Foot and ankle examination

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

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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 IP joints passively (assess for limited movement and crepitus)

Special tests

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

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Common foot and ankle pathology

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1. Foot and ankle exam
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