Examination of the Foot & Ankle Joints

Introduction

• Introduce yourself to the patient and offer the patient a chaperone, as necessary
• Wash your hands
• Briefly explain to the patient what the examination involves
• Ask the patient to expose both legs to above the knee
• Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner

Inspection

While the patient is standing:

• Inspect the ankles from behind, looking for asymmetry, swelling, scars, skin changes
• Ask the patient to stand on their tiptoes to assess the functioning of gastrosoleus complex
  • Heels should move varus during tiptoeing if posterior tibialis tendons are intact
• Look from behind and evaluate how many toes are visible from behind
  • Normally 1-2 toes are visible, however any more than this or significant asymmetry may indicate arch problems
• Evaluate medial longitudinal arch – may be too high (cavus) or too flat (planus)
• Look for any forefoot deformities, skin or nail changes, ulcers
  • Do not forget to inspect the plantar surface and in between toes, as well as for walking aids and asymmetrical wear on insoles of the shoes
• Ask the patient to walk a few steps and assess their gait, from both antero-posterior and lateral views

Palpation

While the patient is sitting or lying on couch:

• Commencing proximally and moving distally, feel for temperature, swelling, and tenderness across surface of ankle joint
• Palpate muscle bulk around the calf and anterior shin compartment
• Feel along the Achilles tendon, palpating for gaps
• Assess foot pulses, both posterior tibial and dorsalis pedis
• Systematically assess for bony and soft tissue tenderness*:
  • Palpate medial malleolus, flexor retinaculum, deltoid ligament
  • Moving laterally, palpate tibialis anterior and long extensor tendons, then feel the lateral malleolus and lateral ligaments (anterior talofibular, posterior talofibular, and calcaneofibular)
  • Palpate the plantar surface of calcaneus and insertion of plantar fascia – dorsiflexion of the hallux will stretch the plantar fascia and recreate the medial longitudinal arch in pes planus
  • Feel the sub-talar joint and mid-foot for tenderness or crepitus
  • Metatarsophalangeal squeeze test (medial-lateral direction) causes discomfort in the presence of synovitis

*The structures in the foot and ankle are superficial, therefore tenderness is likely to indicate the area of pathology

Movement

While the patient is sitting, assess movements with knee initially flexed and then knee extended:

• Active and passive dorsiflexion and plantar flexion of ankle joint (normal range 20° dorsiflexion and 50° plantarflexion)
  • When passively assessing ankle (talar) joint movement, invert the heel to “lock” the subtalar joint.
• Active and passive inversion and eversion should be assessed (normal range 20° inversion, 10° eversion)
  • To passively assess inversion and eversion at subtalar and midtarsal joints, ensure to hold the the heel in place with one hand and move the foot with the other
• Active and passive flexion and extension of the hallux (normal range 70° dorsiflexion to 40° plantarflexion relative to long axis of 1^st metatarsal)

Special Tests

Simmons Test

This is a test to determine rupture of the Achilles tendon:

• Lie the patient prone, with their feet and ankles hanging freely over the end of the bed
  • Note the natural position of the foot on both sides; the tone of gastrocnemius should keep the foot in slight plantarflexion, however will be absent in Achilles tendon rupture
• Gently squeeze the patient’s calf
  • With an intact Achilles tendon there should be a passive plantarflexion of the ankle, whereas in the case of rupture, this will be absent

Talar Tilt

The Talar Tilt test, also known as the inversion stress test or varus stress test, assesses for instability of the lateral ankle ligaments*

• Sit the patient on a chair
• With one hand, passively dorsiflex the ankle to stabilise the talar joint in the anterior-posterior direction
• With the other hand, grasps the calcaneus and invert the foot
• Any laxity present in comparison to the contralateral ankle suggests ligamentous disruption

*In reality, often stress radiographs are required to confirm this

Complete the examination

Thank the patient and allow them to redress. Remember, if you have forgotten something important, you can go back and complete this.

State to the examiner that to complete your examination you would also like to examine the joint above (the knee) the contralateral ankle, and review any relevant imaging available.