Examination of the Foot & Ankle

Summary

Ankle and foot consists of 26 bones and 33 joints with many involved muscles, tendons and ligaments.

Look

General Inspection

  • Adequate exposure,
    • Patient should ideally be wearing shorts to assess ankle, knee and hip as well as a shirt able to assess the back.
  • General
    • RA, diabetes, evidence of systemic disease
  • Mobility aids, external appliances
  • Shoes
    • Wear pattern
    • Off the self commercial shoes with no modifications & orthotic

Gait

Ask patient to walk

  • Walk away then walk towards
  • Normal move of foot through walking – heel strike to toe off
  • Gait
    • Antalgic (shortened stance phase compared to swing phase)
    • Cavus (walking on outside of foot)
    • Planus (walking on inside of foot)
    • Foot drop (high stepping stance)
    • Hallux Rigidis (unable to toe off)

(Gait videos here)

  • Foot progression angle
    • Angle of foot compared to straight line extending forward from middle of body)
    • Slight external rotation normal angle with walking
  • Features
    • Stiff ankle
    • Foot drop
    • Fixed equines
    • Antalgic
    • Rocker

Wall

Get patient to face wall

Double heel raise

  • Ability
  • Neurological
    • likely central cause
    • cerebral palsy, spina bifida, cord injury
  • Muscular
    • muscular dystrophy
    • disuse
  • Heel movement
    • symmetrical heel swing into varus
    • heel remains in valgus (abnormal)
  • Medial arch
    • restoration
  • Single heel raise
    • on normal foot
    • on abnormal foot
  • Neurological
    • central – stroke, polio, radiculopathy
    • peripheral – nerve injury
  • Tendinous
    • tibialis posterior dysfunction

From Front

Stand patient facing you, describe proximal to distal

Deformity

  • Knee alignment: physiological valgus, patella alignment, valgus with pes planus, rotational profile
  • Foot rotation: symmetrical ER
  • Forefoot: splaying
  • Hallux: valgus / varus, pronation, lPJ,
  • Lesser toes: overriding, Hammer(PIPJ flexion)/Claw (hyperextension of MTPJ, flexion PIPJ/DIPJ)/Mallet (flexion DIPJ), callosities over IPJ
  • Cavovarus deformity of foot exposes heel to anterior view

Skin

  • Scars, trophic changes, venous stasis, circulatory disturbance, hair loss, hyperpigmentation, varicosities, ulcers, disuse / denervation, dry skin, dekeratinisation, nails
  • Examine between toes

Contour

  • Swelling
  • Anterolateral ankle
  • Navicular
  • Bunion
  • Bunionette
  • Muscle Wasting
    • EDB
    • Quadriceps

From Medial Side

Turn affected side away

Ensure to assess medial and lateral sides of both feet

Assess arch

  • Pes planus (flat foot)
    • Can doriflex big toe, if flexible flat foot then arch with reform (Jack test)
  • Pes cavus (high arch)

Skin

  • See above

Contour

  • Swelling
  • Tibialis posterior

From Lateral Side

Deformity

  • Knee
  • Flexion attitude
  • Ankle
  • Equinus

Skin

  • Scars

Contour

  • Swelling
  • Peroneal tendons

From Behind

Deformity

  • Back
    • Sagittal spinal deformity
    • Cutaneous manifestations of spinal dysraphism
  • Lower limb
    • rotation/angulation deformity (eg coxa/genu valgum/varum)
  • Hindfoot
    • Physiological valgus (~5o valgus)
    • Varus
      • then ask for Coleman Block
    • Valgus
      • Single heel raise
  • Should only be able to 1 and half toes on review posteriorly, any more indicates likely planovalgus

Skin

  • See above

Contour

  • Swelling
  • Calf
  • Duchenne
  • Tendo Achilles
  • Heel
    • Haglund’s
  • Wasting
    • Calf

Sole

Sit patient on side of bed with you seated, inspect sole

Skin

  • Scars
  • Footprint
    • normal
      • well-distributed weight-bearing
      • heel, lateral border, metatarsal heads
    • abnormal
      • altered weight distribution
      • callosities
      • MT heads (II, III), midfoot
  • Lesions
    • warts
    • ulcers
    • soft corns
    • pedal sepsis

Contour

  • Swelling
    • plantar fibromatosis

Feel

Ask patient “where is it painful?”

Compare temperature of ankle joints

(Add anatomy slides to demonstrate locations of palpation)

Palpation

Sole

  • metatarsal heads
    • I – sesamoids
    • II-V – metatarsalgia
  • interdigital neuroma
  • interdigital tenderness
  • lateral compression – pain & click
  • heel
    • origin of plantar fascia

Medial

  • 1st Metatarsal head
  • 1st metatarsal-Cuneiform joint (flare of base of 1st MT)
  • Navicular Tubercle
  • Head of Talus (evert forefoot)
  • Medial Malleolus
  • Sustentaculum Tali (1.5 cm below medial malleolus)
  • Posterior impingement/ Os trigonum
    • palpate posterior to medial malleolus and dorsiflex to reproduce pain

Lateral

  • 5th Metatarsal head
  • Cuboid
  • Calcaneum
    • Tender in this region in Halglund’s deformity (overgrowth of bone around Achilles insertion)
  • Peroneal Tubercle (separates peroneus longus & brevis)
  • Lateral malleolus

Tendons

  • Tendo Achilles
    • insertion
      • tenderness
    • along tendon
      • tenderness (diffuse or focal)
    • lump
    • retrocalcaneal bursa (pinch tissue anterior to AT)
    • calcaneal bursa (posterior to AT)
  • Tibialis Posterior
    • prominent with plantarflexion & inversion
    • thickening
    • tenderness
    • crepitus
    • check power if abnormal
    • navicular insertion
  • Peroneals – Brevis & Longus
    • thickening
    • tenderness
    • dislocation (resisted eversion)
    • base of 5th MT insertion
  • Tibialis Anterior
    • Prominent with dorsiflexion & inversion
    • Insertion
  • EHL & EDL
    • Dorsiflex toes

Ankle Joint

  • Lateral ligaments
    • 1. Anterior Talo-Fibular Ligament (ATFL)
    • 2. Calcaneo-Fibular Ligament (CFL)
    • 3. Posterior Talo-Fibular Ligament (PTFL)
    • 4. Anterior Inferior Tibiofibular Ligament (AITFL)
    • 5. Posterior Inferior Tibiofibular Ligament (PITFL)
  • Joint line
  • Deltoid Ligament (Medial ligament)
    • 1. Anterior Tibio-Talar Ligament
    • 2. Tibio-Calcaneal Ligament
    • 3. Posterior Tibio-Talar Ligament
    • 4. Tibio-Navicular Ligament
  • Deep
  • Superficial
  • Fluctuance
  • Effusion or synovial thickening

Forefoot

  • Bunion
  • Bunionette
  • Pulses
    • Dorsalis pedis
    • Posterior tibial
  • Capillary refill
  • Neurological
    • SPN- sensation: across forefoot, motor eversion of foot
    • DPN- sensation: 1st webspace, motor extension of hallux/phalanges
    • TN- sensation: sole of foot (medial and lateral sides different branches of tibial nerve); motor: flexion of hallux/phalanges
    • Sural- sensation along lateral aspect of foot

(Insert picture of pulses/neurology/lower limb compartments)

Move

  • Active, Passive, Power
  • Compare both feet at same time
    • Dorsiflexion
    • Plantarfiexion
    • Inversion
    • Eversion
  • Ankle / Tibiotalar (Dorsiflexion/Plantarflexion)
    • thumb on talar neck
    • grasp heel with other hand
    • plantarflex & dorsiflex ankle
    • movement occurring at ankle joint
    • relate to foot at neutral (90°)
    • dorsiflexion 20°
    • plantarflexion 50°
  • Subtalar (Inversion/Eversion)
    • forefoot held in neutral at 90° to tibia (locks wider, anterior part of talar dome into ankle mortise)
    • foot relaxed with thumb on talar neck
    • grasp heel with other hand
    • invert & evert heel
    • inversion 10-15°
    • eversion 0-5°
  • Tarsal Coalition
    • Restricted subtalar motion
  • Midtarsal
    • (Adduction/Abduction; Dorsiflexion/Plantarflexion)
    • Foot held at 90° (to lock talus into ankle mortise)
    • Calcaneus grasped
    • Adduct foot (20°)
    • Abduct foot (10°)
    • Dorsiflexion
    • Plantarflexion
  • 1st MTPJ (Flexion/Extension)
    • Stabilise forefoot & IPJ
    • extension 70-90°
    • flexion 45°
  • 1st IPJ (Flexion/Extension)
    • stabilise proximal phalanx
    • flexion 90°
    • extension 0°
  • Toes (Flexion/Extension)
    • extension only occurs at MTPJ

Special tests

Simmond’s Test

  • With patient kneeling/laying prone
  • Squeeze calf
  • Plantar flexion should occur
  • If nil movement, suspect Tendo Achilles Rupture

Instability

  • Anterior Drawer
  • Due to complete tear of ATFL
  • grasp lower tibia & cup calcaneum
  • “clunk” or draw
  • cf. other side
  • Lateral instability
  • Inversion stress
  • gaping of soft tissues
  • talar tilt (may occur in normal & must cf. with other side)
  • needs to be confirmed on stress views
  • Medial Instability
  • Eversion stress
  • gaping/ widening
  • needs to be confirmed on stress views

Gastrocnemius / Soleus Contracture

  • test if limited dorsiflexion
  • extend knee – dorsiflexion limited by both soleus & gastrocnemius contracture
  • flex knee – gastrocnemius relaxed (crosses knee joint)
  • if dorsiflexion still limited it is due to soleus contracture
  • if limited in extension & not in flexion then due to gastrocnemius contraction

Pes Cavus

  • Modify
  • claw toes
  • individual power cf. other side
  • tibialis anterior (inversion in DF)
  • tibialis posterior (inversion in PF)
  • peronei
  • Add
  • Coleman block test
  • dynamic visualisation of hindfoot correction
  • stand on 2cm block
  • Sensation
  • Spine
  • Hands

Hallux Valgus / Rigidus

  • Add
  • MTPJ
  • dorsal osteophytes
  • passive ROM
  • attempt to correct deformity
  • grind test
  • hallux interphalangeus
  • lesser toes

Lesser Toes

  • Add
  • describe deformity
  • claw, hammer, mallet, overriding, curly
  • callosities
  • palpate joints
  • MTP, PIP, DIP
  • fixed or mobile
  • subluxed or dislocated

Adult Flatfoot

  • Modify
  • tibialis posterior function
  • Lisfranc joint

Tarsal Coalition

  • Modify
  • palpate
  • medially (sustentacullum tali)
  • dorsolaterally (through EDB)

Lateral Ligament Instability

Add

  • Anterior drawer
  • Talar tilt