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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Try some questions

Now try an OSCE station or two

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