Evaluación del complejo

articular del tobillo – pie.

Jorge Ugarte Ll.
2021.
Complejo Pierna – Tobillo – Pie.
Funciones.
• Actúa como base de apoyo que entrega la
estabilidad necesaria para la postura erguida con el
mínimo esfuerzo muscular.

• Provee un mecanismo rotacional para la tibia y el

peroné durante la fase de apoyo de la marcha.

• Provee flexibilidad para adaptarse a un terreno

irregular.

• Provee flexibilidad para la absorción de impactos.

• Actúa como brazo de palanca para el despegue.

Anatomía aplicada.
• Articulación tibioperonea • Retropie.
distal.
• Mediopie.
• Articulación talocrural.
• Antepie.
• Articulación subtalar.
Anatomía aplicada.
• Articulación
tibioperonea
distal.

• Articulación
talocrural.

• Articulación
subtalar.
 Chapter 13 Lower Le

Cuneocuboid Joint. The cuneo

Joints of the Hindfoot synovial joint with a close packed
The movements of slight gliding
TIBIOFIBULAR JOINT at this joint.
Resting position: Plantar flexion
Calcaneocuboid Joint. The ca
Close packed position: Maximum dorsiflexion
saddle shaped with a close packed
Capsular pattern: Pain when joint is stressed
Supporting this joint are the b
TALOCRURAL (ANKLE) JOINT calcaneocuboid ligament, and the
Resting position: 10° plantar flexion, midway between inversion The movement possible at this jo
and eversion junct rotation.
Close packed position: Maximum dorsiflexion
Capsular pattern: Plantar flexion, dorsiflexion
SUBTALAR JOINT Joints of the Midfoot (Midtarsal J
Resting position: Midway between extremes of range of motion
(ROM) Resting position: Midway
Close packed position: Supination motion
Capsular pattern: Limited ROM (varus, valgus) Close packed position: Supinatio
Capsular pattern: Dorsiflex
media

Forefoot
 Anatomía aplicada. Chapter 13 Lower Leg, Ankle, and Foot 891

Cuneocuboid Joint. The cuneocuboid joint is a plane

Mediopie.
s of the Hindfoot synovial joint with a close packed position of supination.
The movements of slight gliding and rotation are possible
FIBULAR JOINT at this joint.
position: • Articulaciones
Plantar flexion
Calcaneocuboid Joint. The calcaneocuboid joint is
packed position: mediotarsianas
Maximum dorsiflexion
saddle shaped with a close packed position of supination.
ar pattern: Pain when joint is stressedde
(Articulación Chopart). Supporting this joint are the bifurcated ligament, the
CRURAL (ANKLE) JOINT calcaneocuboid ligament, and the long plantar ligaments.
position: 10° plantar flexion, midway between inversion The movement possible at this joint is gliding with con-
• Articulación
and eversiontalocalcaneoescafoidea. junct rotation.
• Articulación
packed position: cuneoescafoidea.
Maximum dorsiflexion
ar pattern: Plantar flexion, cuboide-escafoidea.
• Articulación dorsiflexion
ALAR JOINT• Articulaciones intercuneiformes. Joints of the Midfoot (Midtarsal Joints)
position: Midway betweencuneocuboidea.
• Articulación extremes of range of motion
(ROM)
• Articulación calcáneocuboidea. Resting position: Midway between extremes of range of
packed position: Supination motion (ROM)
ar pattern: Limited ROM (varus, valgus) Close packed position: Supination
Capsular pattern: Dorsiflexion, plantar flexion, adduction,
medial rotation
Anatomía aplicada.
Antepie.
892 Chapter 13 Lower Leg, Ankle, and Foot

• Articulaciones tarsometatarsianas
(Articulación de Lisfranc). Joints of the Forefoot

TARSOMETATARSAL JOINTS
Resting position: Midway between extremes of
range of motion (ROM)

• Articulaciones intermetatarsianas. Close packed position:

Capsular pattern:
Supination
None

• Articulaciones metatarsofalángicas. METATARSOPHALANGEAL JOINTS

Resting position: 10° extension
C
A
Close packed position: Full extension
• Articulaciones interfalángicas. Capsular pattern: Big toe: extension, flexion
N
Second to fifth toe: variable
•
INTERPHALANGEAL JOINTS •
Resting position: Slight flexion •
Close packed position: Full extension •
Capsular pattern: Flexion, extension •
•
Clasificación de Esguinces.
Esguince ASPECTOS CLINICOS A DESTACAR.

GRADO I Dolor, inflamación (leve), estabilidad mecánica

conservada. Estabilidad funcional en grado
mínimo.
GRADO II Dolor, inflamación, rigidez, equimosis. Estabilidad
mecánica comprometida (parcial), estabilidad
funcional comprometida.
GRADO III Compatible con ruptura total de ligamento. Dolor,
rigidez, equimosis, edema. Estabilidad mecánica
comprometida, pérdida de movimiento.
Grado III A/B IIIA: ROM >10º - Edema >2cms - Rx Stress
(Malliaropoulos, 2009) normal
Hertel.
IIIB: ROM >10º - Edema >2cms – Rx
comparativa > 3mm posición talo.

!
Lesión de los
tendones
peroneos.
Tendinosis
Aquiliana.
 Observación.
896 Chapter 13 Lower Leg, Ankle, and Foot

A B
Figure 13-5 A, Closed-chain (weight-bearing) supination of the subtalar
joint (right foot). Supination of the subtalar joint in the weight-bearing
A
foot results in motion of both the calcaneus and the talus. The calcaneus
 Observación. 898 Chapter 13 Lower Leg, Ankle, and Foot

• Supinación.

• Pronación.
898 Chapter 13 Lower Leg, Ankle, and Foot

A B
Figure 13-10 Supination (A) and pronation (B) of the (non–weight-
bearing) foot. Figure 13-9 Anterosuperior view of the feet (weight-bearing
Figure 13-9 Anterosuperior view of the feet (weight-bearing position).
position).
 Chapter 13 Lower Leg, Ankle, and Foot 899

Lateral rotation 5–18°

Observación. Outward rotation

(supination)

• Ángulo de Fick.
900 Inward
Chapter 13 LowerOutward
rotation Leg, Ankle,rotation
and Foot
(pronation) (supination)
Figure 13-11 Supination of the foot produced by lateral rotation of
the tibia. The rear foot and midfoot outwardly rotate (supinate) and
the forefoot inwardly rotates (pronates) on the midfoot. As foot is
plantar flexed, plantar fascia becomes tight along with ligaments to
provide stable foot for push off. (Modified from Richardson JK, Iglarsh
ZA, editors: Clinical orthopedic physical therapy, Philadelphia, 1994,
WB Saunders, p. 513.)

Medial rotation
Outward rotation
(supination)

Figure 13-13 Fick angle.

Inward
rotation
Index plus (pronation)Index plus-minus
Index minus cause the gait toMorton’s
Squared foot
be altered.
or
The cumulative force to
Egyptian foot
Figure 13-12 Pronation of13-14
Figure Metatarsal
the foot classification.
produced by medial rotation of which9% each foot isGreek
subjected
foot during the
69% day is the equiva-
 900 Chapter 13 Lower Leg, Ankle, and Foot
Observación.
Index plus Index minus Index plus-minus
Figure 13-14 Metatarsal classification.
asymmetry, in which case a structural deformity is
probably causing the asymmetry. Leg-heel and forefoot-
heel alignment (see the “Special Tests” section) may also
be checked, especially if asymmetry is present.
The examiner should note whether the patient uses a
cane or other walking aid. Use of a cane in the opposite
hand diminishes the stress on the ankle joint and foot by
approximately one third.
Any prominent bumps or exostoses should be noted,
as should any splaying (widening) of the forefoot. Splay-
ing of the forefoot and metatarsus primus varus is more
Squared foot Morton’s or Egyptian foot
9% Greek foot 69%
22%
Figure 13-15 Types of feet seen in the general population.
pressure), but calluses are not. Plantar warts also tend to
separate from the surrounding tissues, but calluses do not.
Corns are similar to calluses but have a central nidus.
They may be hard (on outside or upper aspect of toes)
or soft (between toes) because of moisture.
Any swelling or pitting edema within the Achilles
tendon, ankle, and foot should be noted (Figure 13-16).
If there is any swelling, the examiner should note whether
it is intracapsular or extracapsular. Swelling above the
Observación.
• Carga de peso.
• Vision
posterior.

• Signo de Helbing.
• Deformidad de
Haglund.

Figure 13-18 “Pump bumps” from tight ice skates.

 Figure 13-21 Divisions and arches of the foot (medial view).

Observación. First metatarsal

18°–25°

• Carga de peso. Second metatarsal

15°

• Vision lateral.
Third metatarsal

10°

• Arcos longitudinales medial y Figure 13-19 Lateral and medial views of the feet showing longitu-
dinal arches.
lateral. Fourth metatarsal

8°

Fifth metatarsal

5°

Figure 13-22 Angle formed by each metatarsal with the floor. (Modi-
Normal Pes Planus Pes Cavus fied from Jahss MH: Disorders of the foot, Philadelphia, 1991, WB
Figure 13-20 Footprint patterns. Saunders, p. 1231.)

intrinsic and extrinsic muscles of the foot and their on the medial side. The angle formed by each of the
tendons, which help to support the arches. The longitu- metatarsals with the floor is shown in Figure 13-22.
dinal arches form a cone as a result of the angle of the The medial longitudinal arch consists of the calcaneal
Observación.
• Supino.

• Signo de Keen.
 Deformidades más comunes del pie. Chapter 13 Lower Leg, Ankle, and Foot 907

Callus
Bursa

Exostosis
Figure 13-32 Common areas

Callus
Bursa

Exostosis
Figure 13-32 Common areas of exostosis formation in the foot. Figure 13-30 A bunionette or tailor’s bunion.

Callus
A
Figure 13-33 Forefoot deform
(metatarsal heads raised on med
heads raised on lateral side).

A Claw toe Callus

conditions such as latera
Callus
syndrome, plantar fascii
Figure 13-30 A bunionette or tailor’s bunion. drome, toe deformities,
pain (Figure 13-33, B).25
Forefoot Varus. This str
involves inversion of the
B Hammer toe
Deformidades más comunes del pie.
Chapter 13 Lower Leg, Ankle, and Foot 9

Callus
Bursa

Exostosis
Figure 13-32 Common areas of exostosis formation in the fo
Figure 13-32 Common areas of exostosis formation in the foot.
Deformidades más comunes del pie.

Plane of
metatarsal
A B heads

B C
Deformidades más comunes del pie.
ht-bearing patterns in hallux rigidus. A, Hallux
n. B, Normal gait pattern. C, Shoe develops oblique
x rigidus. (C, Redrawn from Jahss MH: Disorders of
phia, 1991, WB Saunders, p. 60.)
A B
which can lead to increased stress on the proximal
phalanx.49
A callus develops over the medial side of the head of
the metatarsal bone, and the bursa becomes thickened
and inflamed; excessive bone (exostosis) forms, resulting
in a bunion (Figure 13-36).15,50 These three changes—
callus, thickened bursa, and exostosis—make up the
A
B
Figure 13-36 A, Bunions apparent on both feet. B, S
<
8°–20° 20°–30° 20°–60°
NORMAL CONGRUOUS PATHOLOGIC
Figure 13-37 Metatarsophalangeal (hallux valgus) angle.
bunion, a condition separate from hallux valgus, although
it is the result of hallux valgus.
In normal persons, the metatarsophalangeal angle
(the angle between the longitudinal axis of the meta-
tarsal bone and the proximal phalanx) is 8° to 20° Figure
(Figure 13-37). This angle is increased to varying degrees increa
in hallux valgus.
The first type (congruous hallux valgus) is a simple
exaggeration of the normal relation of the metatarsal to aspec
the phalanx of the big toe. The deformity does not prog-
ress, and the valgus deformity is between 20° and 30°. The
rotat
becau
opposing joint surfaces are congruent. It requires little times
 tion necessary at the beginning of stance, normal supina-
tion during early propulsion may be prevented. This
deviation can contribute to conditions, such as retrocal-
caneal exostosis (pump bumps), shin splints, plantar
Deformidades más comunes del pie.
• Retropie
Valgo (Valgo Tibial line
subtalar).

Calcaneal line

• Retropie Varo
(Varo
subtalar).
A B
Figure 13-39 Hindfoot deformities (right foot). A, Hindfoot varus
(heel appears inverted). B, Hindfoot valgus (heel appears everted).
Deformidades más comunes del pie.
 (arrow).

Figure 13-44 Polydactyly (extra digit). (These digits are commonly

amputated early in life.)

indicative of a cavus foot. In its acquired form, it occurs

as compensation for tibia varum (genu varum) with
limited calcaneal eversion. This deformity can contribute
to the same conditions seen with forefoot valgus.25 The
neutral position of the first ray is the position in which
the first metatarsal head lies in the same transverse plane Head of talus
as the second through fourth metatarsal heads when they
are maximally dorsiflexed.58
Polydactyly. This developmental anomaly is character- Figure 13-46 Pes planus (flatfoot) or calcaneus in valgus can lead to
ized by the presence of an extra digit or toe (Figure misshapen shoes. Note the prominence of the talar head.
13-44). It may be seen in isolation or with other anoma-
lies, such as polydactyly of the hands and syndactyly
(webbing) of the toes or hands (Figure 13-45). The
primary concern with this anomaly is cosmesis.59
Rocker-Bottom Foot. In the rocker-bottom foot defor-
mity, the forefoot is dorsiflexed on the hindfoot. This
results in a “broken midfoot,” so that the medial and
longitudinal arches are absent and the foot appears to be
bent the wrong way (i.e., convex to the floor instead of
the normal concave).
Splay Foot. This deformity, which is broadening of the Figure 13-47 Misshapen shoes caused by severely pronated feet.
 gests a valgus or everted foot, whereas excessive bulging
on the lateral side suggests an inverted foot. Drop foot
resulting from musculature weakness scuffs the toe of the
shoe. Oblique forefoot creases in the shoe indicate pos-
sible hallux rigidus; absence of forefoot creases indicates
no toe-off action during gait.
cated testing weight-bearing ROM by putting the test
foot on a 30-cm (12-inch) stool for ease of measurement
and flexing the knee.64
Plantar Flexion
Plantar flexion of the ankle is approximately 50° (see

Movimiento activo. EXAMINATION

As with any assessment, the examiner must compare one
side with the other and note any asymmetry. This
Figure 13-50, A), and the patient’s heel normally inverts
when the movement is performed in weight bearing
(Figure 13-51). If heel inversion does not occur, the foot
is unstable, or there is tibialis posterior weakness or tight-
ness.37,65,66 The tibialis posterior muscle and tendon

• Plantiflexión.

• Dorsiflexión.

• Inversión.
A B C

• Eversión.

• Extensión hallux.

• Flexión hallux. Figure 13-48 Active movements (weight-

bearing posture). A, Plantar flexion. B, Dorsi-
flexion. C, Supination. D, Pronation. E, Toe D E F
extension. F, Toe flexion.
Movimiento activo.
Movimiento pasivo.
Passive Movements of the Lower
Leg, Ankle, and Foot
and Normal End Feel

• Plantar flexion at the talocrural joint

(tissue stretch)
• Dorsiflexion at the talocrural joint
(tissue stretch)
• Inversion at the subtalar joint (tissue
stretch)
• Eversion of the subtalar joint (tissue
stretch)
• Adduction at the midtarsal joints
(tissue stretch)
• Abduction at the midtarsal joints
(tissue stretch)
• Flexion of the toes (tissue stretch)
• Extension of the toes (tissue stretch)
• Adduction of the toes (tissue stretch)
• Abduction of the toes (tissue stretch)
Movimientos isométricos.
Resisted Isometric Movements of the Lower Leg,
Ankle,
and Foot
• Knee flexion
• Plantar flexion
• Dorsiflexion
• Supination
• Pronation
• Toe extension
• Toe flexion
Evaluación funcional.
Functional Activities of the Lower Leg, Ankle, and
Foot
(in Sequential Order)
• Squatting (both ankles should dorsiflex symmetrically)
• Standing on toes (both ankles should plantar flex
symmetrically)
• Squatting and bouncing at the end of a squat
• Standing on one foot at a time
• Standing on the toes, one foot at a time
• Going up and down stairs
• Walking on the toes
• Running straight ahead
• Running, twisting, and cutting
• Jumping
• Jumping and going into a full squat
Evaluación funcional.
• Apoyo monopodal – Levantar ortejos,
antepie.
• Apoyo monopodal – levantar talones
del suelo.
• Apoyo monopodal – levantar aspecto
lateral y medial del pie.
• Sedente – tomar y liberar un objeto
con ortejos.
• Sedente – extender ortejos.
• 10 – 15 repeticiones: funcional.
• 5 - 9 repeticiones: regular.
• 1 – 4 repeticiones: malo.
• 0 repeticiones: no es funcional.
• 5 - 6 repeticiones: funcional.
• 3 - 4 repeticiones: regular.
• 1 – 2 repeticiones: malo.
• 0 repeticiones: no es funcional.
926 Chapter 13 Lower Leg, Ankle, and Foot
Foot and Ankle Ability Measure (FAAM) Foot and Ankle Ability Measure (FAAM)
Activities of Daily Living Subscale Sports Subscale
Please answer every question with one response that most closely describes your Because of your foot and ankle, how much difficulty do you have with:
condition within the past week.
If the activity in question is limited by something other than your foot or ankle, mark not No
applicable (N/A). Foot and Ankle Ability Measure (FAAM) difficulty Slight Foot and Ankle
Moderate Ability
Extreme Measure
Unable N/A (FAAM)
No Slight Moderate Extreme Unable N/A at all difficulty difficulty difficulty to do
Activities of Daily Living Subscale
difficulty difficulty difficulty difficulty to do
Sports Subscale
Running
Standing
Please answer every question with one response that most closely describes yourJumping Because of your foot and ankle, how much difficulty do you have with:
condition
Walking onwithin the past week.
even ground
Lunging
IfWalking
the activity in ground
on even question is limited by something other than your foot or ankle, mark not No
applicable (N/A).
without shoes Starting and stopping difficulty Slight Moderate Extreme Unable N/A
quickly
Walking up hills No Slight Moderate Extreme Unable N/A at all difficulty difficulty difficulty to do
Walking down hills
difficulty difficulty difficulty difficulty to do Cutting/lateral movements
Running
Low impact activities
Standing
Going up stairs
Jumping
Ability to perform activity
Going down stairs with your normal technique
Walking on even ground
Walking on uneven ground Lunging
Ability to participate in your
desired sport as long as you
Walking
Steppingon even
up and ground
down curbs would like
without shoes
Squatting Starting and stopping
How would you rate your current level of function during your sports related activities
quickly
from 0 to 100 with 100 being your level of function prior to your foot or ankle problem
Coming up on your toes and 0 being the inability to perform any of your usual daily activities?
Walking up hills
Walking initially .0% Cutting/lateral movements
Walking down
Walking 5 hills
minutes or less Overall, how would you rate your current level of function?

Walking approximately 10 Normal Low impact activities

Nearly normal Abnormal Severely abnormal
Going up stairs
minutes

Walking 15 minutes or B Ability to perform activity

greater
Going down stairs with your normal technique
Because of your foot and ankle, how much difficulty do you have with:

Walking on uneven groundNo Ability to participate in your

difficulty Slight Moderate Extreme Unable N/A
at all difficulty difficulty difficulty to do
desired sport as long as you
Stepping up and down curbs
Home responsibilities would like
Activities of daily living
Squatting How would you rate your current level of function during your sports related activities
Personal care
from 0 to 100 with 100 being your level of function prior to your foot or ankle problem
Coming up on your
Light to moderate worktoes and 0 being the inability to perform any of your usual daily activities?
(standing, walking)

Heavy work (push/pulling,

Walking initially
climbing, carrying) .0%
Recreational activities
Walking 5 minutes or less Overall, how would you rate your current level of function?
How would you rate your current level of function during your usual activities of daily
living from 0 to 100 with 100 being your level of function prior to your foot or ankle
Walking approximately 10
problem and 0 being the inability to perform any of your usual daily activities? Normal Nearly normal Abnormal Severely abnormal
minutes .0%

Walking 15 minutes or
A B
Evaluación funcional.
• Hop test.

• Variantes.
 930 Chapter 13 Lower Leg, Ankle, and Foot

Pruebas especiales.
• Posicion neutral del
talo.
932 Chapter 13 Lower Leg, Ankle, and Foot

• Alineación pierna – A B

talón.
Figure 13-66 Determining the neutral position of the subtalar joints in the prone position. A, Side view. B, Superior view.

Torsion angle
Knee axis

axis
Ankle

Figure 13-67 Determining the neutral position of the subtalar

joint in supine position.
Figure 13-74 Determination of tibial torsion in sitting (superior
view). The torsion angle (normal: 12° to 18°) determined by the
intersection of the knee axis and the ankle axis. (Modified from Hunt
midline of the calcaneus at the insertion of the Achilles
GC, editor: Physical therapy of the foot and ankle, clinics in physical
 foot.30,33,124–126
Ideally, the knee should be placed in 90° of flexion to
alleviate tension on the Achilles tendon. The test should

Pruebas especiales. be performed in plantar flexion and in dorsiflexion to test

for straight and rotational instabilities.

• Torsion tibial.
A

• “Signo de los dedos”.

Figure 13-75 “Too-many-toes” sign signifying lateral foot or tibial B

rotation. Two-and-one-half toes shown on the left foot, four toes on
the abnormal right foot. (Redrawn from Baxter DE, editor: The foot Figure 13-76 Anter
and ankle in sport, St Louis, 1995, Mosby, p. 45.) foot forward. B, M

A
Pruebas especiales.
• Inestabilidad articular.

• Cajón anterior de tobillo

(Sensibilidad 60% / Especificidad
74%).
Pruebas especiales.
• Inestabilidad articular.

• Tilt talar (Sensibilidad 52%).

 Figure 13-78 Crossed-leg test. The patient sits in a chair, with the syndesmosis (“high ankle”) injury if pain is produced
injured leg resting across the knee of the uninjured leg. The examiner over the anterior or posterior tibiofibular ligaments and
applies a gentle force on the medial knee of the injured leg. the interosseous membrane (Figure 13-81). If the patient

Pruebas especiales.
• Inestabilidad articular.
• Sindesmosis. Figure 13-80 Dorsiflexion maneuver. The examiner stabilizes t
with one hand and passively moves the foot toward dorsiflexion
the other hand using the forearm.
Figure 13-79 Dorsiflexion compression test. A, Step 1:
Patient dorsiflexes feet while standing. B, Step 2: Patient
dorsiflexes feet while examiner squeezes malleoli A B
• Squeeze Test.
together. 936 Chapter 13 Lower Leg, Ankle, and Foot

• Test de compresión en
dorsiflexión.

• Test de estrés en rotación externa

(Test de Kleiger). Figure 13-86 Squeeze test for stress fracture or ankle syndesmosis
pathology.

Figure 13-84 Point (palpation) test. The examiner applies pressure over
the anterior aspect of the distal tibiofibular syndesmosis.

Figure 13-81 External rotation stress test.

 Pruebas
Contralateral.
especiales.
• Línea de Feiss. Figure 13-88 Talar tilt test.
A

of the knee. This test is to determine whether the calca-

neofibular ligament is torn.114,123 The normal side is tested

• Método del “8”. first for comparison. The foot is held in the anatomical
(90°) position, which brings the calcaneofibular ligament
perpendicular to the long axis of the talus. If the foot is
plantar flexed, the anterior talofibular ligament is more
likely to be tested (inversion stress test).122 The talus is
then tilted from side to side into inversion and eversion.

• Test de Morton (Mulder).

Inversion tests the calcaneofibular ligament and, to some
degree, the anterior talofibular ligament by increasing the
stress on the ligament.16 Eversion stresses the deltoid liga-
ment, primarily the tibionavicular, tibiocalcaneal, and
posterior tibiotalar ligaments. On a radiograph, the talar
tilt may be measured by obtaining the angle between the
distal aspect of the tibia and the proximal surface of the
• Test de Thomson. talus (see the discussion of stress radiographs in the Diag-
nostic Imaging section)
Other Tests
Buerger’s Test. This test is designed to test the arte-
rial blood supply to the lower limb.36 The patient lies
• Signo de Tinel. supine while the examiner elevates the patient’s leg to 45°
for at least 3 minutes. If the foot blanches or the promi-
nent veins collapse shortly after elevation, the test is posi-
tive for poor arterial blood circulation. The examiner then
asks the patient to sit with the legs dangling over the edge
of the bed.
A If it takes 1 to 2 minutes for the limb color
to be restored and the veins to fill and become prominent,
Figure 13-98 Thompson’s test for Achilles tendon rupture. A, Prone lying position. B, Kneeling position. In each case, foot plantar flexes
Chapter 13 Lower Leg, Ankle, and Foot 941
B
Figure 13-89 A, Feiss line in non–weight-bearing. Navicular is in normal
position. B, Feiss line in weight-bearing. Navicular is slightly below line
(within normal limits).
tuberosity on the medial aspect of the foot, noting where
it lies relative to a line joining the two previously made
points. The patient then stands with the feet 8 to 15 cm
(3 to 6 inches) apart. The two points are checked to
ensure that they still represent the apex of the medial
malleolus and the plantar aspect of the metatarsophalan-
geal joint. The navicular tubercle is again palpated (Figure
13-89). The navicular tubercle normally lies on or close
to the line joining the two points. If the tubercle falls
one third of the distance to the floor, it represents a
first-degree
B flatfoot; if it falls two thirds of the distance,
it represents a second-degree flatfoot; if it rests on