Foot and Ankle Examinations

Foot and Ankle Examinations are done to evaluate the foot and ankle pathologies and are discussed in the following headings.

History taking in Foot and Ankle Examinations:

• Pain
• Deformity
• Decrease function
• Instability
• Cosmesis
• Footwear difficulty

Inspection

Gait

• Single stance tip-toe
• Double stance tip-toe
• Walk on heels, Lateral border
• Standing on heels: Functions of extensors and Achilles tendons
• Ski stance: How much dorsiflexion can patiently do

Details on Gait Evaluation

Alignment

Look for Hind foot: Valgus/ Varus either

Normally heel is on a slight valgus

“Too Many Toe Sign”

More than 2 toes seen from behind due to adduction in forefoot => PES PLANUS

Heel Size

Look for

• Any broadening
• Pattern
• Position
• Compare with the contralateral side

Tell the patient to stand on toes (tip) and heel

Windlass effect=> Inversion and increased the height of the medial longitudinal arch

Assess Plantar fat pad

Calcaneal tuberosity (abnormal increase prominence of superior aspects is Haglund deformity or pump bump

Retrocalcaneal bursitis

Achilles tendinitis ( Swelling at the level of malleolus);

Achilles tendon rupture= Swelling over the whole length

Calf Atrophy: Residual of CTEV, TA rupture, or prolonged immobilization

Medial Aspects

Medial longitudinal arch see for

• Cavus
• Planus
• Rocker bottom deformity

Bony prominence

Medial malleolus

Head of 1^st metatarsal

Calcaneal tuberosity

Navicular tuberosity

Lateral Aspects

Lateral malleolus

5^th Metatarsal base

Tendoachillis and peroneus brevis tendon

Anterior aspects

See for Alignment

Greater toe : Hallus valgus/ Varus

Other toes: Claw, Mallet, Hammer toes

Rotation of forefoot, midfoot, and hindfoot and their relationship to reach other and lower leg

In toes

• Loss of transverse skin crease at IP joint= Polio
• Thickened cornified skin= Seen in the dorsum of toe deformity
• Nail deformities = Fungal infections, Paronychia, Ingrown nails

Osteophytes

• Medially over 1^st MTP= bunion
• Lateral aspects of 5^th MTP joint = Bunionette

The tendon from EHL and EDL: Visible over the foot

Relation of medial and lateral malleoli=> Normally lateral is below and posterior to the medial malleolus

Swelling over malleolus: Trauma, Tendinitis, Bursa

See anterior crest of tibia and subcutaneous border (swelling, deformity)

Planter Aspects

Callosities

Corns

Ulceration

Warts/ Fungal Infections

Standing on a single foot, another raising- Heel is going into varus–>foot arch is forming,

Signifies:-

• The subtalar joint is moving and flexible
• Intact Tibialis posterior muscle

If no raising heel, the heel does not go in the valgus, which signifies:

• Dysfunctional Tibialis posterior
• Fixed in valgus

In the flexible flat foot

• The heel will be in valgus in standing, medial arch touching the ground and flat but when we raise the heel it changes into varus with the arch formation

Palpation

Palpate in sequence:

Medial sides

Palpate tip of medial malleolus-> Tibialis posterior( at the back of medial malleolus) -> palpate Achilles tendon ->look for hadlung deformity->Heel tenderness also retrocalcaneal bursitis->Plantar fascitis (tenderness over calcaneal attachment, on hyperextending toes, painful nodes

Lateral sides

Lateral malleolus->Anterior talofibular ligaments( in antero lateral gutter)-> calcaneofibular ligaments->Peroneal tendons->calcaneal tuberosity (sever’s disease)-> fibular shaft (stress fracture)

Anteriorly

Anterior tibial crest (stress fracture)-> talonavicular joint (talar dome in OCD)->0.5 cm down -> intercuneiform joint ->TMT joints(move across and feel all TMTs)->palpate all joints (interdigital joints-> palpate for motor neuroma)

Planter

Callosities- tender

Sesamoid- tenderness

Planter fascia-tenderness at calcaneal attachment in fascitis, tenderness on hyperextending toes

Planter fat pad tenderness

Movements

Ankle

Dorsiflexion: 20°

Plantar flexion: 50°

The leg is held with one hand and the foot is grasped such that the head of the talus is grasped in hand to exclude any movement at the subtalar joint

Subtalar Joint:

Inversion: 40°

Eversion: 20°

Forefoot

Adduction/ Abduction

Great toe

MTP Joint

• Extension= 70°
• Flexion= 45°

IP Joint

• Extension=0°
• Flexion=90°

Other toes

MTP Joints

• Flexion=40°
• Extension=40°

IP Joints

• Flexion= 40°
• Extension=0°

Measurements

Heel Length: Tip of the medial malleolus to Heel

Circumferential : Foot: At height of medial longitudinal arch; Calf

Special tests

Achilles Tendinopathy

Morton’s neuroma:

MULDER’S CLICK

Compress 1^st and 5^th metatarsal head together

If neuroma Presents: Pain appears

Syndesmotic injury

1. External rotation test: Externally rotating foot
2. Squeeze test: Squeeze tibia and fibula together
   • Pain appears

Plantar fascitis

• Tenderness at the origin of the plantar fascia
• Pain during hyperextension of the great toe (Windlass effect)

Complete with Neurological evaluation, peripheral pulses, and adjacent joints evaluation.