Table of Contents
Introduction
- Wash hands
- Introduce self
- Ask Patient’s name, DOB and what they like to be called
- Explain examination and obtain consent
- Expose knees and below
- General inspection: patient, e.g. age, pain/discomfort, signs of trauma; around bed, e.g. mobility aids, splint
Look
- Gait: look for limp and movement restriction; assess knee, ankle and foot movements; check for normal heel-strike/toe-off
- Standing inspection
- Front: hallux deformities (lateral angulation of big toe = hallux valgus), lesser toe deformities (flexed PIP joints = hammer toes; flexed DIP joints = mallet toes; flexed PIP joints and DIP joints with pes cavus = claw toes)
- Sides: foot arches (pes planus = flat foot; pes cavus = high arch, usually with clawed toes)
- Behind: alignment of hindfoot (5˚ valgus normal)
- Tip-toe standing inspection: re-inspect foot arch if there was pes planus (if it corrects on tip-toe standing, it is flexible pes planus; if it does not correct, it is rigid pes planus); big toe flexion (no flexion = hallux rigidus); hindfoot varus/valgus angulation change (normal hindfoot 5˚ valgus should correct into varus)
- Lying inspection: skin (scars/arthroscopic portals, bruising, erythema), joints (swelling, effusions), muscles (wasting), heel (callosities), between toes (ulcers), nails (psoriatic changes), feel up extensor surface of lower leg (psoriasis plaques, rheumatoid nodules, gouty tophi)
- Measure calf muscle bulk: measure calf diameter 10 cm below tibial tuberosity and compare with contralateral side
Feel
Ask about any pain and then start by examining the normal side.
- Skin: palpate general area for temperature and soft tissue swelling/tenderness
- Ligaments: deltoid ligament (anteroinferior to medial malleolus), anterior talofibular ligament (anterior to lateral malleolus), calcaneofibular ligament (inferior to lateral malleolus), and posterior talofibular ligament (posterior to lateral malleolus)
- Bony landmarks – assess joints for tenderness and feel for bony swellings, effusions, synovitis, deformities
- Ankle: medial malleolus, lateral malleolus, anterior joint line
- Hindfoot and midfoot: feel around joints in an ‘n’ pattern (distolateral → proximolateral → across dorsum → proximomedial → distomedial)
- Forefoot: feel all joints in circle (tarsometatarsal joints, metatarsal heads, MTP joints and IP joints)
- Plantar fascia: feel for thickening, tenderness, fibromatosis
Move
Movements are best assessed with patient’s legs hanging over bed.
- Ankle movements (actively, and passively while feeling for crepitus): dorsiflexion 20˚ and plantar-flexion 40˚; inversion and eversion at subtalar joint (stabilise ankle with one hand and move heel with the other)
- Midtarsal movements: hold calcaneus with one hand and abduct (10˚) and adduct (20˚) forefoot with your other hand
- Toe movements: ask patient to: straighten toes fully (difficulty = joint disease, extensor tendon rupture or neurological damage); curl toes(can’t curl toes in = tendon/small joint involvement); abduct (spread) toes and adduct toes (hold paper between); move MCP joints and IPjoints passively (assess for limited movement and crepitus)
- SPECIAL TESTS:
| Tibialis anterior | Foot inversion and dorsiflexion against resistance |
| Tibialis posterior | Foot inversion and plantar-flexion against resistance |
| Peroneus longus and brevis | Foot eversion against resistance |
| Anterior drawer test | Hold calcaneum still and push lower leg posteriorly (tests anterior talofibular ligament) |
| Tilt test | Invert foot at ankle and compare to other side (tests calcaneofibular ligament) |
| Syndesmosis test | Squeeze mid-lower leg to test syndesmosis (pain at distal tibia/fibula joint = syndesmosis injury) |
| Simmonds’ test | Ask patient to kneel on a chair with feet hanging over edge, then squeeze both calves. Feet should plantar-flex (no plantar-flexion = Achilles tendon rupture). |
| Mulder’s sign | Squeeze metatarsal heads together in horizontal plane with one hand while applying pressure to the interdigital space with other hand (pain ± Mulder’s click in 2nd/3rd or 3rd/4th webspace = Morton’s neuroma) |
Function
- Balance – stand on one leg (often poor with peroneal weakness/ligament sprains)
To complete
- Thank patient and restore clothing
- ‘To complete my examination, I would examine the knees and perform a distal neurovascular examination.’
- Summarise and suggest further investigations you would consider after a full history
Common foot and ankle pathology
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