The physical exam is of crucial importance for the clinical evaluation of painful conditions of the foot and ankle. These disorders are very common in the outpatient setting, both among professional athletes and recreational exercisers. It is important to be familiar with some basic maneuvers and physical signs necessary to assess the presence and the severity of lesions in the osteo-ligamentous structures of the foot.
- A physical exam should be performed with shoes and socks removed
- Ideally, there is a weight-bearing component and a seated component
Introduction
- Follows the IP-PASS examination methodology
- Inspection
- Palpation
- Passive Range of Motion
- Active Range of Motion
- Strength & Neurovascular
- Special Tests
Inspection
- Skin
- Color: erythema, ecchymosis, white, black
- Trophic changes (altered hair growth, sweat production)
- Scars
- Pressure sores, calluses, blisters
- Bunions, hammer toes, claw toes, calluses
- Toenails
- Swelling or Joint effusion
- Muscle tone: atrophy, hypertrophy
- Deformity: asymmetry, rotation, amputation
- Areas of emphasis for foot and ankle exam exam
- Look at patients shoes (wear pattern, arch support, etc)
- Gait examination and evaluation (consider normal, walking on insides and outsides of feet, heel and toe-walk, tandem, running)
- Arch (Pes Cavus or Pes Planus)
- Ankle alignment (posteriorly)
- Knee alignment
Palpation
- Palpate for
- Effusion
- Clicking
- Snapping
- Crepitus
- Tenderness
- Temperature
- Masses
- Ankle Areas of Emphasis
- Posterior aspect of medial and lateral malleolus
- Lateral Ankle Ligaments: ATFL, CFL, PTFL
- Medial Ankle Ligaments: Deltoid Ligament
- Achilles Tendon and insertion
- Foot Areas of Emphasis
- Navicular
- Lisfranc Joint
- Base of 5th metatarsal
Range of Motion
- Ankle
- Dorsiflexion: 20-30°
- Plantarflexion: 40-50°
- Pronation: 30°
- Supination: 60°
- Foot
- Inversion: 35°
- Eversion: 25°
- Metatarsophalangeal joints
- Flexion: 30°
- Extension: 80°
- Interphalangeal joints of toes
- Flexion: 50°
- Extension: 50°
Strength
- Ankle
- Plantarflexion: Gastrocnemius, Soleus, Plantaris, Tibialis Posterior, Fibularis Longus
- Dorsiflexion: Tibialis Anterior, Extensor Hallucis Longus, Extensor Digitorum Longus
- Eversion: Fibularis Longus, Fibularis Brevis
- Inversion: Tibialis Posterior
- Great Toe
- Extension: Extensor Hallucis Brevis, Extensor Hallucis Longus
- Flexion: Flexor Hallucis Longus, Abductor Hallucis, Flexor Hallucis Brevis
- Abduction: Abductor Hallucis
- Adduction: Adductor Hallucis
- Toes 2-4
- Extension: Extensor Digitorum Brevis, Extensor Digitorum Longus, Lumbricals
- Flexion: Flexor Digitorum Longus, Flexor Digitorum Brevis, Abductor Digiti Minimi, Quadratus Plantae, Lumbricals, Flexor Digiti Minimi Brevis
- Abduction: Abductor Digiti Minimi, Dorsal Interossei
- Adduction: Plantar Interossei
Neurovascular
- Sensory Nerves
- L4: Lateral thigh, anterior knee, medial leg
- L5: Lateral leg, dorsal foot
- S1: Posterior Leg
- S2: Plantar foot
- Dermatome
- Needs to be updated
- Reflexes
- Patellar (L3, L4)
- Achilles (S1, S2)
- Myotomes:
- L4: Knee Extension, Dorsiflexion
- L5: Hip Abduction, Hip Extension, Toe Dorsiflexion, Foot Inversion, Dorsiflexion
- S1 Foot Version, Plantarflexion
- S2: Toe Plantar Flexion
- Vascular:
- Popliteal Artery
- Dorsalis Pedis Artery
- Posterior Tibial Artery
- Capillary refill on toes
Special Tests
- General
- Ottawa Ankle Rules
- Peroneal Tendon Injuries
- Peroneal Tunnel Compression Test
- Achilles Tendon Rupture
- Thompson Test
- Matles Test
- Hyper Dorsiflexion Sign
- Copelands Test
- Obriens Needle Test
- Achilles Palpation Test
- Posterior Tibial Tendon Dysfunction
- Too Many Toes Sign
- Single Limb Heel Rise
- Lateral Ankle Sprain
- Squeeze Test
- Anterior Drawer Test Ankle
- Talar Tilt Test
- Anterolateral Drawer Test Ankle
- Medial Ankle Sprain
- External Rotation Stress Test
- Abduction Stress Test
- Eversion Test
- Anterior Drawer Test Ankle
- Syndesmotic Injury
- Squeeze Test
- External Rotation Stress Test
- Cotton Test
- Fibular Translation Test
- Crossed Leg Test
- Stabilization Test
- Forced Dorsiflexion Test
- Syndesmotic Palpation Test
- Peroneal Nerve Injury
- Tinels Test
- Tarsal Tunnel Syndrome
- Tinels Test
- Dorsiflexion Eversion Test
- Triple Compression Stress Test
- Hindfoot Deformity
- Coleman Block Test
- Dynamic Coleman Block Test
- Calf Strain
- Silfverskiold Test
- Upper Motor Neuron Disease
- Oppenheims Test
- Babinskis Response
- Plantar Fasciitis
- Windlass Test
- Anterior Ankle Impingement Syndrome
- Ankle Impingement Sign
- Foot Pronation
- Navicular Drop Test
- Posterior Ankle Impingement Syndrome
- Plantar Flexion Test
Examination techniques of muscles functions[3]
| Muscle | Ankle position | Manoeuvre of the test |
| Tibialis Anterior | Maximum Dorsiflexion and inversion | Try to plantarflex the ankle with your hand and ask the patient to resist, use your second hand on the tendon to feel the contraction |
| Tibialis posterior | Plantar flexion and inversion | The patient inverts the foot in full plantar flexion whilst the examiner pushes laterally against the medial border of the patient’s foot (in an attempt to evert the foot). The examiner needs to use a second hand on the tendon to feel the contraction |
| Peroneal longus and peroneal brevis | Plantar flexion and eversion | The patient everts the foot in full plantar flexion and the examiner pushes medially against the lateral border of the patient’s foot (in an attempt to invert the foot) |
| Extensor hallucis longus | Neutral | The patient extends the great toe and the examiner tries to plantarflex it |
| Extensor digitorum longus | Neutral | The patient extends the lesser toes toe and the examiner tries to plantarflex it |
| Flexor hallucis longus and flexor digitorum longus | Neutral | The patient curls the toes downward and the examiner tries to dorsiflex them1 |
Different types of abnormal gaits
| Type of the gait | Physical findings and observations | Possible cause |
| Antalgic gait | The short stance phase of the affected side Decrease of the swing phase of the normal side | Pain on weight-bearing could be any reason from Back pathology to a toe problem, e.g., degenerative hip joint |
| Ataxic (stamping) gait | Unsteady and uncoordinated walk with a wide base | Cerebral cause Tabes dorsalis |
| Equinus (tiptoes) gait | Walking on tiptoes | Weak dorsiflexion and/or plantar contractures |
| Equinovarous gait | Walking on the out border of the foot | CETV |
| Hemiplegic (circumduction) gait | Moving the whole leg in a half-circle path | Spastic muscle |
| Rocking horse (gluteus maximum) gait | The body shift backward at heel strike then move forward | Weak or hypotonic gluteus maximum |
| Quadriceps gait | The body leans forward with hyperextension of the knee in the affected side | Radiculopathy or spinal cord pathology |
| Scissoring gait | One leg crosses over the other | Bilateral spastic adductors |
| Short leg (Equinus) gait (more than 3 cm) | Minimum: Dropping the pelvis on the affected side Moderate: Walks on forefoot of the short limb Severe: Combination of both | Leg length discrepancy |
| Steppage gait (high stepping – slapping – foot drop) | No heel strike The foot lands on the floor with a sound like a slap | Foot drop Polio Tibialis anterior dysfunction |
| Trendelenburg (lurching) gait | Trunk deviation towards the normal side When the foot of the affected side leaves the floor, the pelvis on this side drops | Weak gluteus medius |
| Waddling gait | Lateral deviation of the trunk with an exaggerated elevation of the hip | Muscular dystrophy |
Correlations between the anatomical site of the pain and the possible underlying causes[rx]
| Location of pain | Common possible pathology | |
| Anterior ankle pain | Degenerative disease | Impingement |
| Ankle joint capsule injury ex. Sports injury with maximum ankle joint plantarflexion | ||
| Medial pain below the medial malleolus | Sinus tarsi syndrome Subtalar degenerative changes Tarsal coalition of mid facet | Spring ligament or deltoid ligament pathology Tibialis posterior pathology or medial impingement |
| Postero-medial pain | Tibialis posterior tendonitis | Flexor hallucis longus Tarsal tunnel syndrome |
| Posterior pain | Achilles tendinopathy Posterior impingement | Os trigonum pathology |
| Postero-lateral pain | Peroneal tendon | |
| Lateral pain | Stress fracture of distal fibula ATFL injury Lateral impingement | Sinus tarsi syndrome Subtalar pathology Calcaneal fracture malunion |
| Heel pain | Plantar fasciitis Calcaneal stress fracture Entrapment of the first branch of lateral plantar nerve | Fat pad atrophy/contusion Tarsal tunnel syndrome Foreign body reaction Plantar fascia rupture |
| Midfoot pain | Degenerative disease Post-traumatic arthritis | Tarsal bones stress fracture Ligament injury ex Lisfranc injury Insertional tendinopathy of peroneal brevis |
| Forefoot pain | Metatarsalgia Morton neuropathy Stress fracture Freiberg disease | Metatarsophalangeal joint synovitis Nail pathology |
| Forefoot pain – big toe | Hallux valgus/rigidus Inflamed bunion | Sesamoiditis Sesamoid fracture |
| Forefoot pain – 2nd, 3rd, and 4th toe | Claw toe Hammertoe | Mallet toe |
