The 'Too Many Toes Sign' and the Thompson Squeeze

Matthew F. Watto, MD; Paul N. Williams, MD


November 30, 2022

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my great friend Dr Paul Nelson Williams. Today we're going to be talking about foot and ankle pain. We had a great podcast episode on this, The Thrill of Victory and the Agony of the Feet, with Dr Joan Ritter. Paul, let's start with ankle sprains. Give me a pearl.

Paul N. Williams, MD: There were so many. Some of this episode reaffirmed that I was doing the right thing, and some of it, less so. We spent a fair amount of time talking about sprains, which I think is fair, because that's the thing we probably encounter the most in primary care practice.

Something that I found practice-changing is that I will probably be more aggressive in terms of rehabbing ankles after the injury. We talked about your dad and his glass ankles, and the fact that once you've had an ankle injury, you can lose proprioception and be more predisposed to subsequent injuries and keep injuring yourself again. So we should really rehab that part and focus on proprioception in addition to strengthening and stability, which can be really helpful not only in healing the current injury but preventing future injury. I will probably be more aggressive in terms of doing physical therapy and prescribing exercises and that kind of thing.

What changes did you make to your practice?

Watto: The thinking about the braces for the ankle, and not bracing people for too long or using a brace that's too restrictive. The stirrup splint — the one that has two white plastic pieces on the side with an Aircast-type thing in the middle, and it wraps around — lets people do plantar and dorsiflexion movements, but it prevents eversion and inversion of the ankle. If you put someone in a lace-up brace, it restricts motion in several planes. If you really want to immobilize the patient, they should be in a walking boot, but our guest made the point that we shouldn't put people in a walking boot for very long because it can affect their rehab. We don't want them developing glass ankles. Those were the main practice-changing points. Treatment for this is pretty standard: extensive physical therapy, NSAIDs, and bracing.

The other big thing we talked about was the Achilles tendon. She said that when people rupture their Achilles tendons, they think they are being attacked because that's how severe and painful it is. I haven't seen enough patients with Achilles tendon rupture to have that reported to me.

Williams: A colleague on Twitter talked about how they actually felt their ankle pop while they were running. It's very dramatic when it occurs. It's one of those things you just can't miss. And there is a very specific examination for this that we discussed on the podcast. I haven't been doing this in routine practice but will probably start doing it as a screening test now.

Watto: I taught my kids how to do this.

Williams: It's kind of satisfying. We're talking about the Thompson squeeze. Talk us through it.

Watto: You have the patient lay prone, face down, on the exam table so that their shin is flat on the surface of the table. You squeeze their calf, and it should cause plantar flexion of their foot, because when the Achilles contracts, it pulls them into plantar flexion. If they have no plantar flexion response when you squeeze their calf muscle, you should worry about an Achilles tendon rupture. It's a good test and very easy and fun to do.

Williams: You can even determine a partial tear, too, if there's asymmetry in the response. So test both of the patient's Achilles tendons, and if one is far more vigorous than the other, it suggests a partial tear and that should prompt further investigation.

Watto: With the Achilles, it's important to palpate it. Sometimes you can feel nodules on there. People can have bursitis near the area where the Achilles tendon is inserted, and they can have bony enlargement there. Achilles injuries are very common. And I knew that plantar fasciitis causes pain on the first step of the day, but I didn't realize that for similar reasons, Achilles tendonitis can cause pain not just on the bottom of the foot, but also in the back of the foot or heel on the first step of the day. I thought that was a cool thing to ask when taking a history.

Posterior tibial tendon dysfunction is one I hadn't heard much about. Apparently people with this condition present with a burning medial ankle pain, I don't know that I've diagnosed this before. Was that news to you?

Williams: It was news to me. It's not unusual to have ill-defined ankle pain in the absence of trauma. And certainly I have patients with flat feet, which we also see with this. But I'm not sure I had put the two together until this point, so I'll probably be a bit more aggressive in thinking about posterior tibial tendon dysfunction.

I will also be taking patients' shoes and socks off more often and looking behind them and watching their feet, because we learned my new favorite physical examination sign, which is of course the "too many toes sign." Matt, have you been doing the too many toes test?

Watto: Not yet, but it's very much in my memory and I'm going to be very excited. I'm going to high-five everyone in the office the first time I diagnose this condition.

You stand behind the person and as you are looking, their leg should block several of their toes. You shouldn't see more than two and a half toes if you're standing behind them looking at their feet and legs. If you see more than two and a half toes, that's the "too many toes sign" that the arch is flattened. In the flatfoot deformity, the posterior tibial tendon is responsible for partially lifting up the foot's arch. So a flat foot can be a sign of posterior tibial tendon dysfunction. It's treated with NSAIDs, orthotics that support the arch, and early physical therapy.

We don't have time to discuss everything we learned in this fantastic podcast, so people should check it out here. This has been another episode of The Curbsiders, bringing you a little knowledge food for your brain hole. I've been Dr Matthew Frank Watto.

Williams: And I remain Dr Paul Nelson Williams. Thank you.

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