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Foot and ankle examination


  • 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


  • 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


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


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 IP joints 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)

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)


  • 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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Try some questions

What is a foot drop and what are the causes of a foot drop?

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You review a patient with an acutely hot swollen and painful first metatarsal phalangeal (MTP) joint. What is your main differential and how would you treat them?

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What is plantar fasciitis and how can it be managed?

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What are the categories of bones in the foot?

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What is Simmonds’s test used to diagnose?

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What is Morton’s neuroma?

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Now try an OSCE station or two

  1. Foot and ankle exam
  2. Charcot foot exam
  3. There’s more here

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