Foot and Ankle Physical Examination

Goal: To improve my ability to evaluate a patient with an ankle complaint and my proficiency in the ankle exam

Means of Attainment: To achieve this goal I will spend time reviewing the pertinent anatomy, reviewing the steps involved in performing an ankle exam and then I will be examining the ankles of patients that I see in the clinic. I will keep track of how many ankle exams I have performed over the course of the rotation, with the goal being to perform a significant number of exams to allow me improve my skill with this exam

Measured by: To measure my attainment of this goal, I will demonstrate the ankle exam to my preceptor, during the last week of the rotation, and I will request feedback on my technique and the efficiency at which the exam was performed.

Inspection/Palpation

• Anterior View, standing – Observe alignment of toes and position of foot in relation to limb

• Medial View – Inspect for high arch, flat foot or excessive prominence of medial midfoot

• Lateral View – Inspect for ankle swelling or prominence of posterior calcaneus

• Posterior view – Asses alignment which should be neutral or slight valgus (turned out)

• Standing on toes – Heels should move into varus (turned-in) position

• Gait – Equal stride length, foot position and weight distribution

• Angle of gait – Foot should be within 0 to 20 degrees of external rotation when walking

• Anterior view, supine – Observe toe nails and for bunions, hammer toes, claw toes

• Spread toes – Ability to spread toes and look for ulcers between toes

• Plantar surface – Observe for plantar warts, calluses, ulcerations

• Medial Malleolus – Palpate area of tibial nerve, posterior and inferior to medial malleolus

• Posterior Heel – Palpate both sides of Achilles tendon to identify swelling or tenderness

• Peroneal tendons – Palpate posterior & inferior to fibular malleolus for tenderness/swelling

• Anterior Ankle – Palpate along talofibular ligament and calcaneofibular ligament for tenderness

• Plantar fascia – Palpate the plantar fasica for tenderness or swelling

• Sesamoid – Palpate the area beneath the first MT head for tenderness

• MTP Joint – Palpate top of the foot for tenderness and swelling of MTP joints

Range of Motion

• Ankle Motion: Zero starting position – Dorsiflexion 100 – 200, Plantar flexion 350-500

• Inversion and eversion – Perform with ankle slightly dorsiflexed to limit lateral motion

• Supination and pronation – Supination: Inversion of heel, adduction and plantar flexion of the midfoot., Pronation: Eversion of the heel and abduction and dorsiflexion of the midfoot

• Great toe: Zero starting position – Assess dorsiflexion and plantarflexion

Muscle Testing

• Posterior Tibialis – Foot in plantar flexion, resist patient’s attempt to invert foot

• Anterior Tibialis – With toes flexed, resist patient’s attempt to invert and dorsiflex foot

• Peroneus longus and brevis – Foot in planter flexion, resist patient’s attempt to evert foot

• Extensor hallucis longus – Ankle in neutral, resist patient’s attempt to extend great toe

• Flexor hallucis longus – Ankle in neutral, resist patient’s attempt to flex great toe

Special Tests

• Anterior drawer test – Assess anterior talofibular ligament. With ankle 20 degrees plantar flexed, stabilize tibia, grab hind foot and pull forward.

• Varus stress test – Asses calcaneofibular ligament. Stabilize tibia, ankle in neutral grasp calcenus and invert hindfoot

• MTP instability – Dorsiflex or plantar flex proximal phalanx

• Interdigital (Morton) neuroma test – Apply upward pressure between adjacent metatarsal heads and then compress the metatarsal heads from side to side with free head

• Monofilament sensitivity test

References:

1. Essentials of Musculoskeletal Care 3^rd Edition, Walter Greene and Letha Yurko Griffin

2. Bates’ Guide to Physical Examination and History Taking, 8^th Edition, Lynn S. Bickley

3. Atlas of Human Anatomy, 3^rd Edition, Frank H. Netter

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