Examination of the Foot and ankle

Courtesy: Kevin R Wembridge, Consultant Orthopaedic Surgeon, UK

Sequence of Examination

1. Examination of footwear

2. Gait

3. Inspection

4. Palpation

5. Movements

6. Measurements

7. Neurovascular examination

8. Special tests

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1. Examination of Footwear

• Normal wear

  • Outer side of heel

  • Centre of the sole

• Cavus foot

  • Excess wear on the outer side of heel and lateral border of sole

• Flat foot

  • Excess wear on inner side of heel and medial border of sole

• Bulging of medial footwear wall

  • Suggests everted or flat foot

• Bulging of toe box

  • Suggests claw toes or hammer toes

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2. Gait Examination

• Normal gait:

  • Plantigrade feet

  • Equal weight-bearing on heel and forefoot

• Abnormal gait patterns:

  • Antalgic gait

  • High-stepping gait (foot drop)

  • Walking on lateral border of foot (congenital talipes equinovarus)

  • Heel walking: calcaneus deformity

  • Forefoot walking: equinus deformity

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3. Inspection

Inspection should be performed from anterior, lateral, posterior, medial, and plantar aspects.

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Anterior Aspect

• Alignment:

  • Great toe: hallux valgus or hallux varus

  • Lesser toes: claw toes, hammer toes, mallet toes

  • Relationship between forefoot, midfoot, and hindfoot

• Skin condition:

  • Discoloration

  • Ulcers

  • Dilated veins

  • Edema

• Tendons:

  • Extensor hallucis longus

  • Extensor digitorum longus

• Malleolar relationship:

  • Normally, the lateral malleolus lies posterior and inferior to the medial malleolus

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Lateral Aspect

• Lateral malleolus

• Base of the 5th metatarsal

• Tendo-Achilles

• Peroneus brevis tendon

• Lateral border of the foot

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Posterior Aspect

• Hindfoot alignment:

  • Varus or valgus

• Heel:

  • Size and symmetry

  • Position and pattern

• Toe-raise test:

  • Ask patient to stand on tiptoes

  • Normal response shows inversion of hindfoot and increased medial longitudinal arch height (windlass effect)

• Plantar fat pad

• Calcaneal tuberosity:

  • Prominence of posterosuperior aspect suggests Haglund deformity (pump bump)

• Retrocalcaneal region:

  • Swelling suggests retrocalcaneal bursitis

• Achilles tendon:

  • Tendinitis

  • Rupture (typically 2 to 6 centimeters proximal to insertion)

  • Localized swelling at malleolar level suggests tendinitis

  • Diffuse swelling along tendon suggests rupture

• Calf muscle:

  • Atrophy compared to opposite side

  • Seen in residual deformity of congenital talipes equinovarus, tibialis anterior rupture, or prolonged immobilization

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Medial Aspect

• Medial longitudinal arch:

  • Cavus

  • Planus

  • Rocker-bottom deformity (seen in diabetic foot or improperly treated congenital talipes equinovarus)

• Bony prominences:

  • Medial malleolus

  • Head of first metatarsal

  • Navicular tuberosity (prominent in accessory navicular)

  • Calcaneal tuberosity

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Plantar Aspect

• Callosities:

  • Indicate abnormal weight-bearing areas

  • Normally present over metatarsal heads and lateral border

• Painful calluses:

  • Common in claw toes and hammer toes due to metatarsophalangeal joint hyperextension

• Corns

• Ulcerations

• Warts or fungal infections

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4. Palpation

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Anterior Palpation

• Anterior tibial crest: stress fractures

• Talar dome: osteochondral defects

• Navicular: Köhler disease

• First metatarsophalangeal joint: bunions, gout

• Second metatarsophalangeal joint: Freiberg infarction

• Interdigital spaces: Morton neuroma

• Tendons:

  • Tibialis anterior

  • Extensor hallucis longus

  • Extensor digitorum longus

  • Peroneus tertius

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Lateral Palpation

• Lateral malleolus

• Anterior talofibular ligament

• Calcaneofibular ligament

• Peroneal tendons

• Calcaneus and tuberosity: Sever disease

• Calcaneocuboid joint

• Sinus tarsi: subtalar arthritis

• Fibular shaft: stress fractures

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Posterior Palpation

• Gastrocnemius–soleus complex

• Achilles tendon:

  • Tenderness, swelling, or palpable gap 2 to 6 centimeters above insertion

• Posterior calcaneal tuberosity:

  • Tender swelling in retrocalcaneal bursitis

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Medial Palpation

• Medial malleolus

• Subcutaneous border of tibia

• Head of talus (palpable on eversion)

• Navicular tuberosity:

  • Tender swelling in accessory navicular

• Tendons:

  • Flexor hallucis longus

  • Flexor digitorum longus

  • Tibialis posterior

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5. Movements

• Dorsiflexion: 20°

• Plantar flexion: 50°

• Eversion: 20°

• Inversion: 40°

• Abduction: 5°

• Adduction: 5°

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6. Measurements

Longitudinal Measurements

• True and apparent limb length

• Heel length:

  • From tip of medial malleolus vertically to heel

• Foot length:

  • Medial: heel to tip of great toe

  • Lateral: heel to tip of 5th toe

Circumferential Measurements

• Thigh

• Calf

• Foot at level of medial longitudinal arch

• Broadening of ankle measured with calipers suggests inferior tibiofibular diastasis

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7. Neurovascular Examination

• Sensory examination

• Motor examination

• Peripheral pulses

• Capillary refill

• Signs of neuropathy, especially in diabetic patients

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8. Special Tests

• Silfverskiöld test

• Thompson test

• Anterior drawer test of ankle

• Coleman block test

• Peroneal tendon instability test

• Tinel test

• Talar tilt test

• Morton test

• Homan sign

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Summary

• Foot and ankle examination must be systematic and comparative.

• Footwear and gait provide early diagnostic clues.

• Inspection and palpation help identify deformities and localized pathology.

• Special tests assist in diagnosing ligamentous, tendon, and nerve conditions.

• A complete neurovascular examination is essential, especially in high-risk patients.