resulted in excessive with a greater risk of injury. Hypermobility is
patellofemoral joint reaction forces. His struc- often determined by the Beighton score, which is
tural assessment should include examination of based on a nine-point test designed to measure
factors such as: excessive joint movement (Ch. 14). This test has
been used in a number of studies on flexibility
• muscle inflexibility (hamstrings, iliotibial and injury, which has generally shown that
band, quadriceps, lateral retinacula of the hypermobility is associated with a greater inci-
knee and calf muscles) dence of ligamentous injury. Rossiter & Galbraith
380 SPECIFIC CLIENT GROUPS
(1996) found that hypermobility was present in fitness test used. Pope et al (2000) were able to
34% of military recruits with ankle and knee lig- demonstrate that the least-fittest group of their
ament injuries compared with 19% of control army recruits were 14 times more likely to
subjects. Increased flexibility, measured by the sit sustain a lower limb injury than the fittest group.
and reach test, in the absence of ligamentous The fitness method used was the progressive
laxity has not been shown to be a significant 20 m shuttle run test, also known as the bleep
factor in injury prediction. test. This test is one of the most popular fitness
Generalised inflexibility due to muscle tight- tests used today.
ness has been linked to musculotendinous injury: When assessing injured athletes it is important
while this is likely to be true, it has not been to gauge their fitness level, as you may need to
proven in any long-term prospective study. offer advice on a more appropriate training
However, if a theoretical causal link can be made regimen. This is often the case for the novice
between the muscle inflexibility and the injury, athlete who enthusiastically embarks on an over-
then stretching of those muscles should be ambitious fitness programme. This will result in
included in the treatment programme. Likewise, injury, as the musculoskeletal system is not pre-
if hypermobility is present, then stretching pared for such strenuous exercise. When an
should be avoided and athletes encouraged to injury occurs, the athlete should be advised to
perform specific stabilising exercises. modify his exercise to prevent recurrence or
Stretching prior to activity does not appear to further injury to other structures. This advice
reduce the risk of lower limb injury. This has may include changing the method of exercise or
been demonstrated in a number of studies, reducing the intensity, frequency or duration of
including two large randomised controlled trials the exercise.
involving military recruits (Pope et a11998, 2000).
These studies did not measure the level of flexi-
Physical build
bility of the two groups but demonstrated that
the injury incidences of the two groups were the The relationship of physical strength to injury is
same irrespective of whether the athlete unknown. To avoid injury the musculoskeletal
stretched or not prior to exercise. This does not system must be able to cope with the physical
mean that injured athletes with muscle inflexibil- demand of the sporting activity. Some evidence
ity should not be instructed to stretch, as this is suggests that stronger athletes are more injury
an effective treatment modality. However, ath- prone (Knapik et aI1992). The reasons for this are
letes are often questioned as to whether they unclear, but it may be that the muscular forces
stretch before and after activity and encouraged generated by stronger athletes damage their joint
to do so if they do not. There seems little evi- structures and even the muscles themselves. It
dence to support this premise and failure to may also be that stronger athletes exercise at
stretch before exercise should not be viewed as a greater intensity or duration than weaker ath-
risk factor to injury. letes, resulting in higher injury rates.
There is a correlation between strength imbal-
ance and injury that is most frequently seen in
Physical fitness
the knee joint, where differences between ham-
Physical fitness is known to lower the risk of string and quadriceps strengths have been asso-
injury, as shown in a number of studies based on ciated with cruciate ligament injuries. The role of
military and civilian populations (Neely 1998). strength differences between limbs has also
This protective mechanism not only applies to shown a greater injury incidence on the weaker
practising a known sport but also to learning a side. There is general agreement that strength
new sport or athletic skill. The level of reduced differences greater than 10% can increase the
risk varies amongst the studies, and is dependent injury risk to the weaker limb. These injuries may
upon the activity being undertaken and the be acute, as with cruciate ligament injuries, or
ASSESSMENT OF THE SPORTS PATIENT 381
chronic, due to fatigue, e.g. tendonitis, muscle Other obvious psychological injury risk factors
strains and stress fractures. The role of limb dom- are stress and anxiety levels. Stress may come
inance in injury incidence is less certain. Limb from the sport itself or other life stresses.
dominance in racket or ball sports is associated Changes in personal circumstances, careers and
with different injury patterns. However, in sports relationships with family and friends can induce
that require equal stresses through both limbs significant stress on an athlete. The athlete may
there is no evidence to suggest limb dominance is then view sport as an escape or outlet to vent
a risk factor. Herring (1993) was unable to show frustration, which can lead to poor decision
any difference in injury incidence based on limb making and injury. It is important to be aware of
dominance in elite runners. these factors when treating the athlete, as injury
Anthropometric data such as height, weight, recurrence will be high if they are not addressed.
body mass index (BM!) and total body fat have This may mean liaising with the athlete's coach
also been examined as injury risk factors. In or team physician, so that an appropriate social
general, it is only the BMI that has been shown to support network can be provided.
be a positive indicator for injury risk. The BMI is The psychological response of the athlete to
determined by dividing the body weight in kilo- an injury can vary significantly. Most will go
grams by the height of the patient in metres through a reaction of stress and grief. The grief
squared (i.e. kg zm"). The normal BMI range is response to an injury is like a minor or moder-
20-25 with above 25 representing clinically over- ate version of losing a loved one. The severity of
weight, above 30 clinically obese and below 20 the injury and the importance of sport to the
representing underweight. As a general rule, the athlete will determine the level of the grief
injury risk doubles for individuals who fall response. The grief response is characterised by
outside the normal BMI range. three phases:
Phase 1 - shock. The immediate response to
the injury may be one of sudden complete shock.
Psychological factors
The athlete may show signs of anger, disbelief
Psychological factors can playa significant part and deny the existence of the injury.
in both the development of a sports injury and Rehabilitation of the athlete cannot begin until
the rehabilitation of the injury. Although there is this phase is over.
no definite psychological profile of the injury- Phase 2 - preoccupation. The athlete may
prone athlete, there are certain characteristics demonstrate signs of depression and guilt about
which may predispose the athlete to injury. Acute the injury, becoming isolated from other team
injuries may be more frequently seen in athletes members, family and friends. The athlete may
who are extroverts with a low sense of responsi- also show signs of bargaining behaviour when
bility. These athletes are natural risk-takers who undergoing treatment during this phase.
may put themselves in injurious situations Rehabilitation may begin during this phase, but
unnecessarily. The reasons for this type of sport- real progress will not be achieved until the
ing behaviour may be due to a daredevil attitude, athlete enters the next phase.
poor decision making or an attempt to gain pop- Phase 3 - reorganisation. This is characterised
ularity with their peers, coach or supporters. by the athlete fully accepting the presence of the
Chronic overuse injuries may be seen more fre- injury and demonstrating a renewed interest in
quently in athletes who demonstrate high levels the rehabilitation programme. The athlete is also
of responsibility and dedication. These athletes likely to show a renewed interest in the sport and
will often train and play beyond the point of in relationships with family and team-mates.
fatigue, resulting in small repetitive trauma to The practitioner should be aware of the
the tissues. This can cause chronic overuse various emotional states the athlete may
injuries such as stress fractures, tendonitis and demonstrate. This can help in formulating more
muscle strains. appropriate treatment plans with one of the
382 SPECIFIC CLIENT GROUPS
main aims being to guide the athlete to the final Patients with cardiovascular conditions such as
reorganisation phase. peripheral vascular disease or hypertension must
exercise with caution. Dynamic exercise increases
the cardiac output, increases the blood flow to
Systemic disease
working muscles and causes peripheral vasodila-
Practitioners must be aware that not all athletes tion. The net result is a rise in systolic pressure in
are free from systemic disease or medical condi- normotensive athletes. However, with hyperten-
tions. Cardiovascular, respiratory, endocrine, sion there are rises in both systolic and diastolic
arthritic and neurological complaints are seen pressures from already elevated baseline levels.
fairly frequently in the athletic population. The This can elevate the blood pressure to dangerous
spur for many people to start to exercise may be levels, particularly if the athlete has moderate to
the presence of hypertension, cardiovascular severe hypertension, the exercise intensity is too
disease or obesity. Patients with systemic disease high or isometric exercise is performed.
are often prescribed exercise programmes by In patients with vasospastic conditions or
other medical professionals such as CPs, medical peripheral vascular disease, localised tissue
consultants or physiotherapists. The role of exer- hypoxia can result if the metabolic demands of
cise and sport is generally beneficial for patients the exercising tissues are greater than the blood
with systemic disease as it can improve cardio- supply can provide. It is also important to
vascular, respiratory and neurological function remember that certain sports injuries are caused
and help improve strength, flexibility and mobil- by cardiovascular changes such as acute and
ity. However, the exercise must be of the right chronic compartment syndromes of the lower leg
type, intensity, duration and frequency to ensure and foot, and popliteal artery entrapment syn-
medical complications do not arise. Practitioners drome. Exercise can also occasionally be the
should also be aware that undiagnosed systemic cause of cardiovascular pathology, such as effort-
disease may be the underlying cause of the injury induced deep vein thrombosis or external artery
(Case history 15.3). endofibrosis (Bradshaw 2000).
A 38-year-old male physical education instructor was and systemic joint disease. After a thorough clinical
referred by his GP with a 2-month history of localised examination osteoarthritis, stress fracture and tendonitis
pain in both forefeet. The patient was otherwise healthy were excluded. The examination of the joints caused
and participated in a wide variety of sports both at work pain and there were some neuritic symptoms in the right
and socially. Both he and his GP were unsure of the foot. The patient was given a local anaesthetic injection
nature of his pain and he had been referred for further into the web space to exclude a Morton's neuroma and
investigation and orthotic treatment if appropriate. a temporary orthosis. The patient was also referred for
A thorough medical history demonstrated no major X-ray.
illnesses, operations or a history of lower limb injuries. Upon review the local anaesthetic injection had not
There was no significant family medical history or social resolved the symptoms but the temporary orthosis had
history. There was also no recent history of a change in alleviated some of the pain. The X-rays revealed erosive
exercise pattern or footwear. The pain was centred changes in both metatarsal heads and the patient was
around the left fifth and right third metatarsophalangeal subsequently diagnosed by a rheumatologist as having
joints and tended to occur after activity. The pain was rheumatoid arthritis. The patient is currently taking
gradually getting worse. Moderate swelling was present disease-modifying drugs, wearing appropriate orthoses
at both joints, particularly in the right second interspace, and continues to exercise. His exercise programme has
with slight splaying of the second and third toes been modified to avoid high-impact and contact sports.
(Sullivan's sign). A list of differential diagnoses was This case demonstrates the importance of keeping an
considered, includinq stress fracture, capsulitis, open mind when determining the diagnosis of an injury.
synovitis, flexor digitorum longus tendonitis, neuroma, Practitioners should consider all potential causes to
bursitis, soft tissue mass (right foot only), osteoarthritis avoid unnecessary or inappropriate treatment.
ASSESSMENT OF THE SPORTS PATIENT 383
Athletes with diabetes must monitor their systems' or special air or gel pockets to aid shock
blood glucose levels very closely, especially absorption is often used to market the brand as
when starting or altering an exercise programme. being better than that of the competition. The evi-
Exercise increases the demand for glucose in the dence to support such claims is often lacking.
exercising tissues, resulting in a sharp drop in The practitioner should appraise the athlete's
blood glucose levels. This can trigger a hypogly- shoe, identifying good and bad attributes and, if
caemic attack. Athletes will often have to reduce recommending a change in footwear, advise the
their dosage of insulin before exercise and should athlete of what to look for when buying new
always have a ready source of glucose available sports shoes. To recommend one specific model
when they exercise. It is important that diabetics for all patients will fail, as many patients will
exercise to help reduce cardiovascular complica- return dissatisfied if the injury does not resolve
tions and limited joint mobility associated with or complain that the shoe is uncomfortable.
the disease. The aim for the practitioner is to ensure that
Neurological conditions such as upper or lower the patient is exercising in a shoe that is:
motor neurone lesions, hereditary motor and
• comfortable
sensory neuropathies and nerve entrapments
• correct fit in length and width
may occur in athletes. Patients with neurological
• appropriate for the patient's sport
disorders are often advised to exercise. Such
• does not show signs of excessive wear
patients may have altered sensation, altered
• has appropriate tread, studs, spikes, cleats for
muscle function and gait and a pes cavus foot
the sport and exercise surface
deformity. These patients must be carefully
• provides sufficient shock absorption,
assessed to ensure they undertake the appropri-
especially in the midsole
ate exercise programme using appropriate sup-
• provides appropriate motion control for the
ports as required. Avoidance of high-impact and
patient
contact sports is essential in neuropathic patients.
• firm fastening
• lightweight.
Extrinsic factors Many sports shoes do not meet all of these cri-
teria and can playa significant part in the devel-
Sporting equipment
opment of an overuse injury. Worn shoes have
The most important piece of sporting equipment been identified as risk factors in the incidence of
in the assessment of chronic overuse injuries is a number of injuries such as stress fractures, exer-
the athlete's footwear. The athlete's shoes can cise-induced leg pain and Achilles tendonitis due
assist in the diagnosis of the injury as they are to a lack of shock absorption (Gardner et a11988,
often a contributory aetiological factor. They also Myburgh et al 1988). The shoe is the interface
represent an adjunct to treatment, as the practi- between the foot and the ground and must
tioner will often modify the footwear or use it to absorb significant ground reaction forces gener-
accommodate an orthosis. In certain circum- ated by sporting activity. As the shoe ages or
stances the practitioner may recommend chang- becomes more worn, its ability to absorb these
ing the footwear completely. Recommending the forces is reduced, resulting in increased forces
right shoe for the patient is not easy. Sports shoe being passed on to the musculoskeletal system. It
manufacturing is a multi-billion pound industry has been estimated that the average running shoe
and company research data on shoe design and loses 50% of its shock-absorbing capabilities after
function are closely guarded secrets. Each 300-500 miles of running (Cook et al 1985). Old
company produces a number of different models shoes may not only demonstrate signs of exces-
for the same sport making it hard to know which sive wear but also material degradation can
is the best one. The most expensive model does occur, even further reducing the shock-absorbing
not mean it is the best. The use of 'motion control capabilities of the shoe.
384 SPECIFIC CLIENT GROUPS
An uneven wear pattern on the sole of the shoe dence to support this despite several long-term
or the insole inside the shoe can give a guide to prospective studies. However in athletics,
biomechanical abnormalities or sporting tech- harder synthetic track surfaces can increase
nique of the athlete. Excessive lateral wear of the performance but also increase the incidence of
rearfoot can indicate a varus alignment or strike musculoskeletal injury. If athletes exercise solely
pattern and may cause inversion ankle sprains or on hard surfaces, increases in the incidence of
lateral foot and leg injuries. Excessive wear medial tibial stress syndrome by 28%
across the ball of the foot will cause a loss of trac- and Achilles tendonitis by 17% have been
tion and control, which may induce injury. demonstrated (Nigg & Yeadon 1987).
Different wear patterns between the shoes may Artificial grass was first used for sport in 1964
indicate different biomechanics or sporting tech- and has since become a major playing surface in
nique. The most common example of uneven a wide number of sporting activities. The injury
wear is limb-length inequality due to structural, profile of this surface is different to that of
functional or environmental factors. natural grass. Bowers & Martin (1976) identified
The weight of the shoe is important to optimise an injury virtually unique to this surface. Turf toe
performance: the heavier the shoe, the greater the is a hyperextension injury of the first metatar-
muscle exertion and energy expenditure. This sophalangeal joint resulting in a sprain of the
can cause fatigue in the lower leg muscles and plantar capsuloligamentous structures. It is
therefore affect performance. Light running caused by shoes with a flexible sole in the fore-
shoes may enhance speed but should only be foot bending excessively on a hard unyielding
worn for racing as they do not offer appropriate surface. It is primarily seen in American football
support or shock absorption. but can occur in any sport played on artificial
The importance of comfort and correct fit grass surfaces such as AstroTurf.
cannot be overstated. Shoes that are too tight or Harder surfaces invoke greater ground reac-
narrow will obviously cause irritation, resulting tion forces, which must be absorbed by the shoe
in corns, calluses, subungual haematomas and and musculoskeletal system. The body absorbs
other nail pathologies. It is common in kicking these forces primarily through the joints and
sports such as soccer and rugby that the athlete eccentric muscle activity. The harder the exercise
will wear a boot that is too small in order to get surface, the greater the eccentric muscle activity
a better 'feel' for kicking the ball. This practice (Richie et al 1993). Theoretically, exercising on
should be discouraged as it can often lead to harder surfaces should cause greater knee
clawing of the toes and exacerbate nail patholo- flexion, ankle dorsiflexion and greater or pro-
gies. Shoes that are too narrow or fastened longed subtalar joint pronation to aid the
too tightly can cause pain in the arch and neu- absorption of the higher ground reaction forces.
ritic pain in the forefoot during exercise. A shoe No biomechanical studies have shown this to
that is too long will allow excessive movement date.
of the foot, resulting in friction blisters and heel In addition to the hardness of the exercise
slippage. surface, it is important to consider the friction
and energy loss of the surface. Friction, or hori-
zontal stiffness, is integral in acceleration and
Exercise surface
deceleration. Artificial athletic surfaces have
The role that the exercise surface may play in the greater friction than grass, allowing greater accel-
development of overuse injuries is a contentious eration and deceleration. However, these greater
issue. It was previously thought that athletes frictional forces must be absorbed by the body
who exercise on hard unyielding surfaces and can result in increased injuries. These
such as concrete would have an increased inci- injuries may be to the musculotendinous units or
dence of osteoarthritis due to accelerated wear the ligaments designed to limit joint movements
and tear of the joints. There is very little evi- such as the cruciate ligaments of the knee.
ASSESSMENT OF THE SPORTS PATIENT 385
Energy loss of a surface is related to its elastic string muscle activity. Downhill running requi-
behaviour and deformation properties. Surfaces res greater ankle plantarflexion and eccentric
that deform when loaded are termed compliant muscle activity of the foot dorsiflexors. This par-
and result in increased contact time. This ticularly affects the tibialis anterior muscle,
increases cushioning as peak contact forces are which becomes active for longer and elongates
reduced. However, it may reduce performance as further as it decelerates foot slap. Downhill
the contact time is greater, resulting in slower running also increases the load on the quadri-
acceleration. Exercising on softer surfaces can ceps muscles and is known to exacerbate condi-
also alter joint positions. Consider an athlete tions such as patellofemoral syndrome and
running on sand. The greatest contact force patella tendonitis.
occurs at heel strike, so the sand will be maxi-
mally displaced at this time. This results in
Sporting activity
greater ankle dorsiflexion, requiring greater
muscle activity of the calf muscles. Thus, exercis- The type of sport the athlete plays and the tech-
ing on softer surfaces may reduce injuries associ- niques they use are integral to the development
ated with high-impact forces but may lead to of overuse injuries. Certain injuries are even
increases in muscle activity resulting in musculo- named after certain sports or activities (Table
tendinous injury. 15.2). This does not mean that these injuries are
It is also important to consider the terrain and unique to that particular sport, but they occur
incline of the exercise surface. Uneven terrain frequently due to the forces the anatomical struc-
such as grass will mean the body having to ture has to absorb. Metatarsal stress fractures are
adapt to maintain ground contact and stability. not unique to military personnel who march, but
These adaptive changes mainly occur in the this activity involves repetitive impact forces
frontal plane and can result in greater supina- through the forefoot, which can result in a
tory and pronatory moments within the foot stress fracture. Patella tendonitis is most com-
and ankle. If these forces become excessive then monly seen in jumping sports due to the high
frontal plane injury will result. The most ground reaction forces (up to eight times body
obvious example of this is the inversion ankle weight) that this activity produces. A significant
sprain. Pronatory injuries can occur and usually component of these forces is absorbed by eccen-
involve the posterior tibial tendon. If an athlete tric quadriceps activity, which can cause patella
exercises on uneven terrain with frontal plane tendonitis.
movements of the foot and ankle limited by
strapping, a brace or boots, then greater forces
will be transferred to the knee. This can result in
Table 15.2 Common injuries named after a sport
collateral ligament and cruciate damage. This
injury pattern has been seen in skiing. Uneven Injury name Injury definition
terrain can also exist on surfaces which are per-
Footballer's ankle Anterior ankle impingement
ceived to be flat. The camber of roads is usually
Tennis leg Rupture/tear of medial head of
canted up to 14°. This can cause pronatory gastrocnemius
moments on one limb and supinatory moments Fresher's leg Exercise-induced shin pain
on the other, resulting in an environmental March fracture Metatarsal stress fracture
limb-length difference.
Jumper's knee Patella tendonitis
The importance of exercising on an incline
Runner's knee Patellofemoral syndrome
should not be overlooked. Both uphill and
Golfer's elbow Medial epicondylitis
downhill running are associated with different
Tennis elbow Medial (forehand) epicondylitis,
joint angular relationships and muscle activity lateral (backhand) epicondylitis
patterns. Uphill running requires greater ankle Swimmer's shoulder Rotator cuff pathology
joint dorsiflexion and eccentric calf and ham-
386 SPECIFIC CLIENT GROUPS
It is important the practitioner has an under- This will result in different injury profiles seen
standing of the type of sport the athlete plays and between positions: e.g. a prop forward and
its biomechanics. This will help the practitioner: wing back in rugby, a wicket keeper and fast
bowler in cricket, a linebacker and wide receiver
• understand the forces involved in the sport
in American football.
• identify the structures at risk of injury
• determine the potential biomechanical
mechanism of injury Training errors
• formulate the most appropriate treatment
As discussed earlier, athletes may do too much,
plan.
too soon, and too frequently. Training errors are
These four factors are all interrelated. one of the commonest causes of chronic overuse
Identifying the structures most at risk of injury injuries, and practitioners must identify these
requires knowledge of the forces involved in the errors for successful treatment planning. Failure
sport. This knowledge is related to the biome- to do so will lead to a recurrence of the injury or
chanical movements of that particular sport. development of other overuse injuries. To avoid
Determining the biomechanical mechanism of injury athletes who wish to exercise regularly
injury is crucial to formulating the most appro- must find the correct balance of exercise intensity,
priate treatment plan. duration and frequency. This will normally
Without this knowledge it is difficult to involve:
reduce or prevent the forces that caused the
• participating in more than one sport
injury. Appropriate treatment planning must
• combination of strength, flexibility and
also take into account the limitations of the
endurance training
sport on the treatment. This will include the ath-
• incorporation of rest days in the weekly
letes' footwear and other sporting equipment.
training schedule
Some sports do not allow the use of mechanical
• periods during the year of greater
supports as they may compromise player safety
training/sport levels, i.e. seasons
or give the athlete an unfair advantage.
• variation in training methods to help
It is also important to be aware of individual
maintain interest.
variation in sporting technique, which not only
determines the athlete's skill and ability at a When athletes first begin to train they often
sport but can also predispose injury. Minor dif- overestimate their baseline fitness level. This can
ferences in sporting technique can have a result in injury, as the musculoskeletal system is
significant effect on injury development. An not physiologically prepared for this volume of
example is in running techniques between fore- exercise. Common injuries at this stage are muscle
foot and rearfoot strikers. Forefoot striking is strains and exercise-induced leg pain (shin
associated with increased impact forces, a splints). Increasing the volume of exercise too
reduced stance phase and reduced subtalar joint quickly can also occur when an athlete is return-
pronation. These three factors combined could ing from injury or training for a specific competi-
increase the forces being absorbed both in the tion that they are not prepared for.
forefoot and more proximally in the calf muscles, Bones, like muscle, also undergo a normal
shin and knee. physiological strengthening process during the
The team position will also help determine early period of an exercise programme. This
the sporting technique of the athlete. The posi- remodelling process is characterised by initial
tion played may be based on anthropometric bone porosity due to osteoclastic channelling,
characteristics, limb dominance and skill levels. which is then followed by osteoblasts laying
Team position may be important to the practi- down new bone matrix. The result is that the bone
tioner, as the biomechanical movements and is initially weakened by exercise and then eventu-
sporting techniques used by the athlete can vary. ally strengthened beyond its pre-exercise level.
ASSESSMENT OF THE SPORTS PATIENT 387
This whole process usually takes 6 months and nosis or inappropriate treatment planning. The
during the first 2 months the bone is especially consultation will start with noting the patient's
prone to injuries such as stress fracture. This is personal details. In addition to the patient's
one of the main reasons stress fractures are name, address, date of birth, GP, information on
usually seen during the first 2 months of starting other health care practitioners treating the
an exercise programme or significantly increasing athlete should also be recorded. Recording the
the exercise level (Beck 1998). contact details of the athlete's coach(es) is
useful, as communication with them may assist
the practitioner in identifying risk factors and
Environmental factors
ensuring the athlete adheres to any treatment
Changes in temperature, humidity and altitude plan.
can all affect performance and may increase The following areas should be covered to
injury risk. Practitioners providing treatment at achieve an accurate history:
endurance events should be particularly aware
• medical history
of the consequences of environmental factors.
• social history
High temperatures and humidity levels can
• drug history
produce heat-intolerance illnesses including
• sport history
syncope, heat cramps, exhaustion and stroke.
• injury history.
These are most frequently seen in athletes who
have not fully acclimatised to the environment
and become dehydrated and salt depleted.
Medical history
Most cold-related sports injuries are seen in
submaximal endurance sports such as marathon Taking an accurate medical history is essential
running or wilderness sports such as moun- in determining an athlete's suitability to
taineering and skiing. Cold climates reduce per- perform a sport. As already discussed, poor
formance as the body must use energy stores for physical fitness or systemic disease may predis-
thermogenesis. Cold-induced injuries include pose an athlete to injury. Diseases of the cardio-
chilblains, trench foot, frostbite and hypother- vascular, respiratory, neurological, endocrine,
mia. Pre-existing conditions, such as asthma, gastrointestinal and genitourinary systems can
Raynaud's phenomenon and cold urticaria, can affect performance and predispose injury. If
also be triggered by the cold. medical conditions are identified, it is important
High altitude ranges from 1500 to 3500 m to gain information about the onset, the type of
above sea level. Above 1500 m, the maximum symptoms experienced, the treating physician
oxygen uptake by the body reduces by 10% for and the type of treatment. This information will
every 1000 m. This results in reduced perfor- help the practitioner to determine whether it is
mance at endurance events. The opposite is true necessary to recommend participation in a dif-
for performance at short anaerobic events, due to ferent sporting activity or participation at a
lower air resistance. Illnesses associated with reduced level.
high altitude include acute mountain sickness, The history of any surgical procedures should
pulmonary oedema, cerebral oedema and retinal also be recorded. Surgical procedures due to sys-
haemorrhage. temic disease or previous injury may have direct
relevance to the assessment of the current injury.
Information related to all surgical procedures is
HISTORY TAKING
important as it provides an indication of the
A significant part of the patient's initial consul- overall health status of the athlete and the
tation is likely to involve history taking. It is athlete's healing capacity. Also, any recent opera-
important to cover all relevant areas, otherwise tions that may have resulted in a reduced training
vital clues may be missed, resulting in misdiag- programme and fitness level, which may have
388 SPECIFIC CLIENT GROUPS
mass, muscle strength and the psychological cardiovascular fitness it is recommended to exer-
drive to exercise. These drugs may cause injury cise three times a week for a minimum of 20 min
due to the increased forces placed through the each time at an intensity of 70-80% maximum
musculoskeletal system from the greater exercise heart rate.
intensity. There is also some evidence to suggest The duration of activity is important: too
that continual long-term use causes weakening short an exercise period will not produce the
of collagen structures, resulting in injury to desired physiological improvement in fitness,
tendon, ligament and muscle. Other more serious and too long a period will cause fatigue and
long-term effects can include cardiomyopathy, possible injury. Duration should also include
liver damage and testicular atrophy. Abuse at the how long the athlete has been participating in
elite level is further complicated by athletes that particular sport, as this will impact on his
using masking agents, which may themselves be fitness and skill level. When questioning the
detrimental to health. Evidence on the effects of athlete on his sporting activity, it is important to
other ergogenic aids such as protein, vitamin and determine at what frequency, duration and
mineral supplements, creatine, caffeine, blood intensity he was exercising at when the injury
doping and human growth hormone is currently occurred. The practitioner should pay particular
lacking. Although these aids are commonly used, attention to recent changes to the training
their potential benefit to athletic performance has schedule (Case history 15.4).
not been clearly proven. The level at which the athlete undertakes his
sport is also important. This will help the practi-
tioner determine the athlete's motivation to play
Sport history
It is important to gain as much detail about the
athlete's sporting history as possible. This should Case history 15.4
include the following:
A 23-year-old semi-professional soccer player
• type or types of sport returned for treatment complaining of bilateral shin
• frequency (number of times/week) pain. Eighteen months previously he had been
successfully treated for patellofemoral syndrome after
• duration being prescribed an exercise programme and
• intensity orthoses for his football boots and AstroTurf training
• level. shoes. His shin pain had been present for 6 weeks
and was gradually deteriorating. It was initially
The main sport the athlete participates in is of suspected that the shin pain was due to the orthoses
obvious importance but the practitioner should becoming worn and less effective. Additional support
was therefore added to the orthoses and the athlete
also focus on secondary sporting activities the was reviewed 2 weeks later. The pain was still
athlete may undertake. These activities may be present and it was at this stage that the athlete
for interest or fitness but they can play a revealed that his training schedule had changed
slightly. In addition to his normal soccer training,
significant part in the development of an injury which consisted of 5 hours' practice and one game
and should not be overlooked. Other factors to per week, he had started to attend a high-impact
note would include the sports surface, footwear, aerobics class. This was in a school hall with a non-
sprung hardwood floor. For the gO-minute classes he
limb dominance and sporting position. wore an old pair of running shoes in which his
The frequency, duration and intensity of sport- orthoses did not fit.
ing activity will help the practitioner determine if He was advised to discontinue the aerobics class
and the shin pain resolved within 10 days. High-
the athlete is over- or under-training: both can impact aerobics on hard surfaces is associated with
lead to injury. Over-training can cause overuse significant ground reaction forces and this had
injury, as there is insufficient time for tissue caused him to develop medial tibial stress syndrome.
The lack of orthotic control and the poor shock
replenishment and regeneration. Under-training absorption of his old running shoes had probably
can cause injury due to inadequate levels of exacerbated the situation.
fitness or strength. As a general rule, to improve
390 'SPECIFIC CLIENT GROUPS
sport and may also guide the treatment plan. mechanism or pattern of injury. This informa-
Elite or professional athletes may find it harder to tion can enable the practitioner to identify the
rest or modify their activity than novice athletes. injured structure and the likely level of force
Convincing a professional athlete to take time that caused the injury. Diagnosis of both the
out from their sport is often very difficult and injured structure and the injury severity is
should involve collaboration with other therefore easier.
members of the sports medicine team or coach- Identifying the injury mechanism in chronic or
ing staff. These athletes are often more demand- overuse injuries is harder as these injuries are
ing of the practitioner and can present a usually associated with multiple minor traumatic
management challenge. events and the injury may have led to functional
When assessing an athlete's current participa- compensation.
tion level it is important to determine his athletic The location, duration and the type of pain can
goals. Athletes may strive to achieve certain all assist the diagnosis of the injury. The location
goals or reach a specific level of performance, of pain may be diffuse and generalised or focal
such as running a distance in a given time or and specific to a single structure. This character-
becoming a regular first team player for a sports istic is important, as both generalised and focal
club. Although these goals may be achievable the pain can be typical of specific conditions. As an
athlete will often have unrealistic expectations of example, consider patellofemoral syndrome and
the time it will take to reach that level of skill or patella tendonitis, which are both causes of ante-
fitness. Part of the assessment of the athlete and rior knee pain. Patella tendonitis will cause pain
his injury may involve the practitioner giving within the tendon or its sheath and is focal in
advice on whether the athlete's goals are achiev- nature. Patellofemoral syndrome is characterised
able in the short term. by pain medial, posterior or lateral to the patella
and is generalised in nature. This is sometimes
referred to as the 'grab' sign, as the patient will
Injury history grab the whole of the front of the knee when
As much information as possible should be asked to locate the area of pain.
gained about both previous lower limb injuries The duration of pain will inform the practi-
and the current injury. Previous injuries are tioner both of how long the injury has been
important as they can make the athlete more sus- present and its severity. As a general rule, the
ceptible to injury and they may also cause struc- longer the injury has been present the longer the
tural or functional compensations. Information recovery period will be from the initiation of
on this area can be gained easily by asking ques- treatment. This is usually because the injury has
tions such as: become more severe. Consider pathology of
tendons as an example. Long-standing tendonitis
• Have you broken any bones within the lower
can be associated with the formation of adhe-
limb?
sions, scar tissue and mucinous degeneration of
• Have you ruptured or torn any ligaments or
the tendon itself. This is referred to as tendonosis
tendons in the lower limb?
and will require more intensive and prolonged
• Is there a history of prolonged or intermittent
treatment that may take many weeks or months
swelling of any joints in the lower limb?
to resolve. Injuries which are intermittent in
• Have you had any injuries, which have
nature may be less severe or specifically associ-
resulted in missing more than 2 weeks from
ated with a sporting activity.
sport?
Descriptions of the type of pain experienced
With acute injuries there is often a history of a are somewhat subjective. However, certain pain
single traumatic event. The athlete may be able descriptions are characteristic of trauma to
to describe how the injury occurred, making it specific anatomical structures. Neurogenic symp-
easier for the practitioner to determine the toms usually involve paraesthesia, numbness or
ASSESSMENT OF THE SPORTS PATIENT 391
a burning sensation. A dull or intense aching sen- pain is induced by exercise and the athlete must
sation usually represents an injury to deep struc- stop or reduce their exercise intensity. Upon ces-
tures, especially muscle or bone. Sharp or sation of exercise the pain goes completely
throbbing pain may represent trauma to articular within minutes. In medial tibial stress syndrome
structures. The severity of the pain is especially pain is rarely present during exercise but occurs
subjective, as patients have differing tolerance within hours following exercise and may last up
and pain coping strategies. It is therefore best to to 2 days post-exercise. The pain from stress frac-
assess the pain severity in conjunction with all tures is exacerbated by exercise and usually
other injury factors. becomes constant in nature unless the athlete
Other factors to note about the injury are pre- completely rests.
vious conservative treatment and what exacer-
bates or improves the injury. The majority of
EXAMINING THE INJURED
sports patients have usually been treated by
STRUCTURE
another health care practitioner or attempted
self-treatment prior to attending the podiatrist. Following a thorough injury history, the practi-
This information may be particularly useful in tioner may have formulated a provisional list of
determining injury severity and appropriate differential diagnoses. This process is assisted by
treatment planning. Accurate information on observation of the injured site and adjacent struc-
treatment by other health care workers may tures. Marked swelling, bruising and erythema
require communication between practitioners, often accompany acute injuries, whereas in
which can also assist in making an accurate chronic injuries these signs may be minimal or
diagnosis through case discussion. Factors absent. Observation of adjacent structures is
which exacerbate injury are usually sport- useful to gauge the level of any swelling or to
related and may include any of the intrinsic and determine deformity. Unilateral injuries should
extrinsic risk factors discussed earlier. Factors always be visually compared with the asympto-
outside of the athlete's sport may also con- matic side. This will require having the athlete
tribute, such as occupation, social activities and prone when the injury is on the posterior surface
non-athletic footwear. such as with Achilles tendon injuries.
Many injuries have such characteristic histo- From the history and visual inspection the
ries that the injury diagnosis requires only practitioner should be able to identify the
minimal examination. A common example of this potential injured anatomical structures. The
is exercise-induced leg pain, traditionally known next phase of the examination will be to indi-
as shin splints. The characteristics of the common vidually isolate the structures and then apply
causes of exercise-induced leg pain are shown in stress to them in a controlled manner. The appli-
Table 15.3. The relationship of the pain to exercise cation of stress should be gradually increased
is very diagnostic, as each condition significantly until the athlete's symptoms are reproduced.
varies. In chronic compartment syndrome the Stress is initially applied by gentle and then firm
Pain characteristic Medial tibial stress syndrome Tibial stress fracture Chronic compartment syndrome
palpation. The level of pressure required when to stress the posterior tibial tendon or have the
palpating the area is determined by the tissue athlete go up and down on their forefoot with the
type and depth. Deep dense structures such as heel over the edge of a stair to stress the Achilles
tendon or bone will require firmer pressure than tendon. A dynamic functional assessment should
more superficial structures or those that are less be included in any orthopaedic examination. For
dense such as muscle or ligament. the athlete with a sports injury this may require
Movement of the injured structure should also the practitioner to observe the athlete's sporting
be performed. This should initially be passive, technique in addition to normal static stance and
with the practitioner directing the movement. If gait analysis. Many of these sporting movements
this is pain-free, the patient should be directed to can be performed in a relatively small space or
move the structure actively with no resistance on a treadmill. Occasionally, a practitioner may
applied. In the majority of sports injuries both of have to go and observe the athlete in his natural
these types of movements are unlikely to cause sporting environment.
pain. The next step is to apply active resistance to
the movement. This should first be performed
Specialist investigations
with concentric contraction and then eccentric if
the first movement did not induce symptoms. As with any investigation, specialist tests should
These contractions should be held for between 10 only be performed if the results may change the
and 20 seconds. In the majority of cases resisted treatment plan. Specialist investigations in sports
eccentric or concentric contraction will induce medicine are primarily used to assist in diagnos-
symptoms. ing and grading the severity of an injury. A
The method of achieving the greatest stress is summary of the various tests and the common
to have the athlete perform dynamic or func- sports injuries they may be used to diagnose is
tional exercises: examples of these movements given in Table 15.4. X-ray remains the mainstay
are double or single knee squats to stress the diagnostic test for osseous pathology and MRI or
patellofemoral joint and the single leg tiptoe test ultrasound for soft tissue pathology. A number of
conditions such as stress fractures, osteochondral Athletes are often well educated in their area of
defects and the osteochondritides may be diag- sport and this can greatly assist the practitioner.
nosed by several different modalities. In these Likewise, the practitioner must educate the
cases the choice of modality will depend upon patient, as this will play a crucial role in the
the injury history, and the cost and access of the success of the treatment. The majority of sports
modalities. injury treatments require the athlete to follow
specific advice or instructions. Compliance is
intricately linked to understanding so the practi-
Injury grading systems
tioner must educate the athlete about the injury
As with many pathologies, sports Injuries are and the purpose of any treatment.
often graded by their severity. These classification A structured holistic approach is essential in
systems are primarily used to direct treatment the assessment of the sports patient. The practi-
protocols. As an example, grade one ankle sprains tioner should develop a logical assessment
are treated differently from grade three sprains. scheme that meets the patient's and his own
Grading systems are also useful when communi- needs in whatever assessment environment
cating with other health care practitioners in the they are working in. The successful treatment of
sports medicine team about the patient. They can lower limb sports injuries requires the practi-
also be used to help explain the nature of the tioner to assimilate knowledge from areas as
pathology to the athlete or coach. Grading diverse as sports psychology, exercise physiol-
systems may describe an injury to a tissue type ogy and sports biomechanics. This knowledge
such as ligament, bone or tendon, or be specific to will assist in the diagnosis of the injury risk
a certain injury such as posterior tibial tendon factors. Identification of these intrinsic and
dysfunction, osteochondral talar defects or extrinsic risk factors should form the main focus
Achilles tendon injuries. The grading systems for of the assessment. Diagnosis of the injury itself
muscle and ligament injuries and tendonitis are requires detailed knowledge of the regional
given in Table 15.5. anatomy and common sports injuries that affect
the lower limb. Athletes with chronic overuse
injuries can be very difficult to treat. The assess-
SUMMARY
ment principles outlined in this chapter are
The practitioner should involve the patient as designed to help the practitioner meet these
much as possible in the assessment process. management challenges.
One Stretching of the ligament Pain after exercise Minimal tear with no loss of strength
without macroscopic tears
Two Partial macroscopic tear Pain pre- and post-exercise, pain Macroscopic tear with loss of
reduced during exercise strength
Three Complete rupture Pain before, during and after exercise Complete tear with no function
Four Constant pain and volume of
exercise reducing
394 SPECIFIC CLIENT GROUPS
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Surgeons 6: 368-377 of Bone and Joint Surgery 59(6): 825
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characteristics of running shoes. American Journal of sports surfaces: an electromyographic study. Journal of
Sports Medicine 13: 248-253 American Podiatric Medical Association 83(4): 181-189
Dalton S E 1992 Overuse injuries in adolescent athletes. Ross J, Woodward A 1994 Risk factors for injury during
Sports Medicine 13(1): 58-70 basic military training: is there a social element in injury
Friberg 0 1982 Leg length asymmetry in stress fractures: a pathogenesis. Journal of Occupational Medicine 36:
clinical and radiological study. Journal of Sports 1120-1126
Medicine 22: 485-488 Rossiter N, Galbraith K 1996 The incidence of
Gardner L I, Dziados J E, Jones B H et al 1988 Prevention of hypermobility in a military population (abstract).
lower extremity stress fractures: a controlled trial of a Meeting of the Combined Services Orthopaedic Society,
shock absorbent insole. American Journal of Public Aldershot, UK, 165
Health 78: 1563-1567 Strocchi R, DePasquale V, Guizzardi S et al1991 Human
Gerrard D F 1993 Overuse injury and growing bones: the Achilles tendon: morphological and morphometric
young athlete at risk. British Journal of Sports Medicine variations as a function of age. Foot and Ankle 12: 100-104
27(1): 14-18 Tomten S E, Falch J A, Birkeland K I et al1998 Bone mineral
Griffin L Y 1994 The female athlete. In: Delee J C, Drez D densities and menstrual irregularities: a comparative
(eds) Orthopaedic sports medicine Vol 1. W B Saunders, study on cortical and trabecular bone structures in
Philadelphia runners with alleged normal eating behavior.
Herring K 1993 Injury prediction among runners. International Journal of Sports Medicine 19: 92-97
Preliminary report on limb dominance. Journal of Walsh W M 1994 Patellofemoral joint. In: Delee J C, Drez 0
American Podiatric Medical Association 83(9): 523-528 (eds) Orthopaedic sports medicine Vol 2. W B Saunders,
Hreljac A, Marshall R N, Hume P A 2000 Evaluation of lower Philadelphia
extremity overuse injury potential in runners. Medicine Witvrouw E, Lysons R, Bellemans J, Combier D, Vander
and Science in Sports and Exercise 32: 1635-1641 Straeton G 2000 Intrinsic risk factors for the development
James S 1, Bates B T, Osternig L R 1978 Injuries to runners. of anterior knee pain in an athletic population. American
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ASSESSMENT OF THE SPORTS PATIENT 395
FURTHER READING
Brukner P, Khan K 1993 Clinical sports medicine. McGraw- Hartley A 1995 Practical joint assessment: lower quadrant.
Hill, Sydney 2nd edn, Mosby, St Louis
Brukner P, Bennell K, Matheson G 1999 Stress fractures. Nicholas J A, Hershman E B 1995 The lower extremity and
Blackwell Science, Victoria spine in sports medicine. Mosby, St Louis
Delee J C, Drez D (eds) 1994 Orthopaedic sports medicine, Subotnick S (ed) 1999 Sports medicine of the lower
Vols 1-3. W B Saunders, Philadelphia extremity, Vol 2. Churchill Livingstone, New York
CHAPTER CONTENTS
Introduction 397
Factors to consider when assessing 397
Examination of the patient with foot pain 398
Measurement and assessment of pain 398
The painful foot
Tools of assessment - how do we score pain? 399
W. Turner
CAUSES OF PAIN IN THE FOOT 403
R. Ashford*
Articular and bone conditions 403
Osteoarthritis (OA) 403
Footballer's ankle 404
Osteochondritis dissecans(ankls/talocrural joint) 405
Hallux rigidus 406
Accessory ossicles 407
Stress fractures 408
Subungual exostosis 408
Tarsal coalition 409
Metatarsalgia 410
Sesamoiditis 411
Tumours 411
INTRODUCTION
Soft tissue, tendons and ligaments 412
Tendonitis 412 Before embarking on a description of conditions
Subluxing peroneal tendons 413 that affect the foot and can cause pain it is impor-
Chronic ankle sprain 413 tant to have a working knowledge of the concept
Sinus tarsi syndrome 414
Compartment syndrome 414 of pain: how it manifests, how it is measured and
assessed, other indicators of pain and current
Nerves 415 thought regarding the treatment of pain.
Tarsal tunnel syndrome 415
Other entrapments 416 Why do we need to measure pain? Pain in the
Peripheral neuropathy 417 foot has plagued mankind for as long as humans
Morton's metatarsalgia (neuroma) 417 have existed. As practitioners it is only relatively
Skin and subcutaneous tissues 418 recently that the importance of monitoring foot
Retrocalcaneal bursitis 418 pain has been recognised. Previously we may
Heel pad syndrome 419 have asked the patient 'how' their pain was pro-
Plantar fasclitis 419
Soft tissue masses or tumours 420 gressing between treatments; however, rarely did
we chart this most important aspect of patient
General 420 management. Needless to say, as practitioners we
Crystal arthritis 420
Hereditary and motor sensory neuropathy 421 need to chart and monitor all aspects of treat-
Infection 422 ment intervention so as to provide the informa-
Reflex sympathetic dystrophy (RSD) 423 tion to compare single patients as well as groups
Referred pain 424
of patients. This, in turn, gives the practitioner
Summary 424 the facility to monitor the progress of individual
patients as well as objective data to validate new
treatment regimens.
397
398 SPECIFIC CLIENT GROUPS
the experiencing person says it does' (McCaffery Pointers concerning general health include:
& Beeke 1989).
• Does the patient look well?
A simple illustration of a misconception of a
• Is the patient well nourished (obese or thin
painful foot is when a healthy patient seeks treat-
and wasted)?
ment for what looks like the tiniest corn on the fifth
• Colour (pale and anaemic, jaundiced)?
toe. The patient complains of severe pain, finds it
• Look at the hands, are they misshapened
difficult to walk and complains of throbbing when
(rheumatoid arthritis)?
the bed clothes are pressing on it. Compare this to
the frail patient who presents with heavy callosi- The physical examination may reveal findings
ties over the first and fifth metatarsals and with that raise concerns. For example, a manual
deep-seated corns located beneath. The patient worker who has thick calluses on his hands, yet
complains of moderate pain from the lesions. says he cannot work because of the pain in his
Practitioners may intuitively select the frail patient foot, may be less than fully honest.
as the one suffering the most pain. Is this assess- Examination of the foot begins with watching
ment justified? With any assessment it is important the patient walk (Ch. 8). An antalgic limp, where
to remember that pain is relative; it is a very indi- the patient will spend only a short period of time
vidual thing and it is important to distinguish on the painful foot, is a clear positive sign. The
between bias and inaccuracy. limp may be linked with other problems associ-
Studies have shown that practitioners find it ated with proximal joints or the back; these
difficult to assess pain accurately and to assess should be excluded. Look at shoe wear on the
the degree of pain experienced by the patient sole; this may indicate an abnormal gait pattern.
(Sutherland et al 1988). Such inaccuracies can in Are the toes severely clawed, suggesting a neu-
some way be overcome by the use of validated rological problem? It is important to note any cal-
and reliable clinical tools dedicated to the assess- losities, both dorsally and on the sole, as these
ment of pain. However, clinical tools must be indicate areas of high pressure and friction.
seen as an adjunct to patient assessment of pain Similarly, one must remember all the structures
and not a panacea. It is suggested that a clinical running under any area of tenderness.
picture is built up before undertaking charting of The sources of pain are numerous (Table 16.1)
pain levels. As discussed in Chapter 3, it is and can be subdivided for convenience into
important to consider the following: problems affecting different tissues, generalised
• What eases or aggravates the pain? disorders and referred pain. The table provides
• At what time of the day is it worse? an overview of typical problems associated with
• Is the pain constant or intermittent? the painful foot. In many cases the origins are not
• What type of medication is the patient taking? clear and assessment and investigations are nec-
• What is the previous medical history and essary to isolate the cause.
history of injury?
Measurement and assessment of pain
Examination of the patient with foot Measurement and assessment of pain is an inte-
pain gral part of the assessment and treatment plan-
Your first observation should be to look at the ning process. It gives the practitioner
patient, not the foot. It is useful to highlight those information regarding the patient's readiness for
traits that have been discussed under medical treatment, the focus of the appropriate interven-
history (Ch. 5) as the source of pain may be tion and a quantifiable measure of the disrup-
explained by general disease processes. Assess tiveness of the problem.
the patient's attitude. This may reveal psycholog- With pain being such a personal experience,
ical variations from normal and may influence many measures of pain are based on patient self-
the outcome in terms of treatment. reports. More objective measurements of pain
THE PAINFUL FOOT 399
Table 16.1 Sources of pain classified under tissue types. Table 16.1 (Cont'd)
The table provides an overview of typical problems
associated with the painful foot. In many cases the origins Condition Aetiology
are not clear and assessment and investigations are
necessary to isolate the cause Skin and subcutaneous
Retrocalcaneal bursitis Repetitive injury/mechanical
Condition Aetiology rheumatoid
Articular and bone Heel pad Obesity/occupational referred
from back
Osteoarthritis General degeneration
Plantar fasciitis Repetitive injury,
Footballer's ankle Chronic injury biomechanical
Osteochondritis dissecans Chronic injury Onychocryptosis Iatrogenic/congenital
Hallux rigidus General degeneration Plantar warts Infective
Toe deformities Congenital and acquired Callosity/corns Biomechanical/deformity/
Accessory ossicles Congenital/injury endocrine/footwear design
Stress fractures Repetitive injury Ulcers Vascular/infective/trau matic/
Subungual exostosis Repetitive injury dermatological/neoplastic
Exostoses Injury/dislocation/
biomechanical
Tarsal coalition Congenital
Metatarsalgia General degeneration/referred/ tend to rely on a single dimension - namely, pain
multifactorial/rheumatoid intensity. These measures tend to focus on three
Sesamoiditis Repetitive injury/degenerative aspects of pain: physical, functional and behav-
Bony or cartilaginous Neoplastic metastasis, ioural. Physical pain can be measured in terms of
tumours primary or secondary
intensity, location or physical symptoms.
Periosteal/joint Infective/neoplastic metabolic/
autoimmune reactive
Functional measurements of pain rely on assess-
ing such things as walking distance or activity
Soft tissue
levels, whereas behavioural aspects are more
Tendonitis
Subluxing peroneal }
difficult to assess and include assessing patients'
tendons Most of these are associated behaviour towards protecting the affected
Chronic ankle sprain with injury painful area or assessing the abnormal gait which
Compartment syndrome
may have developed because of the pain. Other
Sinus tarsi Degenerative/trauma or
rheumatoid manifestation measurements of pain include multidimensional
Nodules Dermatological/rheumatoid analyses. Such tools attempt to assess pain in a
Ganglia/cysts number of different dimensions. They tend to use
Nerves multiple visual analogue or number ranking
Tarsal tunnel Degenerative/biomechanical scales. Listed below is a selection of single and
Peripheral neuropathies Metabolic/endocrine/proximal multidimensional pain assessment tools.
entrapment or trauma
Interdigital neuromata Repetitive injury and (Morton's)
degenerative Tools of assessment - How do we
Hereditary and motor Congenital with hereditary score pain?
sensory neuropathies predisposition
(HMSN) V~ualana0guesca~s
Radicular pain Lumbar referred pain
Visual analogue scales (VAS) are used to measure
Vascular pain, treatment satisfaction and other related
Peripheral vascular disease Socioenvironmental/endocrine treatment interventions. The main advantages of
and metabolic
this measure are that it is quick, easy to adminis-
Acute embolism Secondary to other factors,
e.g. atherosclerosis ter, cheap and easily attached to any patient
Buerger's disease Ethnic and social factors record card. The disadvantages are that these
predispose to manifestation scales only measure one dimension of pain, give
400 SPECIFIC CLIENT GROUPS
a single reading and misinterpretation of the descriptor is a discrete item, and therefore patients
scoring mechanism, particularly among the are only allowed to choose one. The main disad-
elderly, who frequently mark the wrong place or vantage revolves around the type of data that can
misinterpret the scoring continuum. The VAS be extrapolated from measurements of this kind.
consists of a 10 cm line that ranges from 'no pain' One way round this problem is to give each of the
to 'worst possible pain'. Patients are asked to descriptors a number, so that the data collected
mark on the line their reported level of pain (Fig. can then be analysed as nominal data (see Ch. 4).
16.1). Another form of VAS can be presented as a
pain thermometer (Fig. 16.2).
Questionnaires
A multidimensional pain tool, the McGill Pain
Verbal scales
Questionnaire (MPQ) (Melzack 1975) was
On similar lines, the simple verbal scales (VS) cat- devised in Canada and contains sets of words
egorise pain into discrete groups such as mild that are used to quantify pain levels. The full
pain, moderate pain, severe pain or worst pain. questionnaire consists of 78 adjectives arranged
Again, these can be presented to the patient in a into 20 groups. The groups are set out to reflect
linear fashion (Fig. 16.3). Patients are then similar pain qualities. The advantage of such a
instructed to circle the most appropriate descriptor comprehensive verbal descriptive scale is that it
of pain. One major advantage, like all scale mea- offers patients the opportunity to describe their
surements of this nature, is that they are cheap to pain on a number of dimensions; for example, it
administer; another major advantage is that each endorses both emotional and sensory descrip-
tors. The MPQ is a comprehensive reliable multi-
dimensional pain assessment tool. It has been
extensively tested in the clinical arena for both
reliability and validity and consistently scores
No Worst well in these domains. The major disadvantage,
pain possible especially in a busy clinic, is the length of time
pain
the questionnaire takes to complete. It is there-
Figure 16.1 A visual analogue scale 10 em in length. fore not ideal for continual use in monitoring
chronic pain, and a short version of the MPQ has
Worst been developed which is easy to administer and
possible can be repeated easily at short return dates.
pain
OR
No pain
Mild pain
Moderate pain
Severe pain
Worst pain
No pain
Figure 16.2 Another form of the visual analogue scale can
be presented as a pain thermometer. Figure 16.3 Examples of verbal scales.
THE PAINFUL FOOT 401
A similar and briefer pain scale is the 52-item Related measurement tools
West Haven-Yale multidimensional pain inven-
tory (WHYMPI). This scale is specifically based As well as measuring pain, many of the generic
on cognitive behavioural models of pain behav- tools currently available also assess quality of life
iour and is used mainly for chronic pain monitor- (QoL) issues. It is arguable that pain, particularly
ing. It comprises three parts: the impact of pain on in relation to foot health (see below), cannot be
the patient's life, the patients' perception of the seen in isolation. Other measurements of disease
response of others to their communication of pain have to be considered when assessing and moni-
and suffering and their levels of participation in toring patients' health status. Therefore, coupled
daily life. The major advantages compared with with pain measurement and assessment, another
the long PMQ are that this tool is much quicker to important dimension has entered the patient
administer and it gives a rounder picture of the assessment arena. It has become increasingly clear
patient's distress in relation to pain. that one cannot separate a patient's pain from
Two further tools are worth noting: the their current QoL. Quality of life, in this context,
Wisconsin brief pain inventory and the pain per- can be defined as 'the impact of disease and treat-
ception profile developed by Tursky and col- ment on disability and daily living or a patient-
leagues. Again, both are quicker to administer based focus on the impact of a perceived health
than the MPQ and have a number of disease- state on the ability to lead a fulfilling life' (Price
specific advantages when assessing pain. 1996). In this context, tools such as the sickness
impact profile (SIP) have been introduced. Not
designed specifically for the measurement of pain,
Observational techniques this tool assesses the effect of certain treatment
Although not particularly relevant to painful foot interventions in relation to quality of life. It is
management, but included for completeness, a designed to look at aspects of activities of daily life
short description of this technique is outlined. As affected by chronic low-level sickness.
the name suggests this technique involves the Finally, other related tools have been devised,
practitioner recording observed patient pain again not specifically to measure and assess pain
levels. This might include time spent resting, med- but to quantify the extent of a patient's health
ication used, sleep patterns and verbal! motor status. Included in such tools are measures of
pain behaviour. These techniques are notoriously dimensions such as mobility, physical activity,
difficult and unreliable because precisely defined dependency and pain. A good example of such a
behaviours are required and staff are then generic measurement scale is the Arthritis Impact
required to score these subjective behaviours. Measurement Scales (AIMS). As the name sug-
These techniques are particularly useful in the gests, this tool was specifically designed to assess
assessment of patients with severe learning dis- how a designated disease impacts on the ability
abilities or communication problems. of a patient to function in daily life.
The short form-36 (SF-36) is also worth a
mention in this context. This particular question-
Physiological measures
naire was devised from the Rand health batteries
Unfortunately, little use of physiological moni- (Stewart & Ware 1992). The SF-36 includes in
toring of pain has been reported in the clinical its eight dimensions: physical function, social
setting. Researchers have attempted to measure functioning, role limitations due to emotional
autonomic function or disease activity as ana- problems, mental health, energyIvitality, pain
logues for the experience of pain. The results and general health perceptions. Also included is
from these studies and similar work is equivocal a single item about perceptions of health changes
and suggest that at present physiological mea- over the past 12 months. There are many more
sures of pain are unreliable and really should not examples of these health status tools: some are
be considered for monitoring purposes. disease-specific and others are much more
402 SPECIFIC CLIENT GROUPS
Instructions: The line next to each item represents the amount of pain you typically had in each situation.
On the left is "No pain" and on the far right is "Worst pain imaginable." Place a mark on the line to indicate
how bad your foot pain was in each of the following situations during the past week.
If you were not involved in one or more of these situations mark them as NA.
Questions: How severe was your foot pain:
1. At its worst?
2. Before you get up in the morning?
3. When you walked barefoot?
4. When you stood barefoot?
5. When you walked wearing shoes?
6. When you stood wearing shoes?
7. When you walked wearing orthotics?
8. When you stood wearing orthotics?
9. At the end of the day?
generic. If such tools are to be considered the Another foot-specific questionnaire worth con-
practitioner is well advised to check the reliabil- sidering for foot monitoring is the Foot Health
ity and validity of the selected measuring tools in Status Questionnaire (FHSQ) developed at
the context of the condition they are proposing to Queensland University of Technology, Australia.
monitor (Bowling 1995). This tool was developed to measure foot health
related quality of life. Although not pain-specific,
this tool includes pain as an indicator in one of
Foot specific (pain) questionnaires
the three subsections. In the section including
The pain tools described above are generic and not pain there are a further three hypothesised
specific to the foot. They are useful and have been domains of foot health: namely, foot function,
used in clinical settings and a selection of research footwear and general foot health (Table 16.2)
studies. A foot-specific pain scale that is reliable (Bennett & Patterson 1998). Bennett et al (1998)
and valid has yet to be developed. The develop- demonstrated the validity of this tool in their
ment of the Foot Function Index (FFI) by study and concluded that a tool such as this
Budiman-Mak et al (1991) marked the first attempt could be used by researchers and practitioners to
to measure foot dysfunction. The index is split into identify changes to foot health status as a result
three discrete sections: foot pain (Fig. 16.4), dis- of different interventions (remember this is one
ability and activity restriction. The pain section of of the key points when monitoring pain). It is
FFI consists of nine questions that address the short and easy to administer, particularly in the
severity of the pain experienced during specific clinical setting; it can also be administered by a
circumstances. A study by Saag et al (1996) demon- postal survey. One of the major disadvantages in
strated the reliability of this section (pain) of the relation to pain monitoring is that this tool incor-
FFI in relation to arthritic foot pain. Being easy to porates pain as a dimension of foot health. As a
administer and foot-specific, the pain section of the consequence, pain per se cannot be analysed sep-
FFI is well worth considering in the clinical arena. arately using this tool.
THE PAINFUL FOOT 403
Table 16.2 The four basic domains of foot health as evaluated by the Foot Health Status Questionnaire (FHSQ)
Foot pain 4 Evaluation of foot pain Extreme and significant No pain or discomfort in any
in terms of type of pain, foot pain that is acute part of the foot
severity and duration in nature
Foot function 4 Evaluation of feet in terms Severely limited in performing Can perform all desired
of impact on physical a broad range of physical physical activities: walking,
function activities because of feet: working and climbing stairs
limited in walking, working
and moving about
Footwear 3 Lifestyle issues related Extremely limited in access No problems with obtaining
to footwear and feet to suitable footwear suitable footwear
General foot 2 Self-perception of feet Generally perceives feet Perceives feet to be in an
health (individual's subjective to be in a poor state of excellent state of health and
assessment of body health and identifies poor condition
image related to feet) condition of feet
404 SPECIFIC CLIENT GROUPS
Osteochondritis dissecans
patient may complain of some restriction of (ankle/talocrural joint)
dorsiflexion. Aetiology
This is an interesting condition in which an
Signs osteochondral fragment becomes separated from
Local tenderness over the neck of the talus and the talar dome, usually posteromedially or mid-
anterior tibial margin; pain on dorsiflexion of laterally. It is now thought that all of the lateral
the ankle and perhaps some restriction of this and most of the medial lesions originate from
movement. trauma, probably associated with inversion
injuries of the ankle (De Smet et aI1990).
Investigations
Presenting symptoms
Plain X-rays will demonstrate a dorsal talar spur
and also a spur on the anterior lip of the tibia. Because of the aetiology the diagnosis may be
The spur on the anterior lip of the tibia can be missed acutely and the patient treated for a simple
subtle, appearing as a convex margin rather than sprain or malleolar fracture. If, however, symp-
the normal concave one (Fig. 16.5). Both these toms persist after adequate treatment of the recog-
spurs are intracapsular, although this may be nised injury, an osteochondral fracture should be
difficult to appreciate on a plain X-ray. suspected. Acute symptoms will be those of a
sprained ankle, with the patient complaining of
pain, swelling and difficulty walking. Chronic
Differential diagnosis
symptoms are more general, with patients com-
This mainly associated with early OA of the plaining of discomfort, pain and perhaps stiffness
ankle. It should be noted, though, that in a true during or after exercise. If an osteochondral frag-
footballer's ankle the articular surfaces are ment has become detached from the talar dome,
normal when these bony spurs are removed sur- then there may be locking and giving way in the
gically (Case history 16.1). ankle, suggestive of a loose body.
406 SPECIFIC CLIENT GROUPS
Presenting symptoms
Intermittent pain in adolescents, who may expe-
rience episodes of acute pain made worse by
walking. Adults present with pain on walking,
stiffness and pain over the dorsal exostosis in
more advanced cases, although lateral joint pain
may be observed as well.
Investigations
Plain X-rays of the first MTPJ may be normal or
Figure 16.7 X-ray showing accessory navicular - dorsiplantar
show a dorsal exostosis with a normal-looking view.
joint. In more advanced cases degenerative
changes will be apparent with progressive OA. If
hallux rigidus is due to gout or RA then periar-
ticular erosions may be present with osteoporo-
sis. Blood tests are only indicated if a systemic Presenting symptoms
disease is suspected. The os trigonum causes symptoms with activities
in repeated plantarflexion, affecting football
Differential diagnosis players and dancers standing 'en pointe'.
Patients complain of posterolateral ankle pain
In flexor hallucis longus tenosynovitis, dorsi-
when the ankle is plantarflexed and impinge-
flexion of the hallux may be restricted and painful.
ment occurs. An accessory navicular may cause
Resisted plantarflexion of the hallux will be
rubbing in a shoe, because of local pressure, or
painful and local tenderness may be felt posterior
may become symptomatic following a twisting
to the medial malleolus.
injury to the foot.
of their guilt. A bone scan may help to demon- and up to 5 weeks for calcaneal ones. In the
strate a symptomatic os trigonum. metatarsal shafts early changes may be a fine
line of bone resorption followed either by scle-
Differential diagnosis rosis or periosteal callus, depending on whether
the cortex has been breached. In the calcaneum
A symptomatic os trigonum may be mistaken for the fractures tend to occur in the posterior
peroneal tendonitis, flexor hallucis longus ten- part and appear as endosteal callus with an
donitis or a fracture of the lateral process of the intact cortex on X-ray. Because of the delay in
posterior talar tubercle. A symptomatic accessory plain radiographs a bone scan may be helpful if
navicular is usually obvious because of local ten- there is doubt about the diagnosis. Computed
derness but should not be confused with tibialis tomography (CT) or magnetic resonance
posterior tendonitis. imaging (MRI) scans may be helpful to show
stress fractures which are difficult to depict on
Stress fractures plain X-ray.
Aetiology
Differential diagnosis
Stress fractures occur due to overuse in
unadapted feet or when surgery in the foot leads The clinical picture, relation to activity and local
to high stresses elsewhere. Fractures have been tenderness should point towards the correct
reported in groups such as runners, army diagnosis. One should beware of metatarsal
recruits and dancers. They may also occur, 'stress fractures' in the diabetic as they may be
though rarely, after first ray surgery, e.g. Keller's the precursor of a Charcot foot.
excisional arthroplasty operation, which
increases stresses on the lesser metatarsals. From
whatever cause the most common site is a Subungual exostosis
metatarsal shaft. Stress fractures have also been
reported in the calcaneus, navicular, cuboid and Aetiology
proximal phalanx of the hallux. This is a bony spur usually ansmg from the
dorsomedial aspect of the distal phalanx of the
Presenting symptoms hallux. Rarely it may arise from the lesser toes. It
is generally a benign osteochondroma, congeni-
Pain occurs in relation to activity. Initially it tal in origin, and may be noticed from adoles-
may be vague and difficult to localise but settles cence up to early middle age. There is some
on rest. With time the patient may complain of a suggestion that those occurring in young adult
limp. athletes may be the result of repetitive minor
trauma inside the shoe.
Signs
In the early stages there may be little to find on Presenting symptoms
clinical examination but if activity continues then
local tenderness and swelling will develop. A Patients may notice a swelling under the nail or
limp may be present. may complain of pain on walking or running
with shoes on.
Investigations
Signs
Plain X-rays may often be normal in the early
stages and it can be 2-3 weeks before changes The nail may be elevated and there may be
become apparent for metatarsal stress fractures a darkish discoloration, resembling a haema-
THE PAINFUL FOOT 409
Presenting symptoms
Although these coalitions usually ossify between
8 and 16, symptoms may not develop until late
childhood or into adulthood. Sometimes patients
never develop symptoms and the diagnosis is
made incidentally. When they do present,
patients may complain of stiffness and ankle
pain where playing sport. They may also com- Figure 16.8 X-ray illustrating calcaneonavicular coalition-
plain of recurrent ankle sprains. medial oblique view.
410 SPECIFIC CLIENT GROUPS
---~----~----~-------------~~~~---------------~
Other conditions leading to stiff subtalar or mid- The main sign is tenderness under the metatarsal
tarsal joints, such as degenerative or inflamma- heads on palpation; callosities may be present
tory arthritis. under the symptomatic heads, indicating the
increased load. With a prominent fibular condyle
the callosity is small and well-defined and has a
Metatarsalgia
Aetiology
Metatarsalgia is characterised by pain felt under
one or more metatarsal heads when weightbear-
ing. It may be due to a number of causes:
Patient: 58-year-old garage mechanic.
• Atrophy of the plantarfat pad with age. This Presenting symptoms: The patient presented
with a large bunion on his left foot and discomfort
results in a generalised metatarsalgia because under the centre of the ball of his foot on walking.
of loss of the cushioning effect of the fat pad. Signs: A gross hallux valgus was present, along
• Increased pressure under the lesser metatarsals with pronation of the hallux. There was some callosity
formation under the second and third metatarsal
following first MTPJ surgery, e.g. for hallux heads. The rest of the foot was normal.
valgus of Keller's operation. Investigations: Plain x-rays showed hallux valgus
• Metatarsophalangeal joint problems. of 55° with lateral subluxation of the proximal phalanx
at the first MTPJ. Some minor degenerative changes
Subluxation or dislocation of the proximal were present in this joint.
phalanx may lead to a pistoning effect which Diagnosis: Gross hallux valgus with secondary
depresses the metatarsal head, increasing its transfer metatarsalgia due to unloading of the first ray.
Operation: Arthrodesis of the first MTPJ to correct
load. This may occur in inflammatory the hallux valgus and allow better weightbearing
arthropathies or in a cavus foot with claw through the first ray, thus relieving the transfer
toes. Claw toes that dorsiflex on the metatarsalgia. Usually a secondary reduction in the
hallux valgus is difficult with realignment (osteotomy)
metatarsal head pull the fat pad forward, operations. Postoperatively the patient's symptoms
exposing the metatarsal head to greater were relieved.
loading during stance. Case history 16.3
THE PAINFUL FOOT 411
Differential diagnosis
Other causes of pain around the first MTPJ, such
as hallux rigidus. The high incidence of bipartite
This lies between the various causes of sesamoids (figures vary from 10 to 30%) may
metatarsalgia. A wart may cause a plantar cal- lead to a false diagnosis of a fracture (Hubay
losity but does not normally occur under a 1949).
metatarsal head. A Morton's neuroma is com-
monly referred to as Morton's metatarsalgia,
although the pain and tenderness is actually Tumours
between metatarsals, radiating into toes (digital Aetiology
neuritis).
Bony or cartilaginous tumours are fortunately
rare in the foot. Nevertheless, a number have
Sesamoiditis been reported, both benign and malignant.
Among the most common benign ones are osteoid
Aetiology
osteoma, enchondroma and osteochondroma. Osteoid
Flexor hallucis brevis inserts into the base of the osteomas may occur in the tarsus in the foot,
proximal phalanx of the hallux and within its enchondromas in metatarsals or phalanges and
tendons two sesamoid bones lie under the first osteochondromas normally only occur as subun-
metatarsal head. These may give rise to pain if gual exostoses (Fig. 16.9). Malignant tumours
they become arthritic. This can occur secondary reported include osteosarcoma, chondrosarcoma
to hallux rigidus or inflammatory arthropathies and Ewing's tumour. Osteosarcomas and chon-
such as rheumatoid arthritis. Chondromalacia- drosarcomas have been reported in the tarsus
type changes have also been reported. Rarely, and metatarsals, Ewing's in the tarsus. Although
sesamoids may fracture following trauma a secondary deposit is the most common bony
and stress fractures have been reported. Hyper- tumour in the body as a whole, secondaries are
trophy of a sesamoid can lead to a painful plantar rare in the foot but may occur: if they do, the
callosity. most likely primary is a bronchial carcinoma.
412 SPECIFIC CLIENT GROUPS
Differential diagnosis
The first consideration with any lesion suspected
of being a tumour is whether it is benign or
malignant. Infection should always be consid-
ered as it may sometimes be difficult to differen-
tiate. Although it should not cause any confusion
in diagnosis, an old fracture may sometimes look
suspicious to the untutored eye.
hindfoot will be in valgus and the heel will not Presenting symptoms
invert if the patient stands on tiptoe. When
The patient may complain of a painful snapping
looked at from behind, the forefoot is abducted,
sensation at the ankle on certain movements.
producing the 'too many toes sign' (Johnson
1983).
For the peroneal tendons, tenderness will be Signs
felt distal to the lateral malleolus, along the
There will be tenderness along the peroneal
course of the tendons, with pain on inversion
tendons behind the lateral malleolus and the
and plantarflexion. Differentiating between
tendons may sublux anteriorly with resisted
brevis and longus may be difficult; tenderness
eversion and dorsiflexion.
on the sole of the foot between the cuboid and
base of the first metatarsal will suggest prob-
lems with peroneus longus. Evert the hindfoot Investigations
actively against resistance to clarify such
Again, this is mainly a clinical diagnosis but if
involvement.
doubt exists then a peroneal tenogram may show
In tenosynovitis of flexor hallucis longus there
dye leakage, indicating a torn retinaculum.
will be tenderness posterior to the medial malle-
olus with pain on passive extension of the hallux.
Occasionally, tenderness can be found at the level Differential diagnosis
of the sesamoids and may cause limitation of
Acutely with a sprained ankle and more chroni-
movement at the first MTPJ.
cally with peroneal tenosynovitis.
Signs
At rest physical examination may be normal,
although there may be some tenderness over the
distal tibia. This may become more marked if
r .•i iii ii\ \\--uiliilimc---+--- tibial
f>
Posterior
nerve
the patient exercises on a treadmill to produce
symptoms.
",,",-~--\-- Flexor
retinaculum
Investigations
Plain X-rays should be taken to exclude a stress
fracture or other osseous causes of leg pain.
Measuring compartment pressures with a
catheter introduced under local anaesthetic is the
----
most useful way to confirm the diagnosis. Medial and lateral plantar
Pressures are measured before and after nerves emerging
exercise. There is some debate as to the correct
abnormal compartment pressures. Generally, Figure 16.10 Line drawing to show gross anatomy of the
tarsal tunnel - lateral view.
intracompartmental pressures at rest should be
less than 15mmHg and 5-10 min following exer-
pression may cause direct pressure, leading to
cise should have returned to 15 mmHg or less
motor and sensory symptoms, or may compress
(Pedowitz et aI1990).
the vascular supply, the vasa nervorum, causing
sensory symptoms only. Aetiology of tarsal
Differential diagnosis tunnel syndrome is idiopathic, trauma or asso-
ciated with bony alignment (Cimino 1990).
Shin splints or stress fractures of the tibia will be
Other cases may be related to problems such as
the main differential diagnosis for leg pains. For
rheumatoid arthritis or compression within the
neurological symptoms in the foot an entrap-
tunnel associated with a ganglion, lipoma or
ment neuropathy should be excluded.
venous varicosities.
- - - - - - - _ . _ - -..
Other entrapments
Case history 16.4 ;
Aetiology 1-------------------------_ 1
Investigations
Differential diagnosis
Problems affecting the metatarsal head, such as
synovitis, intermetatarsal bursa and Freiberg's
disease, should be considered. It is important
to be careful about whether the tenderness
is under a metatarsal head or intermetatarsal.
Pain from a neurological cause, such as tarsal
tunnel syndrome, peripheral neuropathy or
referred pain from the back should be
excluded.
Presenting symptoms
Patients complain of heel pain, worse in the early
morning and on weightbearing. They may have a
limp.
Signs
There is localised central tenderness under the
heel.
Presenting symptoms
Differential diagnosis
A ganglion presents as a painful lump inside
As in heel pad syndrome. footwear. Plantar fibromatosis may present with
painful nodules, although often the patient only
Soft tissue masses or tumours notices some mild discomfort or simply a
swelling. A glomus tumour, however, may
Aetiology present with marked pain.
Some benign soft-tissue masses, such as ganglions,
are common in the foot. A ganglion is a mucoid Signs
cyst which usually arises from an underlying joint.
A ganglion will appear as a mobile subcutaneous
In the foot they most commonly occur over the
lump of variable size. Small ones may appear
dorsum of the ankle (Fig. 16.13). Plantar fibroma to-
quite firm, whereas larger ones often have a more
spongy feel. The nodules of plantar fibromatosis
are felt as firm, fairly immobile nodules, often
along the edge of the plantar fascia and under the
instep. A glomus tumour will appear as a subun-
gual mass or may be palpated as a small nodule
in a web space.
Investigations
Plain X-rays may distinguish a glomus tumour
from a subungual exostosis; otherwise, the diag-
nosis is made from clinical information.
Differential diagnosis
Multiple ganglions around the extensor tendons
on the dorsum of the ankle should arouse suspi-
cion of rheumatoid arthritis. A lipoma may be
mistaken for a ganglion and is commonly located
on the dorsolateral aspect of the ankle.
GENERAL
Crystal arthritis
Aetiology
Arthritic changes may be caused by the deposi-
Figure 16.13 Large ganglion on lateral aspect of the ankle. tion of crystals within a joint. This may be sodium
THE PAINFUL FOOT 421
urate crystals in gout or calcium pyrophosphate chronic cases the signs of osteoarthritis will be
dihydrate crystals in pseudogout. Gout is a disease present. Gouty tophi (deposits of sodium urate)
characterised by a disorder of purine metabolism may be found in the cartilages of the ears and in
and is associated with hyperuricaemia. It may bursae, tendons and soft tissues generally.
be primary with a strong hereditary factor or be
secondary to other problems such as renal failure. Investigations
Pseudogout is sometimes associated with other
metabolic conditions, such as hyperparathy- Acutely, the serum uric acid may be raised but
roidism, but otherwise it is idiopathic. acute attacks can occur with a normal uric acid
level. Aspiration of joint fluid and examination
under a polarising lens will show brightly bire-
Presenting symptoms fringent needle-like crystals in gout and more
Up to 75% of initial attacks of gout affect the big pleomorphic rectangular crystals in pseudogout.
toe (Jacoby & Dixon 1991). The patient complains Chronically, X-rays will show degenerative
of acute onset of a swollen, very painful first changes in joints affected. Gout gives a character-
MTPJ. Pseudogout may present with gout-like istic appearance of sharp, punched-out juxta-
attacks but these are usually less severe. About articular lesions, with little reactive sclerosis and
50% of patients, however, will present with pro- no general osteoporosis.
gressive degeneration of joints. In the foot the
ankle, subtalar and talonavicular joints are most Differential diagnosis
commonly affected. Acutely, this will be with acute infection and
septic arthritis. Chronic forms will be associated
Signs with other causes of degenerative joint disease.
In the acute stage of gout the great toe will be
swollen, inflamed and very tender (Fig. 16.14). In Hereditary and motor sensory
neuropathy
Aetiology
This condition is also known as peroneal muscular
atrophy and was first described by Charcot, Marie
and Tooth in 1886. Essentially, it is an inherited
neuropathy with a predominantly motor compo-
nent affecting the lower limbs. Motor weakness
begins in the peronei, then the dorsiflexors, and
may involve all the muscles below the knee.
There may also be sensory changes and involve-
ment of the upper limb. The initial symptoms are
usually in childhood but the neuropathy then
slowly progresses. The adult may then present
with a cavus foot, claw toes and pain and callosi-
ties over the metatarsal heads. Fixed deformities
may develop with equinus of the forefoot and
varus of the hindfoot (Mann 1993).
Presenting symptoms
Figure 16.14 Acute gout in the first metatarsophalangeal This will d"epend on how far the disease has pro-
joint. gressed. Initially, the patient may present with
422 SPECIFIC CLIENT GROUPS
just a clumsy gait and perhaps a history of recur- immunocompromised. Bony infections are most
rent ankle sprains. With time the weakness and commonly due to Staphylococcus aureus but strep-
changes in the shape of the foot become more tococci may also be associated with soft-tissue
apparent. The patient may then complain of infections.
footwear problems and pain along the lateral
border of the foot because of the varus heel.
Presenting symptoms
Signs
These will vary according to the tissue involved
and degree of infection. Cellulitis will present
In the established case there will be a cavus foot with pain, swelling and erythema of the
with a high arch, a plantarflexed first ray, clawing involved area. Because the bones are very
of the toes and peroneal and intrinsic muscle superficial in the foot, osteomyelitis should
weakness. Weakness of other muscle groups always be suspected under any area of eel-
should be looked for and the hands examined. lulites. Septic arthritis is likely to present with
Sensory changes, if present, are usually mild. exquisite pain on moving a joint, usually the
ankle, and with overlying swelling and ery-
Investigations thema. However, in the elderly or immunocom-
promised, symptoms may be strikingly muted,
A careful clinical examination is important reducing suspicion of an underlying joint infec-
because of the differential diagnosis. Plain X- tion. In acute septic arthritis or osteomyelitis the
rays, standing AP and lateral, will show the patient is likely to have systemic signs of being
cavus and demonstrate any degenerative unwell.
changes when fixed deformities are present.
Nerve conduction studies and electromyography
are important for accurate diagnosis and to rule Signs
out other causes of pes cavus. Swelling, tenderness and erythema of the soft
tissues will be noted. In septic arthritis there is
Differential diagnosis likely to be marked pain on very limited move-
ment of the joint. If marked local tenderness is
This is from other causes of pes cavus, which will elicited over a bony area this should alert you to
include idiopathic, muscular diseases such as the possibility of underlying osteomyelitis. If
muscular dystrophy, neurological problems such infection spreads to a tendon sheath, causing a
as cerebral palsy, Friedreich's ataxia, polio- tenosynovitis, then passive movement of the
myelitis and spinal cord problems. In addition, tendon will be limited and very painful and ten-
pes cavus may be due to residual clubfoot or derness may be present along the length of the
compartment syndrome. tendon.
Infection
Investigations
Aetiology
Plain X-rays are necessary to exclude or demon-
Infection may occur in the soft tissues, as strate osteomyelitis. However, it may take
osteomyelitis in the bone or as septic arthritis in 10 days to show any changes. A bone scan will
a joint. The cause may be direct inoculation fol- be positive well before plain X-rays and may
lowing an open wound, either traumatic or sur- help. In septic arthritis a diminution in joint
gically created, or via haematogenous spread. space or adjacent osteomyelitis may be seen.
Traumatic or surgical infection may occur at Aspiration of fluid from a joint and Gram stain
any time but septic arthritis is more likely to and culture can provide a diagnosis. Blood cul-
occur in the very young or the elderly or tures should also be done: a full blood count will
THE PAINFUL FOOT 423
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(FHSQ): a new instrument for measuring outcomes of foot specific quality of life measurement scales. Open
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------------------
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MR imaging in staging osteochondral lesions of the talus Journal of Bone and Joint Surgery 33-B: 94-95
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Surgery 66-A: 976-984 surgery. British Journal of Podiatric Medicine 3(1): 2-6
CHAPTER CONTENTS
Introduction 427
Summary 448
INTRODUCTION
Increasingly, assessment and subsequent man-
agement of the high-risk patient is forming a
major part of the practitioner's workload. As the
population ages and more people live to old age,
the incidence of conditions which place the foot
at risk increase. Furthermore, a restructuring of
clinical caseloads to focus service delivery to
those in greatest medical need is resulting in
high-risk case mixes. Knowledge of factors
which increase risk for foot disease, together
with practical approaches to assessment of the
high-risk foot, is essential for safe and effective
service delivery.
Normal function of the lower limb is depen-
dent on viability of a wide range of tissues.
Optimum function requires that skin, bone,
muscle, nerve, vessels and connective tissues
are structurally sound. Loss of viability results
in reduction of normal function, eventual
total loss of function or systemic complications.
Maintenance of tissue viability enables func-
tional ability, keeping the patient mobile and
independent and maintaining quality of life.
For the lower limb practitioner, skin is the most
common tissue to lose viability, resulting in
potentially serious consequences for the patient.
Key functions of the skin are given in Table 17.1.
Table 17.1 Functions of the skin Table 17.2 Factors responsible for an at-risk foot
also used to indicate the degree of risk, the Table 17.3 An example of an aetiological system of
classification of lower limb ulcers
number of possible factors increases further,
making the designing of an easy-to-use system Category of lesion Examples of conditions
all the harder.
Dermatological Atopic eczema
The second task is to obtain clear definitions
Endocrine Diabetes mellitus
of these factors. The lack of universal consensus
Haematological Sickle-cell anaemia,
on definitions makes comparison difficult. For cryoglobulinaemia
example, a very simple classification system of Iatrogenic Stevens-Johnson syndrome
ulcers which nonetheless is an aid to prognosis Immunological Rheumatoid arthritis
and degree of risk, is to determine whether the Infectious Tuberculosis
ulcer is superficial or deep. However, unless Neoplastic Squamous cell carcinoma,
malignant melanoma, Kaposi's
there are clear definitions as to exactly what is sarcoma, basal cell carcinoma
understood by these two terms, we cannot be Neurological Hansen's disease (leprosy),
sure that an ulcer graded as superficial by one diabetes mellitus, syringomyelia
practitioner, which subsequently deteriorates, Traumatic Burns, friction blisters, cuts,
would not have been classified as deep by pressure sores
Vascular Peripheral vascular disease,
another. venous hypertension
Thirdly, an accurate but simple means is needed
to measure the factors concerned, and such means
are not available for all factors. For example, it is
generally held that if an ulcer can be probed to can be altered according to the wishes of the
bone, it is assumed that osteomyelitis is present, practitioner. For example, vascular could be
regardless of whether it can be detected on X-ray, divided into arterial, venous and lymphatic cate-
but this rule has not been validated by research. gories and iatrogenic could be included as a type
Similar problems apply to the presence of of traumatic cause of ulceration.
ischaemia and neuropathy (Chs 6 and 7). It must be borne in mind that infection can
So far, no single system has been designed complicate many lower limb ulcers, but is rarely
which is appropriate to all situations: each has its a cause of ulceration. Nonetheless, this system
limitations and many practitioners will use a has some limitations. It tells us nothing about the
combination of classification and description to degree of loss of tissue viability. For this we could
record both details of loss of tissue viability and add a descriptive section, based on measurement
to estimate the degree of risk. of depth of the deepest part of the wound. This
has been shown to have a strong correlation with
prognosis and so would be helpful in determin-
Aetiological classification
ing the degree of risk of slow healing, ulceration
One example of a well-validated classification and amputation. It is also possible that a particu-
system for lower limb ulcers is the aetiological lar lesion can be assigned to more than one cate-
system (Table 17.3). This is appropriate for use by gory, which detracts from the precision of the
practitioners in a clinical setting as it is a useful system. For example, a basal cell carcinoma is a
guide for a treatment plan, since removal or ame- skin cancer and could be classified as both a neo-
lioration of the cause will be a fundamental step plastic and a dermatological lesion and the ulcer
in the treatment. There is also some correlation seen in the diabetic foot could be classified as
between cause and prognosis, e.g. an uncompli- both endocrine and neurological.
cated neuropathic ulcer has a significantly better Meggit-Wagner wound classification system
prognosis than a similar-sized ischaemic ulcer. (Table 17.4). This is another well-validated
Although used more often for the classification of system which chiefly yields information as to the
ulcers, this system can be easily adapted to clas- severity of the wound and therefore relates to
sify loss of tissue viability. The precise categories prognosis and degree of risk. It has the further
432 SPECIFIC CLIENT GROUPS
Table 17.4 Meggitt-Wagner wound classification grade for spreading infection, is the Sims
Grade Appearance Implication
classification (Sims et al 1988).
Almost all other systems are mainly descrip-
Loss of tissue involves tive and designed more to assess the degree of
dermis only
2 Loss exposes tendon No significant
risk of ulceration/ amputation than of classifying
3
or bone
Loss exposes tendon or
bone, with osteomyelitis
or abscess
} ischaemic component the ulcer per se. If they are to meet the criteria for
simplicity and ease of use, they inevitably focus
only on aetiological and local factors, e.g.
4 Gangrene of digits or ischaemia and infection present, which gives a
5
forefoot
Extensive gangrene of
the foot
} Primarily an
ischaemic problem
limited view of factors contributing to risk.
San Antonio/Texas System (Armstrong,
Harkless and Lavery). This group of practition-
ers designed two systems: one system is
designed to classify the total range of loss of
advantage of dividing tissue loss into that with tissue viability, but has yet to be validated; the
no significant ischaemic component and that second system is concerned only with actual
where peripheral vascular disease is a major ulcers. The advantage of the first system is its
factor and so is of help in determining the most comprehensiveness; both systems are an aid to
important steps in the subsequent treatment, prognosis and management.
since wounds which are primarily ischaemic will The second system has been validated and
not heal unless steps are taken to improve the grades ulcers according to depth, presence or
blood supply. absence of sepsis and presence or absence of
However, it has limitations, since it was ischaemia. No reference is made to the presence
designed to assess wounds and has no place for or absence of neuropathy however, which is
preulcerative conditions such as callus. This considered by some practitioners as the single
system has been adapted by some practitioners most important contributory factor to diabetic
for the classification of loss of tissue viability by ulceration.
the addition of a grade a category for such con- Using this system to assess the lesions of
ditions where no break in the epidermis has people with diabetes, Lavery et al (1996) were
occurred. In addition, it would usually be able to show that patients with infection and
expected that a patient with a grade 4 ulcer ischaemia were 90 times more likely to have an
would have significant large-vessel disease of amputation than patients with lower-grade
the lower limb and one would expect to find lesions, thus showing the importance of local
non-palpable pedal pulses. However, in patients wound conditions on outcome.
with diabetes, it is quite possible for them to S(AD) SAD system (Table 17.5). This is a com-
have digital gangrene and palpable pedal prehensive system based on the San Antonio
pulses, suggesting a grade 4 ulcer but with no system but with modifications and extensions
significant major vessel pathology, the gangrene (Macfarlane & [effcoate 1999). It is also aimed at
being a result of septic vasculitis or embolism. patients with diabetes but is designed for research
Small-vessel disease (i.e. thickening of the base- and audit rather than as a guide to management.
ment membrane) is no longer considered to be a However, it could be adapted for management
prime cause of digital gangrene in patients with purposes (Serra 2000). The key elements of this
diabetes. Another limitation to this classification system are size of a wound, as measured by both
system is that there would be no place for the depth and surface area, infection, ischaemia and
Charcot foot, even though this condition carries neuropathy. Each of these elements is assigned a
a high degree of risk of ulceration. A more grade from a to 3 according to severity, with grade
detailed but similar classification system, which a representing a normal foot and grade 3 repre-
includes a grade a for intact skin and a separate senting the worst situation. The advantages of this
THE AT-RISK FOOT 433
0 Skin intact Skin intact No infection Pedal pulses palpable PinpricklVPT sensation normal
1 <10 rnrn- Skin and subcutaneous Superficial: Diminution of both pulses Reduced or absent pinprick
tissues slough or exudates or absence of one sensation. VPT raised
2 10-30 rnrn- Tendon, joint capsule, Cellulitis Absence of both pedal Neuropathy dominant: palpable
periosteum pulses pedal pulses
3 >30 rnm'' Bone and/or joint Osteomyelitis Gangrene Charcot foot
spaces
system are that it covers the whole range of loss of these two categories. Edmonds & Forster (2000)
tissue viability and includes the Charcot foot. acknowledge that their system of staging does
However, the authors suggest testing either rather not accommodate the Charcot foot and that the
than both small and large nerve fibres for neu- system would need extending for research and
ropathy which could lead to a false-negative audit purposes.
result since denervation of each type of nerve fibre
does not necessarily progress at the same rate. The
APPROACHES TO DETERMINING
measurement of the vibratory perception thresh-
DEGREE OF RISK
old requires the availability of a neurothesiometer
for the latter, which may not be readily available Holistic overview
in a routine clinic, but the authors do suggest the
To fully determine the degree of risk for any
cheaper alternative method of using a 10 g
patient, one would need to take into account all
monofilament. The authors acknowledge that
factors which can influence healing, including
measurement of neuropathy is an imperfect
not only the local condition of the lesion but also
science. The system awaits full evaluation but
the patient and his environment. Although few
there is a report of its successful use in a large
of these latter factors are included in any pro-
multidisciplinary clinic in Portugal.
posed classification system, because such inclu-
Edmonds and Foster system. This system is
sion would make the system very cumbersome,
designed specifically to aid management of dia-
much of the data will be recorded as part of a
betic foot lesions by assigning the foot to a stage
primary patient assessment (Ch. 5) and will be
of graded severity, according to the criteria
taken into account by the practitioner when
shown in Table 17.6, and dividing the lesions into
assessing the degree of risk. Most work has been
one of two aetiological categories (neuropathic or
carried out on people with diabetes, as these
neuroischaemic), as management differs for
people form the group with highest risk of
worst-scenario lower limb complications of
Table 17.6 Staging the diabetic foot
ulceration and non-traumatic amputation:
40-70% of all non-traumatic lower limb amputa-
Stage Clinical status tions are related to diabetes mellitus and 85% of
Normal. No presence of callus, ischaemia,
all such amputations are preceded by a foot
neuropathy, deformity, swelling ulcer (International Working Group on the
2 High risk. One or more of the above is present Diabetic Foot 1999).
3 Skin breakdown or presence of blister,
splits or grazes for more than 1 week
4 Ulcer and cellulitis Psychological factors
5 Necrosis
Recent research has started to focus on patients'
6 Advanced necrosis, foot cannot be saved
own perceptions of their health and their degree
434 SPECIFIC CLIENT GROUPS
Category Examples
For derivations of these calculations, see A further development is to use a digital camera
Schubert (1997). and associated software, which will enable the
A second method requiring only simple appara- image to be displayed on a computer screen. The
tus is to place a sterile, flexible, transparent grid operator can click on to various points around the
over the wound: the grid has a removable backing margin of the lesion and the software will
and is marked into J-cm squares. The margins of instantly calculate the surface area. The advan-
the lesion can then be traced on to the grid and the tages are increased accuracy and instantaneous
surface area calculated by counting the squares. results. The disadvantages are the initial expense
Disposal of the removable backing prevents cross- of the equipment and the need to develop a skill in
infection, and the tracing can be stored in the operating the equipment.
patient's notes for future reference. There are A group of workers from France have devel-
various strategies for calculation of surface area, oped a planimetry software program, which
such as including all whole squares and all partial uses the tracing of the wound on a transparent
squares on the right, discarding all partial squares grid together with the computer mouse acting
on the left, etc., or using a formula such as: as a digitiser, to transfer the tracing to the com-
puter, whereupon the software automatically
A c =Nc
calculates the surface area. This method was
A c-r = (N c + (0.4 x N p ) )
compared with calculating the surface area by
where A c is the surface area of whole squares, length and width, by square counting and by
A c-r is the surface area of whole and partial using image-processing software and was
squares, N c is the number of complete squares found to be highly reproducible and accurate.
and N p is the number of partial squares within The advantage of this method is that it does not
the traced area. require the expense of a digital camera, but on
If the grid is divided into smaller squares, such the downside it is more time-consuming
as 0.5 cm x 0.5 em then each formula has to be (Rajbhandari et aII999).
multiplied by 0.25 to obtain the area in em-
(Richard et aI2000).
Depth of wound
Both of these methods have the advantage of
being quick, simple to use and inexpensive. The The depth of the wound is an important piece of
disadvantages are that it is more difficult to data, since as mentioned earlier, depth shows
obtain an accurate tracing if the lesion is on a strong correlation with prognosis and degree of
curved surface such as the heel and that these risk. The usual method is to use a blunt, sterile
methods are very subjective. probe and measure the depth at the deepest part
A more objective measurement is made by of the wound. The advantages are ease of use and
using a camera to take a photograph of the low cost. The disadvantages are risk of cross-
lesion. The camera must always be placed at a infection and deciding exactly where the deepest
set distance from the lesion and a scaled ruler part of the lesion lies. It is also difficult to measure
should be positioned at the top or bottom of the the depth of very narrow lesions such as fissures
lesion, in the same vertical plane. The area of the or splits in the epidermis. Lesions of unbroken
lesion can then be calculated from the devel- skin will of course have zero depth.
oped photograph. The advantages are that the
measurement will be more objective and there is
Volume of wound
no risk of cross-infection, but disadvantages are
that errors will again be present if the wound is Although some research is being undertaken
on a curved surface, the equipment is much using stereoscopic equipment, no very satisfac-
more expensive than use of a transparent grid tory method of measuring the volume of a
and the result is not instantly available unless a wound has been developed. Other methods tried
Polaroid camera is used. have included injecting normal saline and mea-
THE AT-RISK FOOT 437
suring the volume used to fill the wound - but change and rolled edges may indicate malignant
this assumes the wound to have no pre-existing change.
fluid present - or using some other medium to
fill the cavity, such as an inert foam or a hydrogel.
Infection
None of these methods work very satisfactorily
and there is no great advantage in measuring Infection is one of the most important indicators
volume rather than depth. for risk (Carlson 1999). Table 17.8 lists useful
indicators of foot infection. The exudate can
further be described in terms of colour and con-
Colour of wound
sistency, which gives some indication of the
The colour of the wound can either be a mere pathogens involved. A more precise way of
recording of colour by name, referring to either determining which pathogens are present is to
the base of the wound or the surrounding epider- take a swab (Ch. 13). The usual method is to
mis, or using some sort of standard colour chart. swab deep in the wound before any lavage of the
Successful use has been made of ordinary house- wound has taken place. However, controversy
hold paint colour charts for this purpose, which rages concerning the detection of infection, since
have the advantage of reducing observer bias and it is recognised that any swab taken of a wound
making it easier to compare the lesion at a later will show the presence of pathogens, but
date. Colour has some bearing on prognosis, since whether these are merely commensals or true
a red base will suggest good granulation tissue pathogens is more difficult to decide. It is rec-
and better prognosis for healing than a grey base, ommended by some that tissue scrapings are
which suggests poor blood supply, or a yellow collected from the base of the wound using the
base, which suggests presence of infection. blunt edge of a scalpel blade and that the blade
and adherent tissue be sent to the pathological
laboratory for analysis. A similar controversy
Margins of wound
surrounds the detection of osteomyelitis, since
Margins of wounds can also be related to progno- X-rays are not reliable in the early stages and
sis. A 'saucer-shaped' wound suggests healing is clinical signs such as a 'sausage' toe and failure
under way, whereas undermined edges suggest to heal are often the only indicators. Probing to
the presence of a sinus, straight edges suggest no bone is used by many as a rule of thumb but this
Pain Not necessarily present (especially with sensory neuropathy). Throbbing, pulsatile or
persistent pain. May also have generalised malaise
Redness Soft tissue infection produces a diffuse area of cellulitis radiating from a central point
(often a portal of entry). May spread via lymph vessels, presenting as clear red lines
(lymphangitis). May herald onset of systemic spread
Exudation Amount of exudate produced is proportional to blood supply to wound. Consistency and
colour altered by microorganisms (e.g. creamy-yellow pus indicates staphylococcal
infection, green pus indicates pseudomonas infection)
Pyrexia Local rise in temperature may be present. Need to distinguish from other causes of
temperature increase (e.g. Charcot foot). Rise in systemic temperature is common in
severe infection, or indicates systemic involvement
Slow healing If wound is slow to heal or failing to heal, suspect underlying infection
Oedema Acute inflammatory response associated with infection produces local oedema. Oedema
may impede normal function (e.g. reduce range of motion of a joint)
Colour change (blue, grey, black) Change in colour usually indicates presence of infection and/or tissue necrosis
Smell Malodour indicates presence of microorganisms, e.g. presence of anaerobes
438 SPECIFIC CLIENT GROUPS
is not entirely accurate as a study by Armstrong tissue viability. Each physiological system will
et al (1998) showed using bone biopsies to now be considered in turn and attention drawn
confirm infection. to changes from the norm which increases the 'at-
risk' status of the patient. Details of actual assess-
ment procedures will not be included, as these
Pain
can be found in the relevant chapters of this text-
The presence or degree of pain does not always book.
bear relation to the severity of a lesion since, in
conditions such as diabetes mellitus, peripheral
Cardiovascular system
sensory neuropathy may mean that the foot is
insensate and the patient feels no pain at the site Tissue viability is compromised whenever local
of a lesion. Indeed, the first time such a patient circulation is compromised. An inefficient
may realise he has a problem is on noticing drainage system can be as threatening as a
hosiery or footwear being soaked in exudate, or reduced blood supply as both can produce local
on routine visit for a foot inspection at the clinic, ischaemia, leading to reduced diffusion of nutri-
or by the observation of a relative or friend. ents and gases with subsequent reduction in
However, practitioners usually record the tissue metabolism. The cause may be local factors
presence and nature of any pain experienced by such as a local vasculitis caused by local infection
the patient, since alleviation of the pain is one or vasospasm as seen in chilblains or Raynaud's
of the therapeutic objectives and, whereas phenomenon, a stenotic artery due to atheroscle-
absence of pain does not necessarily indicate all rosis or stasis following incompetent veins or a
is well, presence of pain is usually a strong indi- damaged lymphatic system; 85% of lower limb
cation of an underlying problem. Pain is often ulcers are venous ulcers and they are often very
recorded using the patient's own description of resistant to healing. Chapter 6 discusses causes
the pain. A more objective method is to use the and signs and symptoms of venous stasis in more
visual analogue scale (VAS) to show intensity of detail. Systemic factors such as congestive heart
pain, with one end of the line indicating no pain failure or severe anaemia can lead to ischaemia in
and the other end indicating worst pain ever the lower limb and external factors such as tight
(Ch. 3). The patient is asked to mark a point on footwear, hosiery or dressings can also be a cause
the line corresponding to the intensity of pain of localised ischaemia.
felt at that moment. Vasospastic disorders such as Raynaud's
A second often-used method is the McGill Pain disease or phenomenon, acrocyanosis, erythro-
Questionnaire (MPQ), or a modification of it, cyanosis and chilblains (perniosis) can result in
which consists of the patient selecting adjectives loss of tissue viability; prolonged vasospasm is
from various groups to show the nature and triggered by exposure to a cold environment or
intensity of pain. Both methods are useful in mon- to sudden changes in temperature.
itoring pain and pain relief, but pain is a very Thromboangiitis obliterans (Buerger's disease)
difficult entity to compare from one patient to is a small-vessel disease affecting smokers. This
another. The VAS is more suited for use in a busy mainly affects young men, and causes small areas
clinical practice than the MPQ, which takes time of necrosis on the tips of the fingers, toes, nose
to complete, but yields more information and is and ears.
more suited for research purposes. The cardinal signs of a compromised circulation
are absence of pedal pulses, an ankle/brachial
pressure index below 0.9, ischaemic pain on exer-
Systems approach to risk cise or at rest and oedema (Ch. 6). Sudden tem-
assessment perature change or a difference in temperature
As can be seen from Table 17.2, pathological between the two lower limbs is also an important
changes within the body systems can threaten sign. Colour changes and absence of hairs are not
THE AT-RISK FOOT 439
sufficient signs on their own, but help to build the Table 17.9 Examples of conditions affecting the skin which
increase the at-risk status of the patient
whole picture of a limb or foot with a compro-
mised circulation. The absence of one pedal pulse Symptom Condition
in a foot indicates a compromised circulation but
Dry fissures Sun, wind, ageing, hypothyroidism,
if the other pedal pulse is intact, significant chemotherapy
ischaemia is unlikely. Although calcification may
Wet fissures Occlusive dressings and footwear,
lead to a false high value for the ankle/brachial poor hygiene, hyperhydrosis, certain
index, a low value always indicates some reduc- occupations, e.g. baker, cook
tion in blood flow: the lower the index, the higher Callus and corns Foot deformities, abnormal foot
the risk. Digital pressures can also be measured function, ill-fitting footwear, ichthyosis
using an appropriate pressure cuff. Further evi- Blisters Epidermolysis bullosa, pompholyx,
dence can be obtained by observing or listening to pemphigus, urticaria, pustular
psoriasis, juvenile plantar dermatitis,
the waveform or flow sounds of major arteries ill-fitting footwear
and veins using a hand-held Doppler or measur- Pruritic lesions Tinea pedis, atopic eczema, venous
ing the transcutaneous oxygen diffusion pressure stasis eczema, contact dermatitis,
(Tcp02) on the dorsum of the foot or at digital asteatotic dermatitis
level. Values below 50 mmHg on the leg or Malignant lesions Melanoma, squamous cell
dorsum of the foot indicate some degree of carcinoma, basal cell carcinoma,
Kaposi's sarcoma
ischaemia.
Trauma Cuts, bruises, ingrown toenail, insect
bites
Dermatological system Infection Paronychia, onychia, erysipelas,
necrotising fasciitis
As explained in Chapter 9, the intact skin is an
important barrier to pathogens and any break or
potential break in that integrity, such as cuts and
bruises, poses a risk of infection. If infection is trauma such as friction from footwear or due to a
already present, as in paronychia or onychia, systemic condition such as bullous pemphigoid,
then there is risk of the situation worsening with as well as callus and corns produced at sites of
development of cellulitis and lymphangitis. Any increased mechanical stress, can all ulcerate,
condition which produces a localised change, exposing the patient to risk of infection. Often the
resulting in the altered ability of the epidermis first sign of increased trauma is a slight redden-
and dermis to withstand normal daily trauma - ing of the skin at the sites of increased stress,
such as an excessively moist or dry skin - poses such as on the dorsum or apices of toes from ill-
a threat to the integrity of the skin (Plates 29 and fitting footwear. This is the initial inflammatory
30). Examples of such conditions can be seen in response to trauma and should never be disre-
Table 17.9. garded. If the lesion is pruritic, such as in atopic
Alteration in the hydration of the stratum or venous eczema, or in tinea pedis, then the
corneum, such as is seen in the dry skin of people chances of infection from scratching are even
exposed to wind and sun, due to ageing, certain higher.
drugs such as those used in chemotherapy, or a In addition, ulcers and other skin lesions such
systemic condition such as hypothyroidism, all as pigmented naevi, may undergo malignant
render the epidermis more likely to form fissures change, which is obviously a threat not just to the
and thus portals of entry to pathogens. Similarly, affected limb but to the whole person. Any
excessive hydration as seen in the macerated skin patient with a lesion which shows rapid change
due to occlusive dressings, prolonged immersion in colour, size or wound margins or which
in water or poor attention to personal hygiene exhibits bleeding or other discharge should be
can lead to moist fissures. Blisters, including immediately referred for further investigation
vesicles and bullae, whether caused by external such as biopsy and pathological examination.
440 SPECIFIC CLIENT GROUPS
Malignant naevi can arise under the nail as well ocular muscle weakness, as sometimes seen in
as on skin and not all malignant naevi arise from Graves' disease, may lead to blurred and double
pre-existing pigmented naevi. In addition, not all vision, and retinopathy associated with diabetes
melanomas are pigmented. mellitus indirectly places the person at a higher
risk of lower limb problems, because of reduced
ability to notice any problem or to carry out
Endocrinological system
routine nail care safely.
Metabolic and endocrine disorders can cause Certain endocrine disorders can place the
widespread effects of morbidity and even mor- patient at risk when undergoing surgery and
tality and need to be noted when taking the require appropriate prophylaxis, extreme vigi-
patient's medical history, but their effects on the lance and prompt treatment if an emergency
at-risk status of the lower limb vary from none to arises. A thorough assessment is essential to
extremely marked consequences, as can be seen ensure awareness of such conditions.
from Table 17.10. Hyperthyroidism can sometimes lead to a life-
In addition to direct effects on the lower limb, threatening situation, thyrotoxic storm, where
many endocrine and metabolic disorders produce the patient may present with cardiovascular col-
other symptoms which may place the person at lapse and shock. The practitioner must be aware
risk of lower limb complications: for example, that infection, surgery, trauma, fright, diabetic
Table 17.10 Endocrine and metabolic disorders with effects on the lower limb
Acromegaly/gigantism (excess pituitary Enlargement of feet; erosion of articular surfaces leading to joint problems;
growth hormone) thickened, sweaty skin
Addison's disease (adrenocortical Increased pigmentation over bony prominences and extensor surfaces,
plus insufficiency) generalised effects of dehydration, weight loss, weakness, fatigue,
orthostatic hypotension
Cushing's syndrome (excess cortisol); may be Muscle wasting and weakness; thin, atrophic skin; poor wound healing;
due to excess pituitary ACTH (Cushing's disease) reduced inflammatory response; tendency to bruising; osteoporosis;
or exogenous ACTH or steroids plus generalised effects of hypertension and glucose intolerance
Diabetes mellitus (a relative or absolute lack Arteriosclerosis, leading to calcification and atherosclerosis of arteries
of insulin secretion, leading to elevated Peripheral vascular disease is 50-100x more common in patients with
blood glucose levels and alterations in lipid diabetes
metabolism) Neuropathy can appear in various forms. The most common form is
bilateral, symmetrical, peripheral sensorimotor polyneuropathy, but wasting
of hip and thigh muscles (diabetic amyotrophy) predominantly affects elderly
males and single nerves can also be affected
Hypocalcaemia (most common causes are Tetany (paraesthesia of lips, tongue, fingers, feet, muscle spasm). Lack of
deficiency of parathyroid hormone, vitamin D vitamin D will lead to reduced calcium absorption in the gut,
or kidney disease) compensated for by parathyroid hypersecretion, leading to bone resorption,
rickets or osteomalacia, with a tendency for bowed legs and fractures
Hypercalcaemia (idiopathic hypersecretion Muscle weakness, bone resorption of phalanges and soft tissue
of parathyroid hormone) calcification, osteitis fibrosa cystica (rare)
Hyperthyroidism (the most common form Moist, warm skin, pretibial myxoedema (infiltrative dermopathy), muscle
is an autoimmune condition called weakness, wasting
Graves' disease, but other forms also exist)
Hypothyroidism (the most common form Dry, scaly, coarse, thickened skin; a tendency to tarsal tunnel syndrome
is an autoimmune disease called
Hashimoto's disease)
Postmenopausal syndrome (fall in Osteoporosis, leading to crush fractures of spine, and fractures of wrist
oestrogens leads to bone resorption) (Colles' fracture) and of neck of femur (Perthes' fracture)
THE AT-RISK FOOT 441
acidosis or discontinuation of antithyroid med- thetic reflex which adjusts vasomotor tone, so
ication can all precipitate a thyrotoxic storm, that blood flow to the foot is increased. The foot
which is a medical emergency requiring immedi- will appear warm with bounding pedal pulses
ate hospitalisation. (Case history 17.1). However, because of the
A patient who is receiving or who has lack of vasomotor tone, appropriate vasocon-
received long-term steroids in the previous year, striction as a postural reflex is missing, leading
such as a person with rheumatoid arthritis, will to orthostatic hypotension and arteriovenous
show a reduced inflammatory response, poor shunting, depriving skin and superficial tissues
healing ability and increased risk of infection of an adequate blood supply. This shunting also
and at times of injury or surgery is at risk of leads to the characteristic sign of engorged
cardiovascular shock due to a sudden fall in dorsal veins. Although the patient may lose the
blood pressure. ability to detect a painful stimulus, when single
The endocrinological condition which has nerves are affected the common symptom is a
extremely important consequences is diabetes severe, lancinating pain, often following the dis-
mellitus. Whatever the cause, be it an autoim- tribution of a single dermatome. This gives rise
mune disease causing type 1 diabetes or a multi- to the phenomenon of the sensitive, insensate
factorial response to obesity, genetic input and a foot.
host of other factors, producing type 2 diabetes, Neuropathy is also a factor in the develop-
the consequences on the lower limb are equally ment of the Charcot foot, where absence of
serious. The major consequences are an increased pain and other protective reflexes plus abnor-
risk of peripheral vascular disease and a high mal blood flow to bone leading to osteopenia,
risk of peripheral neuropathy. In patients with result in gross neuroarthropathy developing
diabetes, the single most important risk factor for from a seemingly trivial injury or even the
ulceration is the presence of peripheral neuropa- repetitive trauma of walking. The first signs of
thy and the most important contribution to such a process are usually a marked increase in
delayed healing is ischaemia. Thus, a thorough the temperature of one foot, with swelling, but
assessment of both the cardiovascular and the with no apparent cause such as infection. Any
neurological systems are essential for patients
with diabetes (Chs 6 and 7).
There are several forms of neuropathy that Case history 17.1
may affect the person with diabetes, but the
most common is peripheral polyneuropathy, Mr Brown, a 35-year-old Caucasian male, with type 1
which can affect all branches of the peripheral diabetes present for 14 years, attended the podiatry
clinic for treatment of neuropathic ulcers. He weighed
nervous system, i.e. sensory, motor and auto- 15 stone and wore trainers bought in a high street
nomic nerves. store. Mr Brown had recently completed a short
prison sentence where the ulcers had developed. He
Sensory neuropathy leads to lack of aware- had a deep, heavily exuding ulcer under the first
ness of injury and a reduction in the protective metatarsal head right foot, surrounded by callus and
function of proprioceptive reflexes. Motor neu- a shallow ulcer on the plantar surface of the left heel.
A full assessment revealed the presence of bounding
ropathy leads to wasting of intrinsic foot pedal pulses, dry, warm skin, insensitivity to a 10 g
muscles and eventual foot deformities such as monofilament as far as the knees and inability to
claw toes and a pes cavoid-type foot (Plate 31). distinguish between warm and cold or sharp and
blunt stimuli in both limbs. Some wasting of intrinsic
This in turn leads to increased pressure foot muscles was observed, with slight clawing of
on metatarsal heads, apices of digits and the toes and prominent metatarsal heads and heels.
heels, with formation of callus and, if no pre- Diagnosis: diabetic neuropathic ulcers. The risk
ventative measures are taken, to tissue break- factors contributing to the ulcerations were deemed to
be peripheral neuropathy, excessive body weight
down and ulceration (Plate 32). Autonomic acting on bony prominences and failure to remove
neuropathy leads to dry skin, with increased callus build-up.
callus formation and loss of the normal sympa-
442 SPECIFIC CLIENT GROUPS
temperature difference of 2°C or more between longer thought to be responsible for necrosis in
the two feet of a patient with diabetes should be the absence of large-vessel disease and are no
immediately investigated to rule out infection longer considered an impediment to the success-
or acute neuroarthropathy. If early detection is ful outcome of vascular reconstruction.
missed and the foot goes on to develop a If ischaemia is present and remains uncor-
chronic Charcot foot, it will be at high risk of rected, loss of tissue viability is inevitable. This
ulceration, due to the abnormal pressure points alone is unlikely to lead directly to tissue break-
created by the deformity (Plate 33). down, but will almost certainly do so in the pres-
Diabetes is an important risk factor for athero- ence of other factors, such as ill-fitting footwear,
sclerosis and peripheral vascular disease. The tight hosiery, etc. Similarly, uncorrected
pathology is identical to that in non-diabetic ischaemia will delay or prevent healing of any
patients, but gender difference is lost so that ulcer. Thus, if ischaemia is present, part of the
females are equally at risk at all ages. The hyper- management must be to improve blood supply if
glycaemia and dyslipidaemia associated with at all possible.
diabetes appears to upset the delicate balance of Ischaemic ulcers, whether associated with dia-
endothelial events that maintains the integrity betes or not, have characteristic features which
and patency of the large and medium vessels, distinguish them from neuropathic and venous
tipping them over towards atheroma formation ulcers, as shown in Table 17.11 (Plates 34 and 35)
sooner than in non-diabetic patients. (Mason et al 1999).
Atherosclerosis also develops more distally in It is considered that at least 35% of all diabetic
people with diabetes, with tibial vessels fre- patients will have asymptomatic neuropathy
quently affected and focal stenotic lesions being (Edmonds & Foster 2000). Various studies into
more common. In addition, development of col- the aetiology of diabetic ulcers have shown that
lateral circulation is impaired, so that proximal over half will be neuropathic and a very small
lesions will have a more profound effect on number will be ischaemic, the remainder having
distal regions than in non-diabetic patients. both neuropathy and ischaemia. Bearing in mind
Early calcification of the tunica media of arteries the role of neuropathy and ischaemia in the pre-
is also seen. This is a separate process from the vention and healing of ulcers, most practitioners
calcification process of Monckebergs sclerosis, assign their patients with diabetic ulcers into
which develops with ageing in medium and either a neuropathic group or a neuro-ischaemic
small muscular arteries independently from group and treat accordingly. Careful cardiovas-
atherosclerosis and is clinically insignificant as cular and neurological assessment of the lower
it does not interfere with blood flow (Cotran et limb is therefore essential.
al 1994). Pedal vessels are rarely affected by The foot that is at highest risk will be the insen-
either atherosclerosis or calcification, an impor- sate, pulseless foot and a common cause of ulcer-
tant point to bear in mind when deciding on ation is poorly fitting footwear (Fig. 17.1) (Case
appropriate tests for measuring the degree of history 17.2). Often such a patient will be
ischaemia in the foot. wearing shoes that are one or more sizes too
H was commonly believed that a similar small, to avoid the sensation that the shoe is slip-
pathology affected small vessels, giving rise to ping off the foot. This of course further compro-
the term diabetic microangiopathy, and being mises the poor circulation, and the tissues with
put forward as the cause of isolated events of an already reduced tissue viability will be unable
digital gangrene in the presence of palpable to withstand the increased ischaemia, resulting
pedal pulses. However, no evidence exists for in breakdown. Thorough footwear assessment
such a pathology and although functional abnor- (Ch, 10) is therefore also essential.
malities of small vessels do exist, the only Diabetes also increases the susceptibility of
demonstrable pathology is that of thickening of the patient to a wide range of infections, both
the basement membrane. Such events are no bacterial and fungal, probably with hypergly-
THE AT-RISK FOOT 443
Usually very painful, pain alleviated Often painless Associated with an aching or bursting
by limb dependency pain, alleviated by limb elevation
Small, shallow, punched-out Often very deep Shallow, spreading, with irregular
appearance borders
Dry or small amount of exudate Often copious exudate, may be bloody Copious, often smelly exudate
Pale, grey or yellow base Red or yellow (infected) base Red or yellow (infected) base
On dorsum or apices of toes, under Under metatarsal heads, apices of Distal third of leg (see Plate 8)
nails, borders of feet (see Plate 2) clawed toes, heels
Thin surrounding skin, often a halo of Thick border of callus surround Often associated with skin scoriation
erythema or eczema, telangiectases and
haemosiderosis. Varicose veins may be
visible (see Plate 6)
caemia, impaired leucocytic function and poor due to an inadequate oxygen supply to the
blood supply all playing a role. As mentioned tissues, i.e. dry gangrene (see Plate 3).
earlier, infection is rarely a cause of ulceration, The hyperglycaemia of diabetes also affects
but once a portal of entry is created, infection is soft tissue such as tendons, leading to a
very likely. The practitioner must be alert to restricted range of motion at joints (cheiro-
any signs of infection, e.g. swelling, pain, arthropathy) and Dupuytren's contracture, both
redness, warmth, pus and any signs that the of which are associated with an increased risk of
infection is spreading, e.g. cellulitis, lymphangi- foot ulceration.
tis. The practitioner needs to be aware of the
possibility of spread of infection to bone (osteo-
myelitis) which is not initially detectable on x-
ray, especially in the neuropathic foot. Severe Case history 17.2
infection in both types of foot can lead to the Mrs Shaw, a 55-year-old Caucasian female, with type
blue-black discoloration of necrosis (wet gan- 2 diabetes diagnosed 12 years ago, presented to the
grene). Where ischaemia is a prominent feature, podiatry clinic with a very painful ulcer over the
dorsolateral aspect of her right fifth toe (Fig. 17.1).
necrosis can occur in the absence of infection, She was an enthusiastic ballroom dancer and had
been taking part in a contest the previous evening, for
which she had worn a pair of new dancing shoes. A
full primary assessment revealed a small ulcer with
no surrounding callus. There was little exudate
present, but there was erythema surrounding the
area. No pedal pulses were palpable on the right foot.
A Doppler tracing revealed dampened waveform of
both dorsalis pedis and tibialis posterior.
Anklelbrachial pressure index for DP was 0.7 and for
TP was 0.65. Tcp02 measurement of the dorsum of
the right foot was 40 mmHg.
The patient was able to detect sharp and blunt
stimuli on some toes but unable to detect a 10 g
monofilament or the vibrations of a 128 Hz tuning,
fork as far as the ankles.
Diagnosis: neuroischaemic ulcer. The main risk
factors were ischaemia, neuropathy and trauma from
ill-fitling shoes.
Figure 17.1 Ischaemic foot after dancing shoes.
444 SPECIFIC CLIENT GROUPS
There are also certain occasions when the Patients suffering from vitamin B12 deficiency
patient with diabetes is at increased risk, even are at risk of neuropathic ulceration, due to
though his physical condition remains un- peripheral sensory neuropathy.
changed, such as when on holiday abroad, par- The haematological system is also very useful
ticularly in hot countries, when the danger of as an aid to diagnosis. Case history 17.3 gives
burns from hot sand or blisters from plastic an example of where simple haematological
beach shoes are high possibilities. tests prove diagnostic for a rheumatological
Thus, in a patient with a diabetic ulcer that is condition which has contributed to an at-risk
failing to heal, an holistic re-assessment is foot. Such tests can be useful for staging of this
needed, to discover any contributory risk factor disease (Ch. 13).
which may have been overlooked, such as non-
compliance with prescribed treatment/advice,
ill-fitting footwear, poor blood glucose control, Case history 17.3
occult infection, peripheral vascular disease or
neuropathy. Mrs Black is a 50-year-old school dinner lady. She
was diagnosed with rheumatoid arthritis 6 years ago
following an acute episode in which her toes and
fingers became painful and swollen. She has been
prescribed prednisolone to control her inflammation
Haematological system during acute attacks. Her feet have become
deformed with severe hallux abductovalgus
Mention has already been made of the general deformities, digital retraction, plantar metatarsal
effects of anaemias on the lower limb in reducing bursae and associated callosity. She finds it difficult
to walk during acute stages of her disease. Recent
available oxygen to the tissues. However, certain blood tests confirm the presence of rheumatoid
haematological conditions have a more direct factor (immunoglobulin M: IgM) and she has both
effect on the tissue viability of the lower limb high erythrocyte sedimentation rate and C-reactive
protein level, indicative of severe or prolonged
(Table 17.12). inflammation. Recently, the medial eminence of her
Patients with sickle cell anaemia (homozy- left hallux valgus deformity has ulcerated and she
gous condition) or sickle cell trait (heterozygous has presented with an acute infection of this lesion.
She has been prescribed Augmentin to manage her
condition) are at increased risk of thrombotic current infection. Her footwear is inappropriate,
episodes, causing small-vessel obstruction due being slip-on style. Mrs Blackfinds laces or other
to sickling of red blood cells in hypoxic condi- methods of fastening difficult, owing to her hand
pain and loss of dexterity. Her peripheral perfusion
tions. Any situation which could promote this is good, with Tcp02 levels of 60 mmHg and normal
must be avoided. In the clinic this applies to ankle: brachial pressure indices. She has no
techniques such as the use of tourniquets and significant neurological dysfunction.
tight dressings.
Condition Effect
disease, renders the person liable to falls. Motor CLINICAL DECISION MAKING
neuropathies threaten tissue viability by creat-
ing deformities leading to high pressure points The role of the practitioner in assessing the at-
which make the tissue vulnerable during every- risk foot is to achieve a rational diagnosis based
dayambulation. on key facts from the history, presenting problem
For a fuller discussion of neurological condi- and physical examination of the patient. It is
tions and their effects on the lower limb, the important to recognise that in many cases the
reader is directed to Chapter 7. patient will be consulting several health profes-
sionals about the primary underlying disorderts)
which have placed their feet at risk. The lower
Renal system limb practitioner should ensure liaison with
these other professionals to ensure that all practi-
Chronic renal failure results in a failure of the tioners involved are in possession of the full facts
kidney to carry out its important regulatory roles relating to the case, and that effective shared care
of water and electrolyte balance, acid-base can be planned.
balance, production of active vitamin 0 3 and pro- In many cases patients will have more than
duction of haemopoietins. Even with dialysis, one, or even multiple causes for their at-risk
careful diet and medication, these disturbances can feet. It is important to identify all potential risk
lead to hypertension and thus increase the risk of factors when assessing the patient. Failure to do
atherosclerosis or occasionally lead to peripheral so can render management ineffective, delay
neuropathy. As the delicate calcium: phosphate resolution or in severe cases result in deteriora-
balance is disturbed, hypocalcaemia and hyper- tion of the patient. The key to full identification
phosphataemia occur, leading to an increase in of risk factors is a comprehensive and system-
parathyroid hormone and bone resorption with atic physical examination and history-taking
rickets or osteomalacia as a consequence. Anaemia approach.
can result from lack of erythropoietin. Communication, and where necessary, referral
Chronic glomerulonephritis which is charac- to other agencies or health professionals is of
terised by diffuse sclerosis of the glomeruli, is utmost importance when dealing with the at-
usually accompanied by hypertension. risk foot. It is important for the lower limb prac-
A familial disease of the kidney which also titioner to ensure that the patient's general
results in rickets is characterised by impaired medical practitioner is aware that the patient has
renal resorption of phosphate and reduced an at-risk foot, reasons for this risk status, the
intestinal absorption of calcium. This in turn chosen management plan, and that he is
leads to resorption of bone to raise plasma informed when the patient's foot health status
calcium levels, resulting in rickets or osteomala- improves or deteriorates. Similarly, if the patient
cia. It is called vitamin O-resistant rickets to dis- is under the shared care of hospital medical or
tinguish it from the deficiency disease. nursing staff, the lower limb practitioner should
ensure that these are likewise kept informed.
From time to time the lower limb practitioner
Respiratory system
will fail to achieve the desired therapeutic inten-
Chronic diseases affecting the respiratory tions. For example, an ulcer may fail to heal,
system, such as chronic obstructive airways infection may spread, or pain may become
disease, chronic bronchiectasis, silicosis or difficult to manage. In these cases the practi-
asbestosis, will affect the ability of the lungs to tioner should recognise as early as possible that
fully oxygenate the blood pumped from the the treatment being provided is not able to bring
right ventricle. Poorly oxygenated blood will about the desired therapeutic effect. In these
then be delivered to the tissues and will impair cases the patient should be referred to the practi-
healing ability. tioner best suited to provide intervention, which
448 SPECIFIC CLIENT GROUPS
may be outside the scope of practice of the refer- ment will clearly be necessary for patients with
rer. Such a referral should not be seen as an risk factors which are likely to undergo rapid
admission of failure, rather part of an overall change (e.g. infection).
management plan. The earlier into the process Second and even third opinions are often good
this referral takes place, the better the likely practice when dealing with the at-risk foot. The
outcome for the patient. Many patients have suf- lone practitioner is often not the best option for
fered because practitioners have failed to recog- the patient with severe foot disease. Practitioners
nise that they are no longer in a position to help need to be sure that they have reached a correct
the patient. Typical indications for referral to diagnosis, have devised appropriate and achiev-
medical or surgical colleagues are presented in able therapeutic objectives, and have put in place
Table 17.14. effective management strategies. The views of
Practitioners should recognise the importance another practitioner (podiatric, medical or
of review and reassessment of at-risk patients. nursing) can be invaluable in ensuring effective
Most people working with the at-risk foot have clinical care for high-risk cases.
felt a sinking feeling when an at-risk patient has
failed to attend several consecutive appoint-
SUMMARY
ments, only to find that the patient has deterior-
ated and either been hospitalised or is sick at Management of the at-risk foot can be a chal-
home. Assessment and diagnosis is not an exact lenging but highly rewarding area of clinical
science at the best of times. In cases of high risk, practice. This is an area of medicine with a
and in situations where rapid change is likely, it growing and strong evidence base. Practitioners
is therefore important to keep diagnosis and practising in this area need to be committed to
treatment plans under review. Formal reassess- continuing professional development to ensure
ment of the patient should be undertaken at that they are capable of practising safely, effec-
regular intervals. Shorter intervals for reassess- tively and with up-to-date knowledge.
REFERENCES
Armstrong D G, Lavery LA, Harkless L B 1998 Validation of patients with type 2 diabetes mellitus. 1: prevention.
a diabetic wound classfication system. Diabetes Care 21: Diabetic Medicine 16: 801-812
855-859 Oyibo S 0, Jude E B, Tarawneh I et al 2001 The effects of
Carlson G L 1999 The influence of nutrition and sepsis upon ulcer size and site, patient's age, sex and type and
wound healing. Journal of Wound Care 8: 471--474 duration of diabetes on the outcome of diabetic foot
Cotran R S, Kumar V, Robins S L 1994 Pathologic basis of ulcers. Diabetic Medicine 18: 133-138
disease. W B Saunders, Philadelphia, p 484 Rajbhandari S, Harris N D, Sutton M et al1999 Digital
Edmonds M E, Foster A V M 2000 Managing the diabetic imaging: an accurate and easy method of measuring foot
foot. Blackwell Science, Oxford, pp 3,17-22 ulcers. Diabetic Medicine 16: 339-342
International Working Group on the Diabetic Foot 1999 Richard J L, Daures J P, Parer-Richard C, Vannereau 0,
International Consensus on the Diabetic Foot, pp 12, Boulot I 2000 Wounds 12: 148-154
66-67 Schubert V 1997 Measuring the area of chronic ulcers for
Lavery L A, Armstrong D G, Harkless L B 1996 consistent documentation in clinical practice. Wounds
Classification of diabetic foot wounds. Journal of Foot 9: 153-159
and Ankle Surgery 35: 528-531 Serra L 2000 Clinic currently testing the SCAD) SAD
Macfarlane R M, Jeffcoate W J 1999 Classification of diabetic classification system -letters. The Diabetic Foot 3: 10
foot ulcers: the SCAD) SAD system. The Diabetic Foot 2: Sims D S, Cavanagh, Ulbrecht J S 1988 Risk factors in the
123-131 diabetic foot. Recognition and management. Physical
Margolis D J, Kantor J, Berlin J A 2000 In: Boulton A J M, Therapy 68: 1887-1902
Connor H, Cavanagh P (eds) The foot in diabetes. John Young M 2000 Classification of ulcers and its relevance to
Wiley and Sons, Chichester, p 63 management. In: Boulton A J M, Connor H, Cavanagh P
Mason J, O'Keefe C, McIntosh A, Hutchinson A, Booth A, (eds) The foot in diabetes. John Wiley and Sons,
Young R J 1999 A systematic review of foot ulcers in Chichester, pp 61-62
FURTHER READING
Banks V 1998 Wound assessment methods. Journal of Letters 2000 The Diabetic Foot 3: 42
Wound Care 7: 211-212
CHAPTER CONTENTS
Introduction 451
enabling the patient to walk to the shops to-face contacts were carried out by community
without pain and discomfort. Even relatively podiatry services, costing a total of £99.6 million
simple foot problems, such as neglected long toe (US$149 million).
nails, can limit an individual's ability to cope The prevalence of foot morbidity amongst
with the demands of daily living. Nail problems elderly populations is difficult to determine.
may prevent a person from wearing outdoor There have been relatively few studies which
shoes, and therefore restrict the person's living have quantified foot morbidity amongst the
environment to their home. Such confinement elderly. In those surveys of foot morbidity which
can result in social isolation, causing further have been published, the most commonly
health deterioration and severe reductions to reported foot problems amongst the elderly were
the quality of life. difficulties with nail cutting, corns and hard skin,
respectively (Crawford et al 1995). In the same
survey, around half of people over the age of 75
ASSESSMENT OF THE ELDERLY
years complained of two or more foot problems.
POPULATION
A recent meta-analysis of the literature shows
The size of the elderly population has increased forecast prevalence data for foot pathologies
over the last century. For example, in the United for populations over the age of 65 years
Kingdom, the number of people of pensionable (Table 18.1). However, this does not include
age has risen from 2 million in 1901 to 10 million studies of high-risk groups (e.g. people with
in 2001 - Office for Census and Population diabetes) and probably underestimates the true
Statistics (OPCS) data. In the UK, the over 65s prevalence of foot conditions in general popula-
now make up around 20% of the general popula- tions. The large standard deviations and
tion. Reasons for improved longevity include confidence intervals for many of the pathologies
improved water and sewage treatment, better reviewed demonstrate the relatively high varia-
nutrition, improvements in housing and better tion of reported prevalence of foot disease in the
social and economic circumstances. The impact literature. Nevertheless, these data can be used
of improvements in medical care on average life to provide a rough estimate of foot morbidity
span is less quantifiable. for a given population.
Community podiatry services predominantly There is certainly evidence that the likelihood
provide foot health services to people over the of experiencing foot problems, and the likely
age of 65 years. In 1997 a total of 975 000 new need for community foot health services,
referrals were made to NHS podiatry services in increases with advancing age. This is particu-
the United Kingdom. Of these, 63% (614250) larly true for elderly women, who are the largest
were for people aged 65 years or over (Hansard consumers of UK NHS podiatry services
1998). In the same year, a total of 9 million face- (Harvey et al 1997).
Table 18.1 Forecast prevalence of foot pathologies amongst the elderly population (from Turner et a12001)
dictable process enables recognition of the signs Young old Recently retired
of ageing to be made. Ageing is a process begin- 65-74 years Active
Generally fit
ning at conception and continuing until death. Independent
The medical concept of ageing is to treat ageing Often able to drive
as a disease process. However, ageing is not a Able to take vacations
Relatively wealthy
disease, in spite of the fact that as one ages dis- Wide social network
eases become more common. The elderly, there- Often care providers to 'oldest old'
fore, experience greater numbers, variety and parents/relatives
severity of diseases than the young. However, for Old old Often widowed
75-85 years Increasing number of minor
a process to be due to ageing, it must be univer- medical problems
sal, progressive, intrinsic and deleterious Increased likelihood of major medical
(Bennett & Ebrahim 1995). It is not surprising, problems
Becoming less mobile
therefore, that the elderly are the greatest users of Often unable to drive
health care services. Dependent on public transport
Arbitrary conventions tend to define 'the Rarely take vacations
Generally not wealthy
elderly' as those over the age of 65. For the pur- Social network reducing, owing to
poses of population assessment, it is probably death of friends/relatives
more helpful to divide this group into three more Oldest old Usually widowed
distinct categories (Bennett & Ebrahim 1995): 85 years + Coping with major and minor
medical problems
• 65-74 years: the young old Generally poor
Dependent on others to assist with
• 75-85 years: the old old everyday tasks
• 85 years + the oldest old. Unable to drive
Travels for essential purposes only
Typical characteristics of each group are given Usually does not take vacations
in Table 18.2. Physical limitation to activity
Social network confined to close
friends/relatives/carers
LOWER LIMB CONSEQUENCES OF
AGEING
The lower limb often suffers the degenerative From an assessment point of view, it is helpful
effects of ageing owing to the fact that the foot is to determine what the individual patient is able
a weightbearing structure which bears the and unable to do. Functional ability is affected
stresses of years of supporting and carrying the by disease and/or the compensatory (coping)
body. As tissues deteriorate with advancing mechanisms for the effects of disease. For
years, disruption to the normal structure and example, an elderly person may be unable to cut
function of the foot is inevitable. Structural her nails. The person is, therefore, defined as
change (e.g. joint disease, skin callus) will invari- being functionally unable to perform that activ-
ably lead to a degree of loss of function, with ity. The practitioner may be able to determine a
more severe structural disturbances leading to range of diseases/age-related changes which
greater functional impairment. Individuals are have resulted in this functional deterioration.
often able to compensate for minor structural Often for any given individual, a combination of
deterioration in order to retain functional ability. coexisting factors contribute to functional loss.
Multiple minor structural defects or single major Deterioration of vision, arthritic fingers, joint
defects are likely to result in failed compensation diseases affecting the hips / spine, hiatus hernia
and adversely affect functional ability. and motor weakness are typical examples of
454 SPECIFIC CLIENT GROUPS
conditions which commonly lead to such loss of Table 18.4 Exogenous factors associated with age-related
changes to the foot
function.
Table 18.3 identifies common structural Ultraviolet light (sunlight)
changes which occur to tissues of the foot and Diet
which are related to the ageing process. Most Smoking
elderly people will frequently show signs of one Alcohol consumption
or more of these structural changes. The underly- Chemicals/drugs
ing mechanisms responsible for such changes are Occupation
Sports, hobbies and activities
complex and often relate to combined, multiple
Trauma
degeneration arising in other systems (e.g. vascu-
Footwear
lar, endocrine and neurological systems). Cosmetics
Common foot pathologies seen in the elderly
are often not directly related to the physiologi-
cal effects of ageing but to the chronic, long-
term exposure to exogenous factors (Table 18.4). exposure to sunlight the skin ages very little
For example, age-related changes to the skin are with time. The action of ultraviolet light expo-
most likely to arise as a result of a lifetime of sure to skin results in the production of free rad-
exposure to ultraviolet light. In the absence of icals which have a long-term damaging effect on
cells. Many skin disorders which are commonly
associated with ageing are related to ultraviolet
Table 18.3 Age-related structural changes to tissues of the
foot exposure (Table 18.5). The foot is often at a
reduced risk of these ultraviolet light lesions
Skin Skin moisture content reduces compared with more exposed parts of the body
Skin becomes drier
Skin more prone to fissuring (e.g. the face), owing to the fact that for most
Skin is less flexible/elastic people for most of the time the skin of the foot
Skin becomes weaker, more likely to tear or split is covered by footwear.
Atrophy or displacement of subcutaneous fat
may occur Foot disorders which occur as a direct result of
Weightbearing forces on skin increase as foot ageing tend to be associated with general systemic
function worsens (intrinsic) disease. The incidence of systemic
Hyperkeratotic lesions become more likely
Number of pigmented lesions is likely to disease increases with advancing age. Elderly
increase people are also more likely to have several coex-
Extravasation of blood into skin is more likely isting systemic disorders. The combined effects on
Loss of skin viability is more likely as a result of
deterioration in circulation the foot of several systemic diseases occurring
Nail Rate of nail growth reduces
simultaneously can be significant. Assessment of
Nail plate becomes drier the elderly patient should always, therefore,
Nail plate becomes thicker include a full and comprehensive medical history
Increased likelihood of debris/callus in nail sulci
or beneath nail plate. Increased incidence of
subungual lesions
Involution of nail plate more likely Table 18.5 Skin conditions seen in elderly people
Nail plate becomes more brittle, and liable to associated with lifelong exposure to sunlight
split/crack
Wrinkles
Joints Increased likelihood of degenerative arthropathy
in weightbearing joints. Long-term compensation Hyperpigmentation
for functional foot abnormalities likely to Hypopigmentation
contribute to joint pathology (e.g. hallux valgus, Solar keratoses
hallux limitus) Basal cell carcinoma
Thickening of joint margins with resultant
decreased range of motion is likely Squamous cell carcinoma
Overall mobility of foot joints reduced Malignant melanoma
Increased likelihood of joint deformity Dry, inelastic skin
ASSESSMENT OF THE ELDERLY 455
and physical examination. Likewise, a familial and in particular risk assessment, can only repre-
history is also important in assessment of the sent foot health status at a specific point in time.
elderly patient. Inferences for the future foot health needs of a
The consequences of lower limb disease for the patient based on such 'snapshot' assessments
elderly patient can be significant. Foot disorders carry significant risks. A single major event - e.g.
can make a significant contribution to the risk for cerebrovascular accident (eVA), trauma and
falls, loss of mobility, loss of independence, infection - or multiple minor events (e.g. neglect
inability to carry out activities of daily living, of self-care, minor trauma, change to footwear)
pain, depression, social isolation, deterioration of can have a dramatic effect on an individual's foot
quality of life, loss of tissue viability and ampu- health status. Since the occurrence of these events
tation. What may appear to be minor foot pathol- is unpredictable in elderly people, it is important
ogy can have a significant effect on the lifestyle of to review or reassess the foot health status and
the patient. The assessment of the elderly patient needs of the elderly patient regularly.
should therefore seek to determine how the
patient's foot health is affecting lifestyle.
ASSESSMENT OF THE ELDERLY
It is also important to bear in mind that condi-
tions can deteriorate very quickly for elderly The practical approach to the assessment of the
people. What is a minor problem one day can elderly patient varies little from the standard
become a major limb or life-threatening problem approach to assessment. However, some addi-
the next. There are several reasons why patholo- tional points are worthy of consideration. For
gies in the elderly patient are likely to deterio- several systems, assessment will take the form of
rate faster. These include a less effective immune history taking and physical examination (e.g. vas-
system, poor peripheral circulation, diminished cular, neurological, orthopaedic, dermatological).
peripheral sensory perception, motor weakness, For some systems, history taking alone is nor-
confusion, loss of tissue resilience, combined mally required (e.g. endocrine, renal). Specialist
systemic pathology, effects of drugs, inability to tests or investigations may be required for com-
self-care, poor nutrition, poor hygiene and inad- plete assessment of other systems where appro-
equate footwear. priate (e.g. respiratory, haematological).
Evidence for rapid change of foot health
amongst an elderly population has recently
Assessment of the elderly vascular
been borne out of a study of the discharge of
system
elderly patients from a community podiatry
department (Turner et al 2001). In this study Leonardo da Vinci cheerily recognised the
5000 people over the age of 65 who were importance of vascular degeneration in the
assessed as being of 'low risk' for serious foot elderly when he wrote:
pathology were discharged from the service. veins which by the thickening of their tunics in the
Within a 2-year period following discharge 712 old, restricts the passage of their blood and by this
(14%) of these patients were re-referred to the lack of nourishment destroys the life of the aged
department with serious foot problems which without any fever, the old coming to fail little by little
caused them to be classified as 'high risk' in slow death
(in Bennett & Ebrahim 1995)
according to the department's criteria. Reasons
for re-referral included infection or ulceration Age-related changes to the vascular system in
(162 re-referrals), diabetes (178 re-referrals), the elderly arise as a result of age-dependent
peripheral vascular disease or neuropathy (310 (physiological) changes and disease (pathologi-
re-referrals), increased risk due to change of cal) processes. It is thought that the physiological
medication (62 re-referrals). changes contribute very little to the overall dete-
Practitioners need to be aware that assess- rioration of vascular function, and that disease
ments of the foot health status of elderly patients, processes are more significant (Wei 1992).
456 SPECIFIC CLIENT GROUPS
The most significant changes to the arteries Deterioration of the peripheral venous system
include calcification of the tunica media (arterio- is also common in elderly people. Venous hyper-
sclerosis), fibre-fatty occlusion of the vessels (ath- tension in the elderly may arise as a result of
erosclerosis) and arterial complications of these right-sided congestive heart failure, lack of exer-
processes (aneurysm, thrombosis, embolism). The cise (inactive skeletal muscle pumps), valvular
prevalence of peripheral arterial insufficiency dysfunction, deep vein thrombosis, venous
amongst the elderly is around 16% (Turner et al occlusion, respiratory disease (poor respiratory
2000). One of the most important factors con- pump mechanism) or abdominal masses (e.g.
tributing to the pathology of arterial disease in tumours). The lower limb consequences of
the elderly is elevation of arterial blood pressure. venous hypertension include venous stasis
Both systolic and diastolic pressures tend to rise eczema, venous ulceration, oedema, hyperpig-
with advancing age. The reasons for this are mentation (especially haemosiderosis) and in
complex, but include increased peripheral resis- rare, usually long-standing cases, malignant
tance and physical fitness. (fungating) wounds.
To reduce the risk of age-related arterial The role of the inter-professional team is
disease, control of blood pressure is important. It important in conducting an assessment of the
is therefore beneficial for all patients to have their vascular system in elderly patients with periph-
blood pressure reviewed at least annually. eral vascular pathologies. Frequently, patients
Treatment for high blood pressure is generally who demonstrate lower limb signs of peripheral
beneficial in terms of improvements to mortality vascular disease will also have coexisting vascu-
and morbidity up to the age of 80 years. How- lar degeneration affecting other tissues and
ever, side effects of antihypertensive therapy organs of the body (e.g. kidney, eye, brain, heart).
(especially diuretics) in the elderly can be Similarly, vascular disease affecting multiple
significant and lead to additional health con- organ systems is a good reminder to the practi-
cerns, including postural hypotension, falls, tioner to conduct a thorough assessment of the
dehydration and occasionally gout. lower limb vascular supply.
Apart from hypertension, other major risk As previously stated, the elderly patient is sus-
factors for arterial disease in the elderly include ceptible to rapid change in vascular status.
hyperglycaemia and hyperlipidaemia. Undetec- Therefore, frequent reassessment and update of
ted or poorly controlled diabetes mellitus is the vascular assessment is necessary, especially for
commonest cause of hyperglycaemia in the the 'old old' and 'oldest old' patients who are
elderly. Early detection of impaired glucose toler- likely to be most at risk.
ance (or elevated glycosylated haemoglobin
levels) coupled with resultant management of
Assessment of the elderly
hyperglycaemia is therefore useful in the long-
neurological system
term prevention of vascular disease. Similarly,
screening for hyperlipidaemia and where appro- Age-related changes to the peripheral nervous
priate dietary modification and/or use of lipid system can result in deficiencies in the motor,
lowering drugs can be important in an overall sensory or autonomic nerves of the lower limb.
plan of action to reduce an individual's risk of Signs of such deficiencies include defects of
vascular disease. sensory perception, muscle weakness, deformity,
The consequences of poor arterial supply to dry skin and vasodilation.
the feet vary from minor changes to poorly nour- The literature suggests that defective sensory
ished tissues, like dry skin, brittle nails, hair loss, perception is present in around 20% of people
atrophy of fat pad, to more severe foot problems over the age of 65 years (see Table 18.1). The
like ischaemia, ulceration and gangrene. A struc- prevalence of peripheral neuropathy is greatest
tured vascular assessment as detailed in Chapter in older people with diabetes mellitus, where up
6 is, therefore, essential for all elderly patients. to 43% of people can be expected to have some
ASSESSMENT OF THE ELDERLY 457
---------------------------------------
abnormal neurological assessment findings people who could perceive the monofilaments at
(Plummer & Albert 1996). Loss of vibration per- all sites (Plummer & Albert 1996).
ception as detected by the use of a tuning fork,
and loss of touch/pressure sensation as detec-
ted by a 10 g monofilament are the commonest
Assessment of the elderly
findings in the elderly. The likely presence of
musculoskeletal system
neurological abnormalities increases with Musculoskeletal problems are extremely
advancing age. common in the elderly. Disorders such as
Defects affecting upper motor neurones are osteoarthritis, osteoporosis and osteomalacia
often related to disorders which occur more fre- have an increased prevalence with advancing
quently in the elderly (e.g. CVA). These disorders age. Deterioration of the musculoskeletal is
may result in severe functional disturbance, and responsible for much of the impaired mobility
limit mobility. Disorders which a younger person seen in elderly people.
could normally compensate for are often difficult As far as the lower limb is concerned, the
for an elderly person to adjust to. Reasons for elderly are more likely to suffer from common
failure to compensate for neurological distur- lower limb disorders, including hallux valgus
bance might include limited capability to re-learn and lesser toe deformities. Around 23% of the
skills (rehabilitation), coexisting or multiple elderly are likely to have hallux deformities and
pathologies and severity of disruption to normal around 30% have lesser toe deformity (see Table
function. As a result, many elderly lose a degree 18.1). Practitioners are therefore likely to see the
of mobility and independence following a consequences of these deformities arising from
sudden deterioration in neurological function. pressure from footwear on deformed joints or
Key neurological indicators include those normal weightbearing forces. These associated
tests described in Chapter 7. However, practi- pathologies include corns, calluses, blisters and
tioners should avoid making long-term predic- thickened or deformed toe nails. In patients with
tions of risk based on clinical assessment. As for vascular or neurological deficit, ulceration is
vascular assessment, deterioration in neurologi- commonly seen to affect deformed toes.
cal function can occur suddenly and may go Assessment of the musculoskeletal system in
undetected by the patient. Regular review of an elderly person is not significantly different
neurological status is important in the overall from that of a younger person. However, it is
risk management of people over the age of often impractical to examine joints of the hip and
65, and is particularly important for those over knee in as much detail (and as vigorously') as for
the age of 85 years. young patients. It should be remembered that
Deterioration of nervous system function in old people bruise easily, skin may be weak and
the elderly is often clinically significant because joints unstable. Rough examination has the
other systemic problems coexist. Many elderly potential to cause the elderly severe discomfort
people with peripheral sensory neuropathy will or even harm.
also have some degree of vascular insufficiency, Most of the information about musculoskeletal
and also foot deformities. Abnormal weight- system disease can be gained from gross exami-
bearing pressures, poor footwear, skin lesions, nation and noting any obvious findings (e.g.
poor hygiene & self-care or trauma can there- obvious foot deformities, swollen joints,
fore place the patient at high risk of loss of inflamed areas). The medical history may reveal
tissue viability. a history of musculoskeletal disease (e.g. rheu-
The relationship between foot neuropathy and matoid arthritis, osteoarthrosis, fracture, back
foot ulceration is a significant one. In one study of problems). Observing the patient during walking
308 patients, 28% of people who could not detect can also provide important indications of func-
a 10 g monofilament at any of 10 sites on the foot tional ability. However, care should be taken with
developed foot ulcers, compared with 3% of elderly people if using a motorised treadmill for
458 SPECIFIC CLIENT GROUPS
the observance of gait. Elderly people may find it blood is much slower than in a younger person.
difficult to adjust their cadence to the speed of These lesions are often collectively referred to as
the treadmill, become unstable and/or fall. 'senile purpura'. Spider naevi, telangiectasiae
Another risk of treadmill use in the elderly is and haemosiderosis are skin conditions which
demanding unaccustomed levels of exercise from are more common in elderly people. These vas-
the patient and placing the patient at risk of acute cular /haemorrhagic skin lesions are more
ischaemia. This may manifest as acute skeletal common and significant in elderly people taking
muscle cramps, or (worse) acute angina or even anticoagulant drugs (e.g. warfarin) following
myocardial infarction. thrombosis.
Skin lesions are another useful indicator of Corns and calluses are likely to be a greater
musculoskeletal problems. Skin lesions such as problem for the elderly. Dryness and reduced
corns or calluses tend to arise as a result of trauma skin resilience predispose to hyperkeratotic skin
to the skin exacerbated by deformed joints, lesions. In addition, the elderly are more likely to
difficulty accommodating the foot in appropriate have functional foot pathology and/or deformi-
shoes or compensation for functional pathologies. ties which cause abnormal weightbearing lesions
Elderly people are more likely to be offered or lead to problems accommodating the foot in
conservative treatment for lower limb joint shoes. Vascular or neurological impairment may
pathologies rather than surgical intervention. then lead to reductions in tissue viability and
This is particularly true where the patient has infection, ulceration or gangrene.
complex or multiple systemic problems includ- The elderly are more likely to be troubled by
ing cardiovascular or neurological disease. A difficult toe nails. Nails become thicker and
significant proportion of elderly people are there- harder with advancing age. Years of repeated
fore prescribed drugs to manage musculoskeletal minor trauma from footwear can result in nail
pain and inflammation. The most common cate- plate abnormalities. Periungual and subungual
gory of drugs prescribed for this purpose is the lesions may also be a problem (e.g. onychopho-
nonsteroidal anti-inflammatory drugs (NSAIDs). sis). Inability to self-care may result from poor
Use of these drugs can result in gastric irritation eyesight, back pain, hiatus hernia, arthritic
and bleeding, particularly when used long term. fingers, hip pathologies or obesity. Neglect of
Therefore, any elderly patient taking NSAIDs simple routine nail care can result in potentially
showing signs of anaemia or gastric disturbance serious foot pathology (e.g. infection, ulceration),
should be more closely investigated. particularly where there are coexisting medical,
vascular or neurological abnormalities.
The skin of the elderly patient has a less effec-
Assessment of elderly skin
tive immune function than younger skin. The
As stated above, most of the changes to the skin number and function of Langerhans' cells and
which occur with advancing age do so as a result epidermotrophic lymphocytes reduce as a result
of cumulative exposure of the skin to ultraviolet of ageing. Skin infection is therefore more likely
light (sunlight) (see Table 18.5). Increased colla- in old age. This is a particularly significant
gen cross-linking, drying and thinning of the problem for elderly patients with hypergly-
skin are all a result of ultraviolet light exposure. caemia, vascular insufficiency or on long-term
Many of the effects of ageing on the skin can be steroid therapy.
prevented by avoidance of exposure to sunlight, Some elderly people have very thin, 'papery'
or use of appropriate covers/barrier creams. skin. This is known as 'transparent skin syn-
Bruises and other vascular lesions are more drome' and results in a skin which looks and
likely in the elderly patient. These lesions arise as feels a little like tissue paper. Skin becomes
a result of increased capillary fragility, with cap- wrinkled and loose, has poor elasticity and
illaries more likely to leak blood into the skin. In bruises and bleeds very easily. Skin tears easily,
the elderly patient reabsorption of extravasated and is slow to heal. Vascular /haemorrhagic skin
ASSESSMENT OF THE ELDERLY 459
lesions are very common. This syndrome is Other consequences of ageing include the
commonly associated with osteoporosis. A menopause. In women the menopause is an
similar skin condition can be seen in some inevitable consequence of ageing. It results in a
patients following long-term steroid treatment depletion of oestrogen production, with a rise
(e.g. for rheumatoid arthritis). in the secretion of gonadotrophic hormones -
Many elderly patients complain about severe follicle-stimulating hormone (FSH) and luteinis-
itching of the skin (senile pruritus). This can be ing hormone (LH). A reduction in oestrogen is
an important indicator of an underlying pathol- associated with osteoporosis, dryness of the skin
ogy. The practitioner should attempt to identify and flushing/sweating. Osteoporosis is a
the cause of any pruritus. Table 18.6 identifies significant risk, and occurs because the bone
some of the common causes of pruritus in the cannot metabolise vitamin D and calcium
elderly. without oestrogen. Pathological fractures may
occur in response to relatively minor trauma in
patients with advanced osteoporosis. The most
Assessment of the elderly endocrine
significant site for osteoporotic fracture in the
system
lower limb is the neck of the femur. Fracture at
Endocrine dysfunction is more common in the this site commonly occurs from falls and can be
elderly. The most significant endocrine disorder extremely disabling, and is even responsible for
for the lower limb is diabetes mellitus. Type premature death in some people.
2 (noninsulin-dependent) diabetes mellitus Postmenopausal changes to the skin can
becomes much more prevalent with advancing result in dryness and increased fissuring of
age. The chronic complications of hypergly- 'fatty' areas of skin. A common complaint in
caemia result in damage to nerves (neuropathy) postmenopausal women is dry heel fissures,
and arteries (angiopathy). These disorders which may be inflamed and prone to bleeding.
create an increased risk of infection, ulceration, This condition is referred to as keratoderma
gangrene and amputation, and account for climaciericum. It is aggravated by summer con-
significant morbidity for a large number of ditions (evaporation of surface water), excessive
elderly people. The primary clinical signs of bathing (including foot spasl), open-backed
diabetes mellitus may often first be identified in shoes and hard soles.
the lower limb. Signs of neuropathy, recurrent Thyroid dysfunction is also a common problem
skin infection or arterial disease in an elderly in the elderly, but can be difficult to diagnose or
patient should always be followed up with recognise. Hypothyroidism is a common finding
testing for diabetes (e.g. glucose tolerance test). in elderly people as a result of decreased secretion
levels of thyroxine. The signs of hypothyroidism
in the elderly may be subtle, and reflect common
symptoms associated with being elderly. Signs
Table 18.6 Causes of pruritus in the elderly include constipation, tiredness, dry skin and hair,
Excessive dryness of the skin weight gain and cold intolerance. Elderly people
Haematological disorder (e.g. polycythaemia rubra vera) with hypothyroidism are at an increased risk of
Hepatic disease winter chilling: hypothermia is a significant risk
Renal disease for people with inadequate household heating or
Malignant disease poor nutrition.
Drugs
Infestations (e.g. scabies, lice, fleas)
Inflammatory skin diseases (e.g. eczema, psoriasis) Assessment of the elderly
Incontinence haematological system
Autonomic dysfunction
Hypersensitivity
Blood disorders such as anaemia can complicate
an already compromised lower limb. Just
460 SPECIFIC CLIENT GROUPS
- - - - - - - ----------------- ----------
because the foot is warm and has bounding disease and vitiligo. For males with pernicious
pulses does not always guarantee adequate anaemia, there is an increased incidence of gastric
tissue nutrition. The quality of the blood is carcinoma.
important too. Anaemia is relatively common in In addition to the general symptoms of
elderly people, and in mild cases can be difficult anaemia, clinical features of pernicious anaemia
to recognise. Symptoms of anaemia can be slow may include weight loss and peripheral neuropa-
to develop, and can be mistaken for 'growing thy. Peripheral neuropathy can be significant and
old'. Lethargy, general malaise, intermittent clau- is similar to that seen in diabetes mellitus.
dication, pallor, headache, breathlessness, angina Posterior and lateral columns of the spinal cord
and skin atrophy are all features of anaemia but are involved (subacute combined degeneration).
are also features which can be seen as part of the Patients often complain of paraesthesia of toes,
ageing process. and demonstrate poor vibration perception,
The lower limb consequences of anaemia can touch/ pressure sensation and proprioception.
be particularly significant for the elderly patient. Progressive muscle weakness may result in
This is particularly true if the anaemia is 'super- digital deformity and ataxia. Other features may
imposed' on coexisting vascular disorders. include a sore red tongue (glossitis), purpura and
Adequate tissue nutrition is dependent upon mild fever.
both adequate quantity and quality of blood Folate-deficiency anaemia is sometimes seen in
reaching the tissues. Quantity is affected by elderly people and is associated with malnutri-
change in the diameter and resilience of the blood tion. The daily requirement for folate is around
vessels. Quality is affected by disorders of blood 100 p.g. Dietary sources include green vegetables,
cells, oxygen-carrying capacity or increased ten- kidney, liver and other offal. Cooking can destroy
dency to form blood clots. Loss of tissue viability folate. Anaemia due to folate deficiency produces
may occur where reductions in either the quantity generalised symptoms as described above.
or quality of blood fails to meet the basic nutritive
requirements of respiring cells.
Assessment of the elderly respiratory
The commonest types of anaemia to affect the
system
elderly are iron-deficiency anaemia, pernicious
anaemia and folate-deficiency anaemia. Iron- The respiratory system serves to oxygenate the
deficiency anaemia commonly arises following blood and to eradicate waste gases from the
haemorrhagic disorders, including those caused body. Disorders of the respiratory system may
by gastric bleeding following long-term use of therefore result in a failure to adequately oxy-
NSAIDS. In addition to the general symptoms of genate the blood, or an accumulation of waste
anaemia given above, clinical features of iron- gases. The latter condition results in acidosis,
deficiency anaemia may include koilonychia which is ultimately fatal.
(spoon-shaped nails) and brittle nails. Assessment of the elderly patient should
Pernicious anaemia is a common form of include observations of respiratory function.
anaemia seen in the elderly. The incidence is Age-related changes to respiration may include
around 1 :8000 people over the age of 60 years. It an elevated respiration rate, shallower breaths,
arises as a result of vitamin B12 deficiency. Usually altered chest sounds and chronic cough. These
this occurs due to a lack of intrinsic factor, which changes are more likely in people who are or
is normally produced by the gastric parietal cells. have been smokers. Respiratory abnormalities
Intrinsic factor is essential for the absorption of may also lead to significant problems for elderly
vitamin B12 in the ileum. Abnormalities of intrin- people with asthma, bronchitis, emphysema and
sic factor secretion usually arise as a result of congestive heart failure.
autoimmune processes. The disease is more Respiratory problems are a significant factor in
common in people with other autoimmune dis- the pathology of some lower limb disorders. As
eases including thyroid disorders, Addison's with many systemic conditions seen in elderly
ASSESSMENT OF THE ELDERLY 461
- - - - - - - - - - - - - - - - - - _ . - - _ ...- - - - - - - - - - _ . - - - - - - - - - - _ . _ - - - - - - - -
people, respiratory problems seen in combina- Table 18.7 Examples of functional assessments of the
elderly patient
tion with other coexisting disorders present the
greatest threat. For example, elderly people with Independence What are the patient's capabilities?
emphysema coupled with peripheral vascular Can the patient carry out activities of daily
living without assistance?
disease may suffer ulceration of the foot. In this Is the patient adequately compensating for
example, the reduction in oxygenation of the the effects of disease?
blood may complicate an already compromised Can the patient adjust to changes in her
environment?
tissue viability. What does the patient need the help of
other people to do?
What does the patient's social network
Functional assessment of the elderly consist of?
Functional assessment of the elderly patient is an Mobility Is the patient able to move around her
environment without assistance?
important part of the assessment process. A good Does the patient drive?
functional assessment will provide the practi- Can the patient climb stairs safely?
tioner with a clear impression of a patient's capa- Can the patient manage to do her own
shopping, visit hairdresser, chemist, doctor,
bilities and limitations and identify the effect of etc.?
lower limb disorders on lifestyle. It will also Does the patient require special aids to
assist with risk assessment of the elderly person. assist her mobility (e.g. stick, frame,
wheelchair)?
Table 18.7 details aspects of functional assess- Is the patient stable when standing or
ment which may be included as part of the walking?
general assessment of the elderly patient. Is the patient likely to fall?
Assessment of function before and after clini- Activities of What activities does the patient feel
daily living she needs to do on a daily basis?
cal intervention can be a useful means for the Can the patient cope with feeding and
determination of clinical effectiveness. Some of grooming herself?
the key therapeutic objectives for managing Can the patient dress/undress
independently?
lower limb pathology in the elderly are con- Can the patient manage to cut her own
cerned with the following: toe nails and/or apply creams to the feet?
Can the patient maintain a clean and
1. maintaining or improving the patient's hygienic home?
independence Quality of life Is the patient satisfied with her life?
2. improving the patient's mobility Is the patient happy or sad?
3. improving the patient's quality of life Is the patient lonely or isolated?
Does the patient keep herself occupied?
4. enabling the patient to undertake activities of Are there things which the patient enjoys
daily living (ADLs). doing?
Does the patient feel guilty about anything?
These objectives are as important as disease/ Is the patient worried, frightened or
symptom specific objectives (e.g. reducing concerned?
Is the patient experiencing painful
pain). Therapeutic interventions which have an symptoms?
effect on the above will often make a significant Does the patient feel that physical disease
difference to the patient. This is true even where or pain is affecting her lifestyle?
cure of the presenting problem is not possible. Cognitive state Is the patient confused?
Is the patient forgetful?
Most patients are more concerned about reduc- Can the patient describe her symptoms?
tions in functional ability and becoming depen- Is the patient capable of giving informed
dent on others (i.e, becoming a 'burden') than consent?
anything else.
An inter-professional approach to therapy
can be particularly useful to the assessment of tional assessment strategies which can provide
function. Physiotherapists and occupational ther- the practitioner with useful information as part of
apists, for example, make use of a variety of func- an overall assessment of the patient.
462 SPECIFIC CLIENT GROUPS
Functional assessment often focuses on the fol- 2. Domestic activities of daily living - i.e. how
lowing: the person manages household tasks - e.g.
cooking, cleaning, gardening, etc.
• mobility and independence
3. Personal activities of daily living - i.e. how
• quality of life
the person manages to care for herself - e.g.
• ability to perform ADLs.
washing, bathing, cutting toe nails,
In addition, there are other functional assess- continence, etc.
ments which may be particularly relevant to the
lower limb: Therefore, an elderly person will usually expe-
rience difficulty with visiting the shops before
• gait analysis having problems with cooking or bathing.
• ability to self-care for feet. Similarly, incontinence usually occurs later on
The most popular means of assessing mobility after the person has developed other functional
and independence is the Barthel index. This was limitations. This can make continence a particu-
first developed by Mahoney & Barthel (1965) for larly difficult situation to manage for both the
the assessment of long-stay hospital patients with patient and carers. Many other factors often con-
neuromuscular or musculoskeletal problems. It tribute to the onset of incontinence, including
has since been used for the assessment of com- loss of mobility, urinary tract infection, auto-
munity- (home-) based patients with a variety of nomic neuropathy, prostatism, stress inconti-
pathologies. The index is designed for the assess- nence, unstable bladder, retention with overflow
ment of function both before and after treatment. and central nervous system (eNS) pathology.
It is therefore useful for the determination of the There are a variety of means to test an individ-
efficacy of clinical intervention. Table 18.8 shows ual's mobility. A simple mobility assessment is
the key elements of the Barthel index. known as the 'timed up and go' test. In this test,
The Barthel index does not include some the elderly person is asked to stand from a chair,
important activities of daily living such as shop- walk 10 feet, turn and return to the chair. The
ping, cooking, social activities and gardening, person is timed during this activity. Most adults
which probably reflects the fact that the index can complete this activity in less than 10 seconds.
was originally designed to assess institution- Frail elderly people may take from 11 to 20
alised populations. seconds for this task. People taking longer than
Deterioration in independence and mobility 20 seconds are generally amongst the most
usually progresses through: immobile elderly. For this latter group a more
detailed mobility assessment is indicated. There
1. Social activities of daily living - i.e. how the is a strong association between the results of this
person relates to the 'outside world' - e.g. test and a person's functional independence in
shopping, visiting friends and relatives, activities of daily living.
vacations, going to the pub, etc.
Table 18.8 Key aspects of Barthel index Assessment of gait in the elderly
Feeding Assessment of gait in the elderly patient can
Mobility (from bed to chair) often be a useful indicator of mobility. It can also
Personal toilet (washing, etc.) enable the practitioner to determine whether
Getting on/off toilet walking aids (e.g. sticks, frame) are indicated. A
Bathing reduction in walking speed is one of the early
Walking on a level surface
features of gait disturbance in the elderly.
Going up/down stairs
Healthy adult cadence is about 1 m/s. A frail
Dressing
Continence (bladder/bowel)
elderly person may walk at less than half this
speed.
ASSESSMENT OF THE ELDERLY 463
--------------------------------
Elderly stride length is often shorter than that Table 18.9 Major factors affecting quality of life
of a younger adult. Gait is often apropulsive, Loss of mobility
with limited toe-off evident. This appears as a Dependence on others
'shuffling' gait. The base of gait is often wide, in Acute or chronic pain
an attempt to improve balance and stability. The General health status
elderly person may grasp fixed objects to Life-threatening! terminal disease
improve stability. In this way, elderly people Poverty
often use objects around their room to move Social isolation
around safely. This is especially common for Loneliness
elderly people with sight problems. Mental state - e.g. depression
Bereavement
Frail elderly people placed in an unfamiliar
Difficulty sleeping
environment will often show a much slower
Boredom
and more 'unsure' gait than they would nor- Inability to perform activities of daily living
mally have at home. Lack of familiar objects for Loss of ability to make decisions
stability or an unfamiliar walking surface can Lack of control
cause perceptual problems and lack of
confidence. Therefore, asking an elderly person
to walk down a long corridor in a hard-floored
clinic can give an unrepresentative picture of the validity and reliability of the questionnaire
the person's gait. Gait is best observed in an for a wide variety of clinical situations.
environment which is familiar to the patient The SF-36 assessment tool is available free of
(e.g. home). charge from the UK Clearing House for
Peripheral sensory neuropathy may produce a Information on the Assessment of Health
'high stepping' gait with a characteristically Outcomes, Nuffield Institute for Health Service
heavy heel strike. Parkinson's disease produces a Studies (see References for web site address).
'festinating' gait where the person appears to More informal assessment of the quality of life
chase their centre of gravity forwards, shuffling of the elderly can be achieved through normal
and stooping. Musculoskeletal problems, joint clinical conversation. The practitioner, as part of
pain or foot pain can result in an antalgic (pain- a normal discussion with the patient, can gain a
avoiding) gait. This often manifests as limping or fair idea of the patient's quality of life. Podiatry is
avoiding certain movements or positions of the a profession which is well suited to this task,
limb during gait. since patients are often seated for treatment for
20 min or so, and treatment does not usually
prevent the patient from talking. Patient and
Determinants of the quality of life podiatrist are usually sitting face to face, and
Quality of life is affected by a complex interac- one-to-one communication is established. Where
tion of multiple factors, some of which can have a podiatrist is concerned that the patient has a
a large impact on quality of life (Table 18.9). poor quality of life, or feels that the patient is
There are many measurement tools for the unusually sad or depressed, a more formal
assessment of quality of life. The most popular assessment of quality of life can be undertaken.
tool used in UK health care for the assessment of This may involve a referral to other members of
quality of life in studies of adults with disease the health and social care team: e.g. health visitor,
states is the short form-36 questionnaire (SF-36). social worker or general practitioner (GP).
The SF-36 questionnaire consists of 36 questions
divided into the following categories: physical
Assessment of cognitive status
health, physiological health, mental health and
social well-being. Its popularity has resulted in a Assessment of cognitive function in the elderly
large number of studies which are able to attest can be important for all health care workers.
464 SPECIFIC CLIENT GROUPS
-------------------------------------
This is particularly important where a practi- Table 18.10 Mental test score
tioner seeks informed consent from a patient for 1_ Name
a clinical procedure. Those changes most fre- 2. Date of birth
quently associated with the ageing process are 3. Age
4. Date and time of day
forgetfulness and confusion. Forgetfulness is a 5. Address
behaviour which affects all people, young or 6. Name of prime minister
old. The fact that elderly people appear to forget 7. Date of First World War
8. Place
things more often may be related to several 9. Remember an address 5 min later
factors. First, people who are old today received 10. Count backwards from 20 to 1
a different education to people who are young
today. Some elderly people will have received a
very basic education, had poor schooling and,
as a result, may appear less intelligent and more Assessment of mental state can easily be
forgetful. Coupled with this is the fact that most achieved by means of a mental test score (Table
elderly people had limited exposure to the 18.10). This is performed by the practitioner
media when they were young compared with asking 10 simple questions to the patient. A low
young people today who are exposed to a mass score (less than 7) indicates confusion and war-
media. This cohort effect is probably an impor- rants referral to other agencies (e.g. GP, psychia-
tant factor in explaining why elderly people trist). Deterioration in mental test score may
have difficulty remembering certain facts, indicate the presence of a chronic dementing
recalling events and handling complex ideas. It illness (e.g. Alzheimer's disease).
is important to remember that forgetfulness is
not necessarily indicative of the onset of brain
Assessment of ability to perform
disease or dementia.
basic foot care
Dementia is another cause of forgetfulness. It is
a relatively common finding in elderly people. For the practitioner, accurate determination of an
Dementia can arise as a result of reductions in elderly patient's ability to perform basic tasks
supply to the brain of oxygen, nutrients or hor- relating to foot care will be important. The fol-
mones. Dementia is not a single disease, but a lowing activities are important as part of per-
term used to encompass a variety of brain dis- sonal activities of daily living:
eases. The most common causes of dementia in
• cutting and/ or filing of toe nails
the elderly are Alzheimer's disease and multi-
• filing of hard skin
infarct dementia (recurrent mini-strokes of corti-
• application of cream to the sole of the foot
cal/subcortical areas).
• washing and drying of feet
Confusion is where an individual has difficulty
• putting on stockings, tights or socks
placing herself in terms of time and/or place. It
• putting on and fastening shoes
can lead to disorientation, loss of short-term
• change of a dressing applied to the foot
memory, changed levels of activity, speech
(where appropriate)
defects, hallucinations and clouding of con-
• inspection of feet for lesions.
sciousness. Acute confusion (delirium) is a rela-
tively common finding amongst elderly people. Inability to perform the above activities may
It may also be an important indicator of an place an elderly person at greater risk of deterio-
underlying systemic disease (e.g. CVA, infec- rating foot health. This is particularly likely
tion). Confusion may be aggravated by drugs where the elderly person is not able (or eligible)
(e.g. alcohol), sight or hearing defects and pres- to receive podiatric care and where there is an
ence of other brain diseases (e.g. Parkinson's assumption that the person will manage her own
disease). Confusion may also be a feature of feet. Failure to perform these basic activities may
acute or chronic dementia. ultimately also contribute to deterioration in
ASSESSMENT OF THE ELDERLY 465
mobility, independence and quality of life. For those people most at risk. Usually, notions of risk
example, patients may feel less inclined to go have centred on medical need for foot care. It is
outside of the house if putting on shoes and clearly a worthy desire to focus limited resources
hosiery becomes difficult. Provision of simple on those most at need. However, risk assessment
aids, such as elasticated laces and stocking of the elderly can be a hazardous pursuit and
helpers, can sometimes rectify this problem, by should not be undertaken without appropriate
providing assistance with difficult activities. validation of risk assessment protocols.
Inability to check and clean feet can be a The risks of prioritisation are enormous, both
major risk for deterioration in foot health status. to individuals and to health services. Getting it
This is especially true for patients with either wrong has major consequences for individuals
peripheral vascular insufficiency or defects of (ulceration, infection, falls, gangrene, amputa-
sensory perception. Sight defects may com- tion) and for health services (litigation, com-
pound the problem. In these cases, the patient plaints, costs of managing complications, effect
should be encouraged to ask a carer to check on other service providers, etc.).
their feet regularly, or seek regular professional Generally, the elderly can be divided into three
assessment. groups in respect of risk status: high risk,
The best way to assess an individual's ability medium risk and low risk (Table 18.11). What
to perform basic foot care tasks is to observe
them being performed. Practitioners should
spend some time with patients looking for Table 18.11 Definitions of elderly risk groups
signs of difficulty reaching feet, putting on High risk Patients with systemic pathology presenting a
shoes and hosiery, and problems with manual risk to foot health (e.g. diabetes mellitus,
dexterity (e.g. arthritis of fingers). This can often Cushing's disease, leukaemia, anaemia, etc.)
Patients with existing foot ulceration or other
be determined during the course of a normal loss of lower limb tissue viability
consultation: Patients who have a history of falls
Patients with peripheral vascular disease
• Is the patient able to take off and put back on Patients with peripheral neuropathy
her own shoes and hosiery? Patients with hip joint pathology or prosthesis
Patients who are bed-ridden
• Can the patient touch areas of her feet? Malnourished patients
• Is the patient able to manipulate a pair of Patients taking certain medications (steroids,
scissors / nippers? anticoagulants, anticancer drugs, etc.)
Patients with severe cognitive impairment
• Can the patient manage the use of a file? Patients unable to self-care with poor carer
• Can the patient apply a cream to the foot? support
• Is the patient able to change a dressing on her Infirm or frail people living alone
Poor patients
foot? Socially isolated patients
It is important for the practitioner observing Medium risk Patients with poor skin quality or skin disease
Patients with thickened nails
these skills to bear in mind that conditions in the Patients with calluses or corns
patient's own home may be totally different to Patients with toe deformities
those in the clinical environment. Patients may Immobile patients
Patients with superficial fungal infections of
find it easy to manage their feet while seated in a skin or nail
podiatry chair, but find the same tasks difficult in Patients unable to self-care with adequate
an armchair or on a sofa or bed. carer support
Low risk Patients with mild foot pathology
Patients with good circulatory status
RISK ASSESSMENT AND THE Patients with good neurological status
ELDERLY Independent patients or those receiving good
levels of home care
Limited resources for public podiatry services Mobile patients
Patients with good personal care/hygiene
have resulted in attempts to prioritise services to
466 SPECIFIC CLIENT GROUPS
becomes clear when looking at these definitions • existence of a valid risk assessment protocol
is that most podiatry departments are already • patient understanding of the process
focusing on those at greatest risk. • compliance of the patient with advice
Several providers of foot health services have • availability and motivation of carers (where
attempted to use risk 'scoring' methods to make appropriate)
decisions on eligibility for podiatry services. • awareness of CPs (and others) of the
These criteria are often rigidly applied, allow no protocols / eligibility for re-referral
professional discretion and are sometimes • ability to reassess/review risk status as required.
administered by people other than those spe- Even the most effective risk assessment proto-
cialised in the assessment of the lower limb. col fails from time to time and patients who were
Where risk assessment protocols are used, it is identified as low risk may develop serious
important for practitioners using such protocols pathology. Where risk assessment does fail,
to be able to obtain second opinions, and identify departments need to ensure that patients can
patients who they feel are at risk but who do not receive rapid assessment and treatment to
fit the 'rigid' criteria. prevent the likelihood of significant adverse con-
Risk assessment of the elderly is further com- sequences.
plicated by the fact that elderly people tend to It is impossible to be completely certain when
deteriorate much faster than young people. An assessing the risk of individuals, particularly the
elderly person who seems quite fit today may be old. Health providers need to weigh up the costs
infirm or ill tomorrow. This effect can have dev- (personal, social and economic) of risk assess-
astating consequences for foot health where a ment with the costs of universal provision of
patient is under the impression that they are no podiatry services.
longer eligible for foot care.
Reassessment of the elderly patient is neces-
SUMMARY
sary at regular intervals. Risk status changes with
corresponding changes in general health status, This chapter has examined a range of factors that
physiological changes and social circumstances. are pertinent to the assessment of the elderly.
Even changes in time of the year can have a pro- Although the overall assessment process for the
found effect on risk status. For example, during elderly should be no different to that of any
the summer a patient may appear to have ade- other age group there are specific factors that
quate peripheral circulation, but the same patient should be taken into consideration. It is essential
might assess as high risk during the winter when that practitioners are aware that any assessment
circulation deteriorates. of the elderly provides a snap shot of the elderly
The most effective risk assessment protocols person at the time of the assessment. In view of
have used qualitative descriptors of risk rather the ageing process and increased risk of acquir-
than rigid/quantitative risk-scoring mecha- ing a range of diseases the status of the elderly
nisms. Effective risk assessment is dependent person may change from low to high risk within
upon the following: a relatively short period of time.
REFERENCES
Bennett G C J, Ebrahim S 1995 health care in old age, 2nd people. Journal of the American Podiatric Medical
edn. Arnold, London Association 85(5): 255-259
Clearing House's web site: Hansard 1998. HMSO, London
(http://www.leeds.ac .uk Inuffield I infoservices IUKCH I Harvey I, Frankel S, Marks R, Shalom 0, Morgan M
home.html) 1997 Foot morbidity and exposure to chiropody:
Crawford V L S, Ashford R L, McPeake B, Stout R W 1995 population based study. British Medical Journal 315:
Conservative podiatric medicine and disability in elderly 1054-1055
ASSESSMENT OF THE ELDERLY 467
Mahoney F I, Barthel D W 1965 Functional evaluation: the Chiropodists & Podiatrists Annual Conference,
Barthel Index. Maryland State Medical Journal 14: Commonwealth Institute, London, May 2000
61-65 Turner W A, Campbell J A, Milns D 2001 The cruelest cut?
Plummer E S, Albert S G A 1996 Focused assessment of Effects of podiatric discharge on 5000 'low risk' elderly
foot care in older adults. Journal of the American people over two years. Podiatry, People & Politics
Geriatrics Society 44: 310-313 Conference, University College, Northampton,S April 2001
Turner W A, Campbell J A, Milns D et al 2000 Prevalence of Wei J Y 1992 Age and the cardiovascular system. New
foot problems amongst the elderly. Society of England Journal of Medicine 327(24): 1735-1739
CHAPTER CONTENTS
Introduction 469
INTRODUCTION
Corrective surgery can provide a resolution to
many chronic foot conditions that have tradition-
ally been treated by conservative care, e.g. ingrown
toe nails, hammer toes, hallux abductovalgus.
The majority of surgical procedures on the foot
performed by podiatrists in the UK are undertaken
on an elective basis under local or regional anaes-
thesia rather than general anaesthesia. This
chapter focuses on the assessment of patients
having surgery under local anaesthesia. Many
texts assume preoperative assessment means
surgery to be performed under general anaesthe-
sia. Such texts may state that, for example, the
insulin-controlled diabetic patient is not fit for day
surgery. However, as long as the insulin-diabetic
patient has been appropriately assessed and there
are no major contraindications it is possible to
undertake surgery under local anaesthesia on an
outpatient basis. Moreover, early and effective
intervention in the diabetic could prevent later
amputational and salvage surgery.
The process of surgery can be broken down
into three distinct phases: the pre-, intra- and
postoperative phases. These phases are collec-
tively known as the perioperative period and
may overlap and vary in relative importance,
depending on the individual patient and the
nature of the planned surgical procedure. The
overall results of surgery depend upon the
effective assessment and management of each
phase. Table 19.1 identifies the key issues in the
assessment process.
469
470 SPECIFIC CLIENT GROUPS
Table 19.1 The preoperative assessment process functioning within normal limits and, if not,
Diagnosis
to facilitate the management of this
• Information from the primary patient assessment • arrive at an informed position regarding the
• What is the diagnosis? medical appropriateness of the planned
• What are the important facets of the history?
• What further investigations are required?
surgical procedure
• identify any factors that may contraindicate
Fitness for surgery
• Is the patient fit for surgery? surgery or place the patient 'at risk'.
• Are there any concomitant diseases that increase the
perioperative risk? At the end of the assessment the practitioner
• Is the patient on any drugs that could influence the surgical will have an opinion in his mind as to whether
outcome? the patient is fit for surgery. This will allow the
The anaesthetic practitioner to proceed knowing that the risk of
• Local anaesthetic (or general anaesthetic) encountering an intra- or postoperative compli-
• Which technique will be used?
cation has been reduced to a minimum.
The operation
• What is the surgical plan? An inadequate assessment of the patient's
• Does the surgery itself pose any special problems? health status may have serious consequences for
• Has informed consent been obtained? the surgical patient.
After the operation The patient is placed at risk. Inappropriate or
• Can any problems be anticipated?
• Have redressing appointments been arranged?
unsafe surgery is performed because of inade-
quate knowledge of the patient's medical history.
Surgery carried out on patients with certain sys-
temic pathologies carries an increased risk of
postoperative morbidity. Medical disorders can
PREOPERATIVE ASSESSMENT complicate surgical practice in various ways: e.g.
a patient with rheumatoid arthritis on steroid
Clear communication between the practitioner
therapy is prone to impaired healing and infec-
and the patient is vital and forms the basis of
tion. An occult condition may manifest under the
informed consent, which is a prerequisite to any
stress of surgery: e.g. a cerebrovascular insult
invasive procedure. The decision to recommend
may occur intraoperatively in patients with un-
surgery to the patient is taken in light of the pre-
diagnosed hypertension. Invasive treatment on
senting problem after non-surgical treatment
haemophiliacs or patients taking anticoagulant
options have been tried (or at least considered)
therapy requires special consideration because of
and when the potential risks and benefits of
the likelihood of very slow blood clotting and
invasive techniques have been calculated in the
haemorrhage. The use of postoperative analge-
surgeon's mind. It is the responsibility of the
sia, especially if obtained on group protocol,
practitioner to determine the most likely diag-
requires that the practitioner is familiar with the
nosis of the problem based on a detailed history
indications, contraindications, interactions and
taking and physical examination. Appropriate
side effects of the analgesic medication.
laboratory investigations and diagnostic
The surgeon is placed at risk. The practitioner
imaging support and confirm the provisional
will inevitably encounter blood and tissue fluids
diagnosis.
on a regular basis. Inadequate history taking
with regard to identifying known or potential
The purpose of the preoperative assessment blood-borne diseases such as hepatitis B places
the practitioner and his assistants at risk.
The purpose of the preoperative assessment is to:
An increased risk of clinical emergencies. A
• review the history of the presenting illness or number of intraoperative emergencies, such as
complaint hypertensive crises, can arise. A detailed pre-
• review the major systems of the body and operative assessment should identify those at
ascertain whether these systems are greatest risk.
PRE- AND POSTOPERATIVE ASSESSMENT 471
reactions, either by the patient or any member of general practitioner (GP) to allow surgery to
the patient's family, to previous local anaesthetic proceed with relative safety. Drugs that alter
injections and other drugs (e.g. penicillin) should platelet function include aspirin, nonsteroidal
be sought and explored. anti-inflammatory drugs (NSAIDs), steroids and
Steroids such as prednisolone are commonly antihistamines. With patients who regularly take
used in the treatment of asthma, obstructive aspirin it may be necessary to cease its use
airway disease and rheumatoid arthritis. They because of delayed clotting after surgery. If
have three main effects, which can be of impor- aspirin use is to be stopped, with the consent of
tance during the perioperative period: the patient's GP, in order for surgery to proceed,
it should be done so 1 week before surgery. It
• suppression of the hypothalamus/pituitary
should be noted that women who take oral con-
adrenal (HPA) axis
traception carry a slightly increased risk of post-
• poor wound healing
operative DVT formation.
• a predisposition to infection.
The use of all recreational drugs should be
There will be a suppression of the HPA if the recorded. Patients who use injectable drugs are at
patient has taken more than 7.5 mg/ day of pred- a higher risk of hepatitis and human immuno-
nisolone for more than 1 week. In such instances, deficiency virus (HIV). Long-term or heavy use of
consideration must be given to the administra- tobacco can affect wound healing due to the
tion of exogenous steroids to prevent hypoten- immediate vasoconstrictive effect of nicotine as
sion or cardiovascular collapse. For minor well as the long-term effect of increased platelet
procedures a typical regimen would be 15 mg PO adhesiveness and atherosclerosis. Tobacco
(by mouth) at 6 a.m. on the day of surgery; and smokers are also at greater risk of bronchitis,
the same dose 12 and 24 hours later. asthma and lung cancer. Heavy alcohol consump-
Anticoagulants are used in ischaemic heart tion can affect peripheral sensation, immune
disease, mitral stenosis, atrial fibrillation and in response, postoperative healing and the metabo-
the prevention of postoperative thrombosis for- lism of local anaesthetics, as well as having impli-
mation. Heparin inhibits the intrinsic clotting cations for treatment compliance.
pathway and is used in the short-term prophy-
laxis of DVT. Warfarin inhibits the extrinsic clot- Past medical history
ting pathway and is used in long-term therapy.
The past medical history consists of information
The use of an oral anticoagulant has obvious
about previous lower limb problems and the
implications if surgical treatment is planned
treatment received, as well as details about any
(Case history 19.1). Adjustment of the dosing
problems that have affected the patient's general
regimen can be undertaken by the patient's
health. The nature of previous treatment, the
name of the practitioner, details of relevant inves-
Case history 19.1 tigations such as X-rays and the patient's view of
the treatment success should be recorded. This
A 54-year-old lady presented with an interdigital corn
that has failed to respond to many years of palliative
information may prevent the repetition of tests or
treatment. The history and physical examination treatments which have previously been ineffec-
revealed that she suffered from atrial fibrillation for tive. Of particular interest is the operative history
which she took warfarin (to prevent ventricular
thrombosis).
of the patient. In an audit of an NHS surgical
Outcome: surgery was indicated for the patient. At caseload, 10% of patients were referred for revi-
first assessment her INR was 4.1. In consultation with sionary surgical intervention.
her general practitioner, her dosage was adjusted to
reduce the INR to below 2.5. Surgery was carried out
with the INR 1.9 on the day. The postoperative Home circumstances
course was unremarkable and the patient was
discharged after the 12-week follow-up visit. It is important to assess the patient's home situ-
ation. In the case of surgical treatment, the prac-
PRE- AND POSTOPERATIVE ASSESSMENT 473
\-------------------------,
titioner must establish who is going to transport
the patient to and from surgery and who is I Case history 19.3 !
going to assist her through the immediate post- A 47-year-old publican attended for a surgical
operative recovery period. Lack of home opinion. He suffered from a complex digital
deformity and the preoperative assessment
support may rule out surgical intervention indicated that he required extensive digital and soft
(Case history 19.2). tissue reconstruction. While discussing his
occupation as a landlord, the patient expressed his
~------------------·---l intention to return to bar work the evening followinq
I Case history 19.2 I surgery. He equated the surgery he was to receive
as akin to that of a tooth extraction under local
A 59-year-old widow was referred for treatment for a anaesthesia from a dentist. Clear (and written)
tailor's bunion. Palliative treatment did not control the advice was given regarding the need to rest in the
symptoms. A preoperative assessment was postoperative period.
undertaken with a view to performing a metatarsal Outcome: the patient did not comply with the
osteotomy of the fifth metatarsal head. The patient advice given. He presented at his first redressing
lived alone and had no children. The only home appointment with marked forefoot swelling and pain -
support the patient was able to organise was from more than would have been expected from the
neighbours. This support was not very reliable as the procedure performed. The final result was a less than
neighbours were out at work all day. satisfactory 'sausage toe', through a failure to take
Outcome: the typical postoperative course is to appropriate advice. This example highlights the need
rest completely for 2 days and to be on 'light duties' to document the advice given to patients during the
for between 2 and 4 weeks. Patients are asked not to perioperative period to protect the surgeon from
perform any household duties and to have someone litigious action.
to stay with them for the first 2 days in case an
emergency should arise. In view of the lack of home
support, surgery was not offered to the patient.
infection. In particular, travel to tropical coun-
tries and any foot injuries sustained while
Occupation walking barefoot should be recorded. Many
countries have a higher incidence of HIV than
A patient's occupation may be a contributory
the UK. A history of blood product transfusion
cause of the lower limb problem and may
abroad could, therefore, be important.
influence whether surgery could or should be
offered. Some patients may experience particular
difficulties in taking time off from work to attend The systems enquiry
for treatment and need to be aware of the vari-
The cardiovascular system
able amount of time needed to recuperate from
surgery (Case history 19.3). The patient who A history of cardiovascular disease should be
cannot or will not devote the time to heal after taken with respect to systemic, peripheral and
surgery is not a good surgical candidate. haematological disease states, followed up by a
review of symptomatology.
Patients with ischaemic heart disease (IHD)
Sports and hobbies
may present with a history of previous myocar-
Details of any sporting hobby should be sought dial infarction (M!), stable or unstable angina or
from the patient. As indicated in Case history 19.3, a history of previous coronary artery bypass
the patient needs to devote time to postoperative graft (CABG). A detailed history must be taken
healing, and therefore cessation of sporting activ- of all patients who have suffered previous
ity must be emphasised to the patient. cardiac problems or have high-risk factors
such as obesity, hypertension, shortness of
breath on exercise, smoking or a family history
Foreign travel
of cardiac problems. Ten percent of patients
Details of foreign travel should be recorded in over 50 years old presenting for non-cardiac
case the patient has acquired an unusual foot surgery had previously suffered MI. This is
474 SPECIFIC CLIENT GROUPS
significant because there is a known risk of re- jugular venous pulse or pulmonary oedema. As
infarction in the perioperative period. The rela- patients who undergo procedures under local
tive significance of that risk is dependent on the anaesthesia frequently experience considerable
time elapsed since the first MI. A quarter of stress from fear and apprehension, those in
patients presenting for non-cardiac surgery are cardiac failure represent a high risk of an
likely to have another MI if less than 3 months adverse perioperative cardiac event. Conduction
has passed since their first attack. However, if defects represent a low risk in elective foot
more than 6 months is allowed to elapse, the surgery under local anaesthesia; however, the
incidence of repeat MI falls to less than 5 in opinion of the general practitioner and anaes-
every 100 patients. thetist is useful.
Angina may be classified as stable or unsta- Patients with a history of fainting attacks may
ble. Stable angina takes the form of chronic, pre- require specific assessment before any elective
dictable, exertional chest pain. In these surgery under local or general anaesthesia.
circumstances, when there is no history of a pre- Patients will often offer a history of palpitations,
vious MI, and other risk factors are absent, the 'missed heart beats' or fainting attacks. Any
risk of perioperative MI is low provided that the patient who gives a history suggestive of an
patient is not exposed to any excessive stress. arrhythmia should have an electrocardiogram
The patient's anti-anginal medication should be (ECG) that can then be carefully assessed by a
continued perioperatively. An assessment needs cardiologist prior to local anaesthesia.
to be taken of how the patient will respond to Major heart valve disease is becoming rarer
having surgery under local anaesthesia - in but a heart murmur is still a regular finding in
other words, while the patient is awake. Some routine medical examinations. Most murmurs
patients may find this very stressful and, there- are related to turbulent flow of blood in the heart
fore, would be considered unsuitable. Unstable and are not significant and do not represent
angina is characterised by increased frequency, heart valve damage. A history of valvular heart
severity and duration of painful attacks that is disease is of concern because it carries a risk of
not easily controlled by their medication. bacterial endocarditis, CHF and MI. The
Angina of recent onset, angina at rest or with American Heart Association recommendation
minimal exertion or angina awakening the for cases with mitral valve prolapse and a
patient from sleep should also be considered detectable murmur is that antibiotic prophylaxis
unstable. Such unstable angina symptoms carry should be prescribed in all procedures where a
the same perioperative risk as having had an MI transient bacteraemia is created. In the main,
in the previous 6 months. Surgery is contraindi- bone surgery on the foot is clean and prophy-
cated until the angina has been stabilised by laxis is not required. Antibiotic prophylaxis is,
medical or surgical means. however, required in nail surgery where there is
A history of CABG should also be taken into paronychia or in any incision and drainage pro-
consideration. In essence, these patients have cedures of infected tissue.
had their symptoms controlled by surgery but Well-managed, mild to moderate hypertension
they may still have limited cardiac reserve and poses no increased perioperative risk, although
may not be able to respond well to the additional in all cases hypertensive medication should be
stress of surgery. continued perioperatively. Treated hypertension
Patients in congestive heart failure (CHF) is associated with ischaemic heart disease and
have diminished cardiac reserve and do not stroke. In cases of uncontrolled hypertension, the
respond well to perioperative stress. CHF carries patient may present with a variety of symptoms,
a high perioperative risk of MI in patients including headaches, transient visual impair-
undergoing general anaesthetic and therefore ment, anorexia or even nausea. Two very
elective surgery must be avoided in patients pre- significant findings are impaired renal function
senting with third heart sounds, an elevated manifesting clinically as proteinuria and/or
PRE- AND POSTOPERATIVE ASSESSMENT 475
retinopathy. All patients who have blood pres- Haemophiliacs and other patients with clot-
sures above 160/95 on more than one occasion ting abnormalities require thorough history
should be investigated and treated prior taking. Enquire about bruising, nose bleeds and
to surgery. Diastolic pressures greater than any previous surgical problems. Further studies
120 mmHg are of grave concern and contraindi- that will be indicated include a platelet count and
cate any surgical intervention; they require bleeding time.
urgent medical referral. Sickle-cell disease affects those of African or
A comprehensive literature review regarding West Indian descent. It is an autosomally inher-
perioperative considerations of the patient with ited haemoglobinopathy resulting in the forma-
cardiovascular disease has been performed by a tion of haemoglobin S (HbS) instead of HbA.
member of the Trent Region Podiatric Forum, Small changes in oxygen tension cause HbS to
and is presented in Table 19.3. polymerise and form pseudocrystalline struc-
Anaemia represents a reduction in the oxygen- tures, which distort red blood cells into the char-
carrying capacity of the blood. Since there are mul- acteristic sickle shapes. Sickle cells increase blood
tiple causes and types of anaemia, preoperative viscosity and obstruct microvascular blood flow,
consultation is appropriate. Both cardiopulmonary leading to thrombosis and infarction. A compre-
integrity and wound healing are dependent on hensive literature review regarding the use of
tissue oxygen levels. Anaemia is rarely a con- tourniquets in this condition has been under-
traindication to surgery unless it is of a severe taken by a member of the Trent Region Podiatric
magnitude. Haematocrit values below 30 are con- Forum, and is presented in Figure 19.1.
sidered insufficient for elective foot surgery. For a surgical wound to heal uneventfully, ade-
quate peripheral circulation is a prerequisite.
Assessment of the vascular status of the lower
Table 19.3 Surgical recommendations for the limb is covered under physical examination, and
cardiovascular patient (information included with thanks to
Dr T Kilmartin of the Trent Forum) in detail in Chapter 6.
New Patient
Afro-caribbean
Asian
Mediterranean
Have you been
screened or tested for
sickle-cell disease?
Arrange appointment
with sickle-cell service
for screening and issue
of risk card
Consider
alternative care:
• orthotics
• clinopody
• referral on
Surgery
Tourniquet as necessary
without
Examination of the
tourniquet foot prior to inflation
of the tourniquet
Figure 19.1 Decision-making algorithm for patients with sickle-cell anaemia (with thanks to Mr C Bicknell of the Trent
Forum).
Confirmation of kidney disease requires specific reducing red blood cell viscosity. Elective surgery
investigation. Screening urinalysis remains the should be avoided in diabetic patients with blood
classic measurement of renal performance sugar values greater than 200 mg/dI. Chronic
(Ch. 13). Abnormal findings include the pres- hyperglycaemia greatly increases the risk of post-
ence of glucose, protein, ketones, bilirubin, operative infection. The use of haemoglobin AlC,
more than four red or white blood cells per an index of hyperglycaemia, is helpful in evaluat-
field, bacteria, casts and crystals. Surgery ing trends in diabetic control. Inadequate nutrition
should be postponed until renal function is and reduced total plasma albumin have been
stabilised. shown to deter wound healing in patients with
diabetes and should be normalised preoperatively
when possible. Diabetics with a propensity
The central and peripheral nervous system
towards ketosis require intraoperative intravenous
Diseases of the nervous system may cause pain insulin and monitoring. Wide blood sugar varia-
in the lower limb, deformity or gait abnormali- tions are associated with unpredictable healing
ties. The significance of some symptoms in the ability and an increased surgical risk. A patient
neurological enquiry will be very difficult to who is taking multiple medications is more prone
interpret because the enquiry relies on the to drug interactions, which may also affect dia-
patient's subjective account. However, inade- betes management.
quate assessment of the neurological basis of foot General anaesthesia creates a greater perioper-
pathology can lead to inappropriate surgical ative risk because of increased insulin demands,
intervention through a missed diagnosis. A the risk of silent MI, nausea and vomiting, and
detailed assessment of the peripheral nervous delays in food and oral medication intake. Early-
system can be found in Chapter 7. morning surgery allows the optimal equilibrium
between insulin dose and caloric intake, with
immediate oral nutrition postoperatively.
Endocrine system
Diabetes, thyroid disease, growth disorders,
The locomotor system
obesity and problems associated with the
menopause are particularly relevant. Diabetes To determine the presence of musculoskeletal
mellitus is a complex systemic disease that may disease the patient should be asked if they have
manifest as vascular, neurological, dermatologi- ever had:
cal and structural changes in the foot and lower
• any form of arthritis
leg. The perioperative goal is to reduce hypo- or
• back, hip, knee, ankle or foot pain
hyperglycaemia. In the normal subject, hypergly-
• fractured bones in the legs or feet
caemia activates insulin production, but in the
• pulled or injured muscles in the legs
diabetic this feedback control loop is defective.
• joint swelling or stiffness
Surgical stress causes a catabolic reaction, result-
• limb pain during any specific activity.
ing in glucagon, adrenaline (epinephrine) and
cortisol secretion. Blood glucose levels rise and Arthritic patients may be considered to include
other fuel pathways are mobilised. persons with single-joint osteoarthrosis and
The practitioner should ensure that a good those with more complex multiorgan arthritides,
metabolic balance is obtained preoperatively. including rheumatoid arthritis, systemic lupus
Avoidance of the extremes of hypoglycaemia or erythematosus (SLE) and seronegative arthritis.
hyperglycaemia will help optimise wound healing Osteoarthrosis. There are no specific perioper-
and host defence function. Hyperglycaemia ative considerations for the management of the
impairs wound healing by retarding wound osteoarthritic patient. However, the patient may
closure, delaying wound contraction, slowing col- be on a range of analgesic and anti-inflammatory
lagen synthesis, impairing granulocytes and preparations, which must be considered in the
478 SPECIFIC CLIENT GROUPS
body. Because surgical techniques require their Where surgery is still indicated, the use of a
use, any contraindication to local anaesthetics general anaesthetic should be considered and the
must be identified. The following contraindica- patient referred.
tions should be considered:
Unstable epilepsy. High blood levels of local
Psychiatric status
anaesthetic agents are known to cause convul-
sions in some epileptic patients through their Patients approach surgery with an understand-
action on brain tissue. Their use is therefore best able amount of fear and anxiety. They know that
avoided in such individuals. they will be in an unfamiliar environment to
Methaemoglobinaemia. Methaemoglobin is a which they are unaccustomed. Some fear that
form of haemoglobin consisting of globin with they will experience pain during the operation.
an oxidised haem-containing ferric iron. Met- Most of their anxiety is down to inadequate
haemoglobin is unable to transport oxygen and knowledge based on hearsay and rumour.
therefore compromises cardiovascular function. During the preoperative assessment it is impor-
When prilocaine is metabolised by the liver, small tant that the practitioner recognises the hyper-
amounts of a chemical called O-toluidine are pro- nervous patient and provides appropriate
duced which inhibits the enzyme involved in the information and counselling to allay any concerns.
conversion of methaemoglobin to haemoglobin. However, it is important that the practitioner
In patients with known methaemoglobinaemia, recognises when a patient is unsuitable for surgery
an alternative local anaesthetic agent to prilocaine under local anaesthesia and, if surgery is neces-
should be utilised. sary, refers the patient for general anaesthesia.
Pregnancy and breastfeeding. The British
Medical Association suggests that drugs should
Age
only be used during pregnancy where the poten-
tial benefit outweighs the risk of harm to the Older patients. An increasing percentage of the
fetus, particularly during the first trimester population is over 65 years of age, a trend that is
where all drugs should be avoided if possible. expected to continue well into the 21st century.
There is no specific guidance on the risks associ- Independent ambulation is an important compo-
ated with the low doses of local anaesthesia used nent of wellness, although a majority of patients
in the foot of a pregnant woman. However, over the age of 65 complain of foot pain limiting
because of the ability of local anaesthetics to their activity. In geriatric patients who have foot
cross the placental barrier, they are probably best conditions which can be surgically corrected, and
avoided whenever possible during pregnancy. If where the physical condition is satisfactory,
a local anaesthetic were to be given during preg- surgery can safely be performed. The chronolog-
nancy it would seem prudent to avoid prilocaine ical age of the patient is less important, as long as
hydrochloride, as fetal haemoglobin is more sus- the physiological age of the patient is adequate
ceptible to the development of methaemoglobi- for the planned surgical procedure.
naemia. Both lidocaine (lignocaine) and The problems of surgery on the older patient
bupivacaine are considered safe for use with include:
breastfeeding mothers, as the quantities secreted
• an adverse physiological status
into breast milk are small.
• impact of surgery on the patient's lifestyle
Porphyrias. The porphyrias are a group of
• selection of the operative procedure - simple
metabolic disorders. Included in the list of drugs
procedures versus complex procedures - even
contraindicated for use in patients with por-
though the latter would give a better result.
phyria are some local anaesthetics. These drugs
must therefore be avoided in known carriers of Generally, in the older patient, it is found that
the porphyrogenic gene to avoid precipitating an destructive rather than functionally reconstruc-
acute attack. tive procedures are often more appropriate.
480 SPECIFIC CLIENT GROUPS
--------------------------------------------------------------------------------------------
Children. Attention to the child's psychology, haemoglobin levels - blood sampling is most cer-
patient-parent relationships and stress levels is tainly indicated.
important in the surgical treatment of the paedi- The patient on anticoagulant therapy has
atric patient. Parental presence during the opera- already been discussed. Similarly, patients who
tion may be beneficial. suffer from clotting abnormalities also require
further investigation (Table 19.5).
Radiographs. Radiographs are vital to the
Infection
surgeon for a number of reasons:
In general, the elective procedure is performed
when the patient is free from all systemic infec- • they allow the identification of many
tion. A patient with established infection rheumatological, metabolic, endocrine and
that does not respond to oral antibiotics infective disease states
and appropriate wound care demands a thor- • they allow the progression of deformity to be
ough preoperative evaluation and specialty monitored
consultation. • they show the precise relationship between
osseous anatomical structures that are of
particular interest to the surgeon
Laboratory investigations and • they aid in the selection of the most
imaging modalities appropriate surgical technique
• they demonstrate the position of retained
Urine testing. As indicated in Chapter 13, uri-
internal fixation and are used to confirm
nalysis is an aid in the diagnosis of renal
bone healing in the postoperative phase.
disease, hepatic disease and diabetes mellitus.
Diabetes mellitus can have widespread conse- The identification and use of angular relation-
quences for the lower limb and is of particular ships, or charting, between the foot bones has
interest to the surgeon. Renal and hepatic dis- become a key skill of the podiatrist.
eases may have serious systemic repercussions Osteoporosis begins in middle life and is pre-
and, if identified, require further investigation dominantly a disease of postmenopausal
before it is safe to proceed with surgery. women. Histologically, bone formation is
Urinalysis is therefore useful in the preoperative normal, but bone resorption is increased. If pre-
assessment of patients to screen for illnesses operative radiographs suggest significant osteo-
which may complicate or contraindicate elective porosis, systemic disease is likely and multiple
procedures. Screening for a urinary tract infec- contributing factors, including dietary deficien-
tion (UTI) or the presence of bacteria in urine cies, endocrine imbalances, sedentary lifestyles
can also identify those patients at increased risk and genetic predisposition, may be implicated.
of developing postoperative wound infections. The implications for the fixation of osteotomies
Testing is non-invasive and cost-effective, and are clear. Radiographic assessment is covered in
urine specimens are easily obtained. Chapter 11.
Blood analysis. The use of blood analysis in the
preoperative assessment of the surgical patient is
a matter for debate. Routine screening prior to
surgery is likely to reveal a small percentage of
Table 19.5 Common clotting abnormalities
abnormality, most of which is insignificant to
anaesthetic or surgical management in any case. von Willebrand's disease
Therefore, the general rule for the use of Haemophilia
Type A - classical haemophilia
confirmatory diagnostic testing should apply: Type B -Christmas disease
their use is indicated from the initial patient Type C - PTA (plasma thromboplastin antecedent)
assessment. In cases where systemic pathology is deficiency
Vitamin K deficiency
known or suspected - e.g. in anaemia to ascertain
PRE- AND POSTOPERATIVE ASSESSMENT 481
When examining the wound postoperatively, alone, or with analgesic medications to raise
the surgeon is expecting to see: pain thresholds postsurgically.
Injections of a long-acting local anaesthetic
• an intact wound that shows no sign of
immediately after surgery are commonly per-
dehiscence
formed and will delay postoperative pain for
• a 'normal' amount of inflammation
some time. Combinations of opioid analgesics
• no sign of excessive bleeding, oedema or
and NSAIDs, however, provide the mainstay of
haematoma formation
postoperative pain management. Paracetamol
• the position maintained if any reconstructive
may be combined with opioid analgesics, such as
technique has been performed.
codeine, to gain enhanced analgesia. while
Meticulous suturing technique combined NSAIDs may be added to an opioid regimen to
with anatomical dissection, adequate haernosta- provide additional anti-inflammatory and intrin-
sis and careful skin handling are important to sic analgesic effects.
reduce the incidence of these complications. During the postoperative period, the patient
When the sutures are removed it is important to should be asked about pain levels and details of
check the healing of the wound edges by gently their responses recorded. There are several tools
applying tensile force across the area. available to assess pain, including visual ana-
Dehiscence will require further support of the logue scoring and complex questionnaires such
wound until the area has regained its mechani- as the McGill Pain Questionnaire (Ch. 3). The use
cal strength. of (or lack of) prescribed analgesic medication
should also be discussed. The most common
causes of excessive postoperative pain in the first
Evaluation of pain
week after surgery are excessive swelling within
The degree and severity of pain in the postoper- a restrictive dressing or cast and haematoma for-
ative period depends on: mation. Extreme levels of pain occurring in the
second postoperative week, 'returning pain', are
• the physiological and psychological make-up
suggestive of infection. A suspicion of
of the patient and his tolerance of pain
haematoma formation or infection requires
• the site and nature of the operation
prompt intervention and management.
• the amount of surgical trauma.
Pain reflects not only tissue injury but also
SUMMARY
represents a psychological dimension to suffer-
ing. Much unnecessary suffering may be The continuum of surgical care encompasses the
avoided by the reduction of preoperative pre-, intra- and postoperative phases. Careful
anxiety. Simple, clear and honest communica- attention to detail during each phase is essential
tion with the patient should include an explana- for the achievement of a successful surgical
tion of what will happen and when it will outcome. The approach outlined in this chapter
happen, and can have a positive influence on will ensure that a broad range of factors are taken
postoperative pain levels. Certain patients may into consideration when assessing the pre- and
benefit from prescription of an anxiolytic, used postoperative patient.
FURTHER READING
British National Formulary (BNFl Updated twice yearly. Greenberger N, Hinthorn D 1993 History taking and
British Medical Association and Royal Pharmaceutical physical examination: essentials and clinical correlates.
Society of Great Britain, London Mosby Year-Book, St Louis
Forrest A P M et al 1995 Principles and practice of surgery, McGlamry E D 1992 A comprehensive textbook of foot
3rd edn. Churchill Livingstone, Edinburgh surgery. Williams & Wilkins, Baltimore
PRE- AND POSTOPERATIVE ASSESSMENT 483
O'Higgins N J et al1991 Surgical management, 2nd edn. Tally N, O'Connor S 1989 Clinical examination. Blackwell
Butterworth-Heinemann, Oxford Scientific, Oxford
Pinnock C et al1999 Fundamentals of anaesthesia. Turner R, Blackwood R 1991 Lecture notes on history taking
Greenwich Medical Media, London and examination, 2nd edn. Blackwell Science, Oxford
Seymour C, Siklos P 1994 Clinical clerking: a short Zier B 1990 Essentials of internal medicine in clinical
introduction to clinical skills, 2nd edn. Press Syndicate of podiatry. W B Saunders, Philadelphia
the University of Cambridge
Index
Anterior superior iliac spine (ASIS), purpose, 3-4 Bilirubin, urinary, 329
207,208 records, 8-9 Biochemistry, blood, 334-335
Anterior talofibular ligament (ATFL), repeat, 7-8 Biomechanics, 308
189,190 risk,4-5 Biopsy, 336-337
Anti-hypertensive drugs, 90 time management, 7 excisional. 337
Antibiotics, 321 Asthma, 66-67 muscle, 150
prophylactic, 474 Astrocytes, 115 needle, 337
sensitivity testing, 326, 327 At-risk foot, 5, 427-448 nerve, 144, 150
Anticoagulant therapy, 60, 472 assessment, see Risk assessment punch (incisional), 336-337
Anxiety, preoperative, 479 causal factors, 428-429 shave,336
Aorta, 80, 81, 88 clinical decision-making, 447-448 skin, 228
Apgar score, 345 elderly, 455 Biothesiometer, 142
Aphasia, 155 Ataxia, 114, 151, 175 Bleeding time, 332, 334
Aplasia, congenital, 281 Atenolol, 93 Blistering disorders, 231-232
Apley's compression test, 185 Atherosclerosis, 95-96 Blisters, 223, 231-232, 439
Appearance, physical, 20 coronary, 90 Blood,331
Application letters/forms, 22 in diabetes, 442 analysis, 331-335, 480
Apprehension test, 183 Atopic eczema (dermatitis), 221, biochemistry, 334-335
Arch 232-233 components, 331
height, 201, 362 Atrioventricular (AV) node, 87 coughing up, 67
index (Staheli), 362 Atrophie blanche, 107-108, Plate 5 count, full, 95, 332-333
longitudinal, 204 Atrophy film, 333
Arm muscle, see Muscle, atrophy sample collection, 332
extensors, weak, 155 skin, 223 serology, 335
swing, 168-170, 348 soft tissue, 98 in urine (haematuria), 69, 330
Arrhythmias, 64, 92 subcutaneous fat layer, 239 Blood gases, arterial, 334
surgical risk, 474, 475 Auspitz sign, 222, 231 Blood pressure, 64, 93-94
Arterial emboli, 96 Autoimmune disease, 288-289 in autonomic dysfunction, 153
Arterial insufficiency, 95-106 Autonomic nervous system (ANS), elderly, 456
seealso Ischaemia; Peripheral 87-88,122-124 measurement, 93-94
vascular disease assessment of function, 153 regulation, 88
Arterial tree, 81 Autonomic neuropathy, 153,441 seealso Hypertension
Arteries, 81, 83 Axon, 115, 116 Blood urea nitrogen (BUN), 334
ageing changes, 456 Axonal degeneration, 149 Blood vessels
aneurysms, 101 Axonotmesis, 139 anatomy, 81-84
bruits, 102 major, 80
calcification, 103, 285, 442 physiology, 88-89
Miinckeberg's sclerosis, 103,442 B skin, 218
Arteriography, 105, 392 Babinski response (plantar reflex), 145, Blount's disease, 355
Arterioles, 81, 83, 88 146,347 Body mass index (BM!), 381
Arteriovenous (A-V) anastomoses, Back pain, low, 424 Body weight (mass), 59-60
82-83 Bacteria, 320 loss, 72
Arthritis bone and joint infection, 287 preoperative assessment, 471
crystal, 420-421 culture, 228, 323-325 Bone
degenerative, see Osteoarthritis identification, 324, 325-327 cyst
enteropathic, 445 microscopy, 323 aneurysmal, 293
gonococcal, 70 skin infection, 237-238, Plate 21 solitary (simple), 292-293
juvenile idiopathic (JIA), 367, 368, in urine, 330-331 density, 282-285
369 Balance, 133 infection, 287, 288, 422
preoperative assessment, 477-478 Ball tread, 249 isotope scanning, 298-300, 392
psoriatic, 234, 445 Ballottement test, 183 metastatic disease, 285, 296
rheumatoid, see Rheumatoid Barefoot walking, 255, 260 tumours, 292-296
arthritis Barlow's test, 353 Bone marrow, MRI imaging, 296, 298,
septic (infectious, pyogenic), 422, Baroreceptor reflex, 88, 153 299
446,478 Barthel index, 462 Boots, 253-254
sero-negative, 445, 478 Basal cell carcinoma, 243 Bottoming, 250
Arthritis Impact Measurement Scales Basal ganglia, 117, 130 Bow legs, see Genu varum
(AIMS),401 dysfunction, 151 Bowel habit, altered, 68
Aspirin, 60 Beau's lines, 224, 225 Bowen's disease, 242-243
Assessment, 3-10 Behcet's disease, 445 Brachydactyly, 281, 282
components, 4, 8 Beighton scale, 352, 379 Brachymetatarsia, 201
interview,4,11-26 Bendrofluazide, 60 Bradycardia, 92
loop, 8 Beta-blockers, 60, 90, 93 Brain
process, 4-7 Bias errors, 48 anatomy, 117, 118
INDEX 487
ascending pathways, 127, 128 history, 64-66, 90 sports injury risk, 376-377
descending pathways, 127, 129 hospital tests, 94-96 weightbearing assessment, 348-350
scans, 137 observable signs, 92, 225 Chloramphenicol, 60
Brain stem, 117, 118, 128 symptoms, 90-92 Chloride, plasma, 335
Breastfeeding, 479 see also Heart disease; Hypertension; Chondrocalcinosis, 288
Breathlessness (dyspnoea), 65, 67, 91 Peripheral vascular disease; Chondromalacia patellae, 183
Brodie's abscess, 287 Venous insufficiency Chondromatosis, synovial, 293
Bromhidrosis, 227 Cardiovascular system (CVS), 80-89 Chondrosarcoma, 294--295, 411
Bronchitis, chronic, 66, 67 anatomy, 80-86 Chopart's joint, see Midtarsal joint
Brown-Sequard syndrome, 138-139 at-risk foot, 438-439 Choreo-athetotic movements, 151, 155
Bruits, 102 elderly, 455-456 Chromonychia, 224, 225, 226
Budiman-Mak Foot Function Index, 34 general overview, 90-95 Cine photography, 314
Buerger's disease (thromboangiitis physiology, 86-89 Cinema seat sign, 354
obliterans), 96, 438 preoperative assessment, 473-475 Circulation
Buerger's elevation/dependency test, Carpal tunnel syndrome, 143 collateral, 83-84
100 Cartilage, 285 peripheral (systemic), see Peripheral
Bulla, 222, 223 Casts, urinary, 330 vascular system
Bullous pemphigoid, 232, Plate 15 Catalase test, 326 pulmonary, 81, 89
Bundle of His, 87 Cauda equina, 121 Circumduction test, 178
Bunion, tailor's, 205 Cellulitis, 237-238, 422, 448, Plate 37 Clarke's test, 183
Burrow, 222 Central nervous system (CNS), 70-71 Claudication
Bursae, calcification, 285-286 anatomy, 116-119 distance, 97, 103
Bursitis, retrocalcaneal, 418-419 in posture/balance/ coordination, intermittent, 97
Buschke's disease, 290 133 Claw toe, 172,206
see also Neurological disorders Clinical environment, 45, 51-52
Cerebellum Clinical examination, 4
c anatomy, 117, 118 Clinical measurement, see
C fibres, testing, 142-143 dysfunction, 150-151, 152 Measurement
C-reactive protein (CRP), 332, 333 function, 129-130 Clinical tests, 4
Cadence, 307 Cerebral cortex, 117, 118 Clogs, 254, 255
Calcaneal stance position Cerebral palsy, 348 Clostridium welchii, 325
neutral (NCSP), 202-204 Cerebral vascular accident (CVA, Closure,24
relaxed (RCSP), 202-204 stroke), 114, 128,446 Clothing, 49
Calcaneocuboid fault, 280 loss of consciousness, 136, 137 practitioners, 20
Calcaneofibular ligament (CFL), 190 risk factors, 135 in sports assessment, 375-376
Calcaneonavicular coalition, 363, 409 upper motor neurone lesions, 146 Clotting
Calcaneus Cerebrospinal fluid (CSF), 115, 118-119 abnormalities, 480
bone density, 283 Champagne legs, 109 tests, 332, 333-334
deformity, 161 Charcot foot, 299, 403, 441-442, Plate Clubbing, 92,224,225
fractures, 291, 298 34 Clubfoot, 360
inclination angle, 279-280, 352 Charcot-Marie-Tooth disease, see one-third of, 358
position, 171 Hereditary motor and sensory Coalitions, 187,281-282
spurs, 280 neuropathy tarsal, see Tarsal coalitions
Calcification, degenerative, 285-286 Cheiroarthropathy, 443 Codrnan's triangle, 294
Calcinosis cutis, 287 Chemicals, in shoes, 253 Cognitive status, assessment, 461,
Calcium antagonists, 60,90 Chest pain, 65, 67, 90-91 463-464
Calibration, instrument, 45-46 Chest X-ray, 95 Colchicine, 60
Callus, 229-231, 439 Chilblains, 235, 369 Cold-related sports injuries, 387
elderly, 458 Children, 341-369 Collagen, 377
periungual, 226 assessment, 343-353 Collar (sports shoe), 248
Caltrac device, 316 generalapproach,343-344 Collaterals, 83-84
Candida spp., 327 initiating, 343 Colour
Capillaries, 81, 82-83 conditions affecting lower limb, nail, 225, 226
fluid flow, 86 353-369 skin, see Skin, colour
function, 89 examination, 346-352 urine, 328-329
skin, 218 footwear, 258, 352-353 wound,437
Capillaroscopy, 105 gait analysis, 59, 348, 367 Coma, 137
Capillary filling time (CFT), 100 history taking, 344--346 Common peroneal nerve, 119
Carbon dioxide, blood, 335 interviewing, 344 Communication, 12-21
Cardiac output, 87 limping, 365-368 listening skills, 15-16
Cardiovascular disease non-weightbearing assessment, non-verbal, 16-21
clinical tests, 92-94 350-352 questioning skills, 13-15
current medication, 90 normal development, 342-343 Compartment syndrome, 414-415
exercise cautions, 382 perioperative risk, 480 chronic, 391, 414-415
488 INDEX
Patellofemoral joint tests, 183 Perthes test, 109 Positron emission tomography (PET)
Patellofemoral syndrome, 377, 379, 390 Pes cavus, 173, 262, 263 scanning, 105
Patient-centred approach, 12 Petechia, 222 Post-neonatal history, 345
Patients Phalangeal fractures, 291 Post-thrombotic syndrome, 106-107,
assessment, 3-10 Phantom limb, 139 108,109
'at risk', seeAt-risk foot Phlebitis, 106, 107, 108 Posterior, 158
choice of practitioner, 31 Phlebo-thrombosis, 106 Posterior cruciate ligament, 184
confidentiality, 9-10, 25 Phonocardiography, 95 Posterior talofibular ligament (PTFL),
expectations, 6, 22-23 Photoelectric plethysmography, 105 190
measurement errors, 50-51 Photography Posterior tibial artery (tibialis
measurement techniques, 41 cine, 314 posterior)
perceptions of problems, 30 digital, 41--42, 436 patency testing, 100
records, see Records skin problems, 228-229 pulse, 51-52, 100, 101
stereotyping, 21 wounds/ulcers, 436 Postmenopausal syndrome, 440, 459
Patrick's test, 178 Physical appearance, 20 Postoperative assessment, 481--482
Pattern recognition, 5 Physical build, 380-381 Posture, 17-18, 133
Pedigree chart, 62 Physical fitness, 380, 388 approaching, 17-18
Pedobarograph,309-311 Physiological cost index (PCD, 316 contraction, 18
Pelvis Physiological measures, pain, 401 early childhood, 342
in children, 350-351 Piezogenic papules, painful, 239 expansion, 18
tilt, 170 Pigmented skin lesions, 240-242 withdrawal, 18
Pemphigus, 232 Pinprick testing, 140, 142-143 Potassium, plasma, 334
Perinatal history, 345 Piriformis test, 180 Potassium hydroxide, 228, 323
Peripheral arterial occlusive disease Piston (telescope) sign, 353-354 Pott's fracture, 291
(PAOD), see Peripheral vascular Pitted keratolysis, 238, Plate 22 Practitioners
disease Pivot shift test, 184 appearance, 20
Peripheral nervous system (PNS), Placing reflex, 347 measurement errors, 47-50
120-121 Planes, cardinal body, 157, 158 measurement techniques, 41
Peripheral neuropathy, 71, 114, 417, 446 Planimetry, wound, 436 patient's choice of, 31
diabetic, 417, 441--442 Plantar, 158 Precision, 42
elderly, 456--457 Plantar dermatitis, juvenile, 236, Prednisolone, 60
sensory testing, 140-143 368-369 Pregnancy
Peripheral resistance, 88 Plantar fasciitis, 63, 419--420 history, 345
Peripheral vascular disease (PVD, Plantar fat pad, atrophy, 410 surgery in, 471, 479
PAOD),95-106 Plantar fibromatosis, 420 X-rays in, 271
causes, 95-96 Plantar pressure sensors, see Pressure Premature babies, 345
clinical tests, 99-104 measurement sensors, plantar Premotor cortex, 128
in diabetes, 442 Plantar reflex (Babinski sign), 145, 146, Preoperative assessment, 469, 470--480
elderly, 456 347 current health status, 471
exercise in, 382 Plantarflexion, 158, 159 factors affecting surgical risk, 478--480
Fontaine classification, 97 Plantarflexors, 193 home circumstances, 472--473
history, 65-66, 95-96 Plantaris muscle, 193 investigations, 480
hospital tests, 104-106 Plaque, 222, 223 past and current medication, 471--472
observation, 98-99 Plasma, 331 past medical history, 472
symptoms, 97-98 viscosity, 333 physical examination, 478
seealso Ischaemia Platelet count (thrornbocytes), 332, 333 purpose, 470--471
Peripheral vascular system Play, 344 systems enquiry, 473--478
anatomy, 81-86 Plethysmography, 110 PREPSOCS indicators of foot
assessment, 65-66, 95-111 photoelectric, 105 infection, 437
physiology, 88-89 Podotrack plantar pressure measuring Presenting problem, 29-36
Peritendinitis, 412--413 device, 41 articulating, 30-31
Periungual disorders, 226-227 Pole test, 104 assessment,31-35
Pernicious anaemia, 89,444,460 Poliomyelitis, 114, 147, 148,446 high priority, 5
Perniosus (chilblains), 235, 369 Polycythaemia, 444 history, 31-33
Peroneal muscle atrophy, see Polydactyly, 281 patient perceptions, 30
Hereditary motor and sensory Polymyositis, 147,446 Pressure, 308
neuropathy Polyneuropathy, 134 sensation testing, 141
Peroneal muscles, 194 Polyuria, 69, 72 Pressure measurement sensors,
Peroneal spastic flat foot, 363-364, 409 Pompholyx, 233 plantar, 41, 46--47,309-313
Peroneal tendons Pons, 117, 118 dynamic range, 47
subluxing,413 Popliteal angle, in children, 355-356 platform systems, 46, 309-312
tenosynovitis, 412, 413 Porocarcinoma, 243 sampling frequency, 47
Personal space, 18-20 Poroma, eccrine, 242 in-shoe systems, 46--47,312-313
Perthes' disease, 289, 367 Porphyrias, 479 spatial resolution, 47
INDEX 497
Please complete the health questionnaire in your own time. Do you take any recreational drugs? Yes/No
Take as long as you feel you need. If there are any areas of Have you ever been injured at work? Yes/No
the form that you are not clear about, please ask the Did you have any major childhood illnesses? Yes/No
practitioner for help. It is important that we know about all If Yes, please state which ones:
aspects of your health as this may affect your legs and feet
and may be important when deciding the best form of
treatment. Family history
Does anyone in your family suffer from foot or leg problems?
Your foot/leg problem Yes/No
Have you had any previous treatment for your feet? Yes/No Please place a tick if a member of your family suffered from
Who provided the treatment? any of these illnesses:
Haemophilia 0
Were any X-rays taken? Yes/No Sickle cell disease 0
Were any blood samples taken? Yes/No Diabetes 0
Rheumatoid arthritis 0
Your general health Epilepsy 0
Are you generally well? Yes/No
Are you under a doctor or consultant currently? Yes/No Social history
Are you sleeping well? Yes/No What is your occupation?
What is your weight?
Do you participate in sporting activities? Yes/No
For women, could you be pregnant? Yes/No If Yes, please state which sports and how regularly do you
participate:
Past medical history
Has your weight recently changed? Yes/No
If yes, how has your weight changed? Heart and circulatory problems
Have you ever had:
Are you taking any medication or tablets? Yes/No A heart attack? Yes/No
If Yes, please list below: Angina? Yes/No
High blood pressure? Yes/No
Heart failure? Yes/No
Are you allergic to anything? Yes/No Irregular heart rhythms? Yes/No
If Yes, please list below: Rheumatic fever? Yes/No
A thrombosis or blood clot? Yes/No
Do you smoke? Yes/No Night cramps? Yes/No
If Yes, how many do you smoke per day? Muscle cramps when walking short distances? Yes/No
An ulcer on your leg or foot? Yes/No
Have you ever: Chilblains? Yes/No
Been off sick from work for more than a week? Yes/No Varicose veins and/or surgery? Yes/No
Been admitted to hospital? Yes/No Anaemia? Yes/No
Undergone an operation? Yes/No Hepatitis or jaundice? Yes/No
Have you ever been under the care of a hospital Haemophilia? Yes/No
consultant? Yes/No Any other blood disorder? Yes/No
If Yes, please give details: Do you suffer from:
Chest pains? Yes/No
78 SYSTEMS EXAMINATION