This document provides details on performing an examination of the foot and ankle. It begins with taking a history including pain characteristics, swelling, deformity, and instability. The physical examination is then described step-by-step including inspection of gait, the feet while standing and sitting, and range of motion testing. Specific tests are outlined to assess the ligaments, tendons, nerves and vasculature. Common foot deformities and injuries are also discussed. The presentation concludes with references for further information.

1. Examination of Foot and Ankle
Moderator: Dr Sunil Singh Thapa
Presenter: Dr Ajay Shah (Resident)
Department of Orthopedics and Trauma Surgery, TUTH, IOM

2. History
Common reasons for patient’s presenting to the foot and ankle
clinic are:
• Pain
• Swelling
• Deformity
• Stiffness
• Instability
• Abnormal gait

3. Pain: Ask about
• Site of maximum pain and its onset
• Radiation of pain
• Quality or nature of it (sharp, dull or burning)
• Whether it is related to weight bearing (degenerative changes, stress fracture or
Inflammatory conditions like plantar fasciitis),
• Severity of the pain (0-10) like prevents activity, waking up during the night
• Time (early morning or night pain which disturbs the sleep),
• Pattern (constant/intermittent)
• Aggravating factors (like walking distance, walking on flat or uneven floor; Going up
and down the stairs; relation with shoes),
• Any alleviating factors (rest, analgesia, preferred type of foot wear)

6. Swelling
• Onset : Immediate or delayed
• Localized to one area or whole leg or ankle
• Whether ,unilateral or bilateral, pitting or non-pitting
• Associated with activities
• Frequency and the duration of swelling
• Acute painful or painless swelling with or without the deformity
• Generalized bilateral swelling usually related to systematic pathology,
such as cardiac or renal problems
• Localized swelling is more likely result from a specific local pathology

7. Deformity
• Duration whether congenital or acquired
• When the patient or their family member
first noticed
• Which area it involves
• Is it progressive
• Whether associated with other symptoms
(for example, skin ulcer, pain, recurrent
infection, rapid wear of shoes)

8. Instability
• When the first episode of instability or sprain occurred
• How often it happens and what can precipitate it
Past History
• History of trauma with details of symptoms and treatment,
• Surgery
• Injections in and around joint
• Infection

9. Associated Symptoms
Important to look out for red flags symptoms such as
• Fever, difficulty to bear weight night sweating, temperature or weight
loss, which may be related to an infection or neoplasm
• Neurological symptoms like numbness, weakness or burning sensation
are usually related either to spinal problem or peripheral neuropathy

10. General Medical History

11. Steps in Physical Examination
• Consent
• Privacy
• Exposure
• Gait analysis
• Inspection
• Palpation
• Range of Motion
• Neurovascular Assessment
• Special Tests

12. Exposure
• Both shoes and socks off
• At least have trousers rolled up to knees
preferably down to underwear

13. Gait Analysis
• Begins from the first moment of meeting the patient by observing the gait
and whether he/she uses any walking aids
• Helps to identify dynamic problems and pathology on other lower limb
joints
• Note whether gait is smooth or halting and whether feet are well balanced
• Gait may be disturbed by pain, muscle weakness, deformity or stiffness

14. • Gait is easier to analyze if concentrating on sequence of movements that make
up walking cycle.
• It begins with heel-strike, then moves into stance, then push-off and finally
swing-through before making the next heel-strike
• First rocker begins with heel-strike
If the anterior compartment muscles are weak, a ‘foot-slap’ is noticed
if the ankle is in fixed equinus, this rocker may be absent

15. Different types of abnormal gaits
• Antalgic gait: Short stance phase of the affected side
Decrease of the swing phase of the normal side
• Equinus (tiptoes) gait: Walking on tiptoes
eg. weak dorsiflexion and/or plantarcontractures
• Equinovarous gait: Walking on the out border of the foot eg. CETV

16. • Steppage gait (high stepping -slapping - foot drop)
No heel strike
Foot lands on the floor with a sound like a slap
eg. Foot drop, Polio
• Short leg (Equinus) gait
Minimum: Dropping the pelvis on the affected side
Moderate: Walks on forefoot of the short limb
Severe: Combination of both
eg. Leg length discrepancy

17. Inspection of patients footwear, insoles and walking aids
• Patient shoes whether they are commercial or surgical shoes
• Pattern of the wear, usually involves outside of shoe heel
• Different patterns of wear indicate abnormal contact of foot with the ground
Wear on lateral and proximal border indicates a supination deformity
Wear on the medial border indicates a pronation deformity
• Absence of wear simply reflect new or unused pair of foot wears
• Look for any orthosis or walking aides

18. Examination from standing position
• Assess the alignment of the lower limbs as a whole
• Look for any excessive varus or valgus knee deformity
• Inspect the alignment of spine in case of scoliosis, and look for
any pelvic tilt
• Inspect for any thigh or calf muscles wasting

19. Inspection From Front
• Inspect for any big toe and lesser toes deformity
• Previous scar marks, spurs, exostosis , swelling
• In normal ankle, unable to see heel pad on medial side inspecting from the front
• If this is visible then it is called “peek a boo” sign which exists with pes cavus

20. Hallux valgus
• Normally foot assumes a slight toe-out position.
• This angle (the Fick angle) is approximately 12° to 18°
Causes
• Those who wear high-heeled shoes or shoes with
narrow toe box
• Rheumatoid arthritis
• Positive family history

21. • Hammer Toes
MTP-Hyperextended
PIP-Flexed
DIP-Hyperextended
• Claw toes
MTP-Hyperextended
IP Joint-Flexed

22. Inspection From Back
• Bulk of calf muscles: compare on both sides
• Achilles tendon: vertical on both sides
• Inspect the ankle for posterior crease, localized swelling or any bony
bumps like calcaneal boss
• Observe calcaneum for Shape ,Position ,Callosity
• Also notice if there is a “too many toes” sign, indicate an increased
heel valgus angle

23. • Ask the patient to stand onto tiptoes
• Normally ankles turn into varus , indicates normal subtalar movement
• In case of flat foot, if a medial arch forms on standing on tip toes indicates
flexible pes planus

24. • Forefoot Varus
Mid tarsal joint- Inversion
Subtalar joint- Neutral
• Forefoot Valgus
Mid tarsal joint- Eversion
Subtalar joint- Neutral

25. Inspection From Medial
• Observe longitudinal arch of foot
• Medial longitudinal arch should be higher
• Previous scar marks, localized swelling, medial crease
Pes planus
• Apex of the arch has collapsed and the medial border
of foot is in contact with ground
• Heel becomes valgus
• Foot pronation at the subtalar-midtarsal complex

26. Pes cavus
• Arch is higher than normal
• Often clawing of the toes
• Varus heels
Causes
• Muscular dystrophies
• Poliomyelitis
• Cerebral palsy

27. Hallux Rigidus
• Stiffness of great toe at MTP joint
• May be due to OA

28. Foot Print Pattern
• Light film of baby’s oil on patient foot
and apply powder
• Ask patient to step on piece of colored
paper
• Observe for pattern of foot
Normal
Flat foot
High arched foot

29. Examination in sitting position
Inspection
• Start with meticulous inspection of the sole then rest of the foot.
• Look for
Skin discoloration, scar, ulcer, nails
Any skin thickening (callosity), hard/soft corns
Any signs of infection

30. Nail changes

31. Skin Changes

32. Palpation
• First ask the patient if there are any areas which are painful to touch, so we
can try to avoid causing pain during the examination
• Feel for local rise of temperature and compare with other side
• Second part of the palpation is to establish area of tenderness
• Always follow a systematic method of palpation so we will not miss any part

34. Range of Motion

35. Eversion Inversion

36. ROM of Toes
Extension: 0-65 Flexion: 0-40
Restricted in hallux rigidus, hallux valgus

37. Neurological Examination of Ankle
If a disorder related to spinal nerve root (L4–S2) or peripheral nerve is suspected
• Motor Examination
• Sensory Examination
• Reflexes
• Specific tests

38. Motor Examination
Tibialis anterior Tibialis posterior

39. Plantar Flexors Peroneus Muscle Group

40. Medical Research Council Scale

41. Sensory Examination

42. Semmes-Weinstein monofilament test
• To assess the degree of sensory deficit
• Pressure testing using a 10 g Semmes-Weinstein mono- filament
• Especially useful in diabetic charcot feet

43. Tinel's Sign
• Test for tarsal tunnel syndrome
• Posterior tibial nerve may be tapped
behind the medial malleolus
• Tingling or paresthesia with this test
is considered a positive finding.

44. Morton's Test
• Transverse pressure applied to heads of
metatarsal causing pain in forefoot
• Positive sign may indicate neuroma or
metatarsalgia
• No diagnostic accuracy studies have been
performed to determine sensitivity and
specificity of this test

45. Vascular Status
Homans' Sign
• Used to detect a deep vein thrombophlebitis
(DVT)
• Supine position with knee extended
• Passively dorsiflexe patient’s ankle
• Pain in the calf is considered a positive sign
for DVT
However, a positive Homan sign has been found to be
insensitive, nonspecific, is present in less than 30% of
documented cases of DVT

46. Buerger's Test
• Used to assess adequacy of arterial supply to leg
• Buerger’s angle: Angle of elevation at which pallor occur
• No change in color of leg of normal individual i.e remains pink color
even raised to 90 degrees

47. Tests for Syndesmotic Injury
Squeeze(Hopkins) Test
• To help identify inferior tibiofibular
syndesmotic injury
• Compression of fibula against tibia at mid
calf level producing pain in syndesmosis

48. Kleiger (External Rotation) Test
• To implicate the syndesmosis if pain is produced
over anterior or posterior tibiofibular ligaments
• Can also be used to assess the integrity of the
medial (deltoid) ligament complex
Alonso et al.170 reported data that indicate external rotation
stress test is more reliable than squeeze test and
dorsiflexion–compression test for diagnosing syndesmosis
injuries

49. Fibula Translation Test
• A positive test is pain during translation and
more displacement of fibula than the
compared side
• A cadaveric study by Beumer et al.166 found
this test to have a sensitivity of 82% and
specificity of 88% , the study only found
increased translation when all ligaments
were removed in cadavers.

50. Posterior Drawer Test
• Used to test for presence of instability at distal tibiofibular joint
• If distal tibiofibular joint is stable, there will be no drawer available,
but if there is instability, there will be a drawer.

51. Tests for Lateral Collateral ligament Complex Injury
Talar Tilt Test
• Tilting of talus 15 degrees may indicate rupture of ATFL alone
• Tilting 15 to 30 degrees indicates rupture of ATFL and CFL
• Tilting >30 degrees may indicate rupture of all three of lateral ligaments

52. Calcaneus Tilt
• Gapping on lateral side of the ankle
• Pain on lateral aspect of the ankle and/or
displacement (depending on severity), may
indicate a sprain of the ligament
Hertel et al.177 found this test to have a
sensitivity of 78% and specificity of 75%

53. Anterior Drawer Test

54. • To assess anterior talofibular ligament of the lateral ligament complex.
• False-positive findings may be seen in up to 19% of uninjured ankles in
those with ligamentous laxity
• Diagnostic accuracy
Sensitivity: 71
Specificity: 33
Carrie L. Docherty: Reliability of the Anterior Drawer and Talar Tilt Tests Using the LigMaster Joint Arthrometer
Van Dijk et al.185 reported that when the combination of pain on lateral ligament
palpation, hematoma formation of the lateral ankle, and a positive anterior
drawer test were used a lateral ligament lesion was correctly diagnosed in 95% of
cases.

55. Dimple Sign
• Another positive sign for a rupture of the anterior
tibiofibular ligament
• Dimple is located just in front of tip of lateral
malleolus during the anterior drawer test
• Results from a negative pressure created by forward
movement of the talus, which draws skin inwards at
the site of ligament rupture
• Only present within the first 48 hours after injury

56. Tests for Achilles Tendon Rupture
Thompson Test
• Normal or partial tear : plantar flexion present
• Absence of plantar flexion indicates a complete rupture of Achilles
tendon
• Low sensitivity (40%).

57. Matles Test
• If the foot falls into neutral or slight
dorsiflexion, test is positive for Achilles
tendon rupture
• In normal patients, the foot remains in
plantar flexion
Maffulli found this test to have a sensitivity of 0.88, a
specificity of 0.85, and a positive predictive value of
0.92

58. Coleman block test
• Used in cavo-varus foot to ascess whether
the hindfoot varus is fixed or mobile
• A block is placed beneath the foot such
that 1st ray isnot supported
• If the heel is mobile it should adopt a
valgus position.
• Persistent varus position  fixed
deformity

59. Silfverskiold test
• Test to distinguish whether gastrocnemius or soleus is the cause of reduced
dorsiflexon of the ankle.
• Maximally dorsiflex the ankle first with the knee extended and then with the
knee flexed to 90°.
• No change in ankle dorsiflexon with knee flexion or extension, contracture in
both gastrocnemius and soleus.
• Reduced dorsiflexion with knee extension alone  gastrocnemius tightness.

60. Feiss Line
• Used to assess the height of the medial arch,
using the navicular position
• If the navicular falls one-third of the distance
to floor, it represents
1/3rd : first-degree flatfoot
2/3rd : second-degree flatfoot
Rest on floor: third-degree flatfoot

61. References
• Dutton’s orthopaedic examination, 3rd edition
• McRae’s clinical orthopaedic examination, 6th edition
• Apleys system of Orthopedics, 9th edition
• Articles

62. Next Presentation by Dr Parshva on topic “Calcaneum fracture and
malunion”
Thank You