11/13/24, 6\:50 PM Guide | Ankle and foot examination

Ankle and foot examination

Table of contents
/
0\:00 4\:19

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adequately expose the patient’s legs from the knee down.
Position the patient standing for initial inspection of the ankles and feet.
Ask the patient if they have any pain before proceeding with the clinical examination.

Look

General inspection

Clinical signs
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
Body habitus\: obesity is a signi
Scars\: may provide clues regarding previous lower limb surgery.
Wasting of muscles\: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.
https\://app.geekymedics.com/osce-guides/clinical-examination/ankle-and-foot-examination/ 1/711/13/24, 6\:50 PM Guide | Ankle and foot examination
Objects or equipment
clinical status\:
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
Walking aids\: the ability to walk can be impacted by a wide range of knee, hip and ankle pathology.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications (e.g. analgesia).

Gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Gait cycle\: note any abnormalities of the gait cycle (e.g. abnormalities in toe-o
Range of movement\: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, in
Limping\: may suggest joint pain (i.e. antalgic gait), weakness or joint instability (e.g. ligamentous injury).
Leg length\: note any discrepancy which may be the cause or the result of joint pathology.
Turning\: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
Height of steps\: high-stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy (e.g. trauma,
surgery).
Ask the patient to walk on their tip-toes and then on their heels to further screen for pathology. Patient's with arthritis or lower
limb muscle weakness will struggle to perform these tasks.
Observe the patient's gait
Gait cycle
The gait cycle has six phases\:
1. Heel-strike\: initial contact of the heel with the
2. Foot
3. Mid-stance\: the weight is aligned and balanced on this leg.
4. Heel-o
5. Toe-o
6. Swing\: the foot swings forward and comes back into contact with the
https\://app.geekymedics.com/osce-guides/clinical-examination/ankle-and-foot-examination/ 2/711/13/24, 6\:50 PM Guide | Ankle and foot examination
Stages of the gait cycle (1-5)

Closer inspection of the ankles and feet

Ask the patient to stand and turn in 90° increments as you inspect the ankles and feet from each angle for evidence of
pathology.
Anterior inspection
Inspect the anterior aspect of the ankles and feet noting any abnormalities\:
Scars\: note the location of scars as they may provide clues as to the patient's previous surgical history or indicate previous
joint trauma.
Bruising\: suggestive of recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting
disorders such as haemophilia).
Swelling\: note any evidence of asymmetry in the size of the ankle joints that may suggest unilateral swelling (e.g. e
in
Psoriasis plaques\: typically present over extensor surfaces and important to note due to the association with psoriatic
arthritis.
Fixed
Big toe misalignment\: note any evidence of lateral (hallux valgus/bunion) or medial (hallux varus) big toe angulation.
Calluses\: thickened, hardened skin that develops as a result of repetitive friction which may be caused by poorly
footwear or a gait abnormality.
Lateral inspection
Inspect the lateral aspect of the ankles and feet, noting any abnormalities\:
Foot arch\: inspect for evidence of
Posterior inspection
Inspect the posterior aspect of the ankles and feet noting any abnormalities\:
Scars\: again look for scars indicative of previous trauma or surgery.
Muscle wasting\: inspect for any asymmetry in the muscle bulk of the posterior compartment of the lower leg suggestive of
disuse atrophy or a lower motor neuron lesion.
Heel misalignment\: may be caused by a valgus or varus deformity of the ankle joint.
Achilles tendon\: discontinuity and swelling may indicate tendonitis and/or rupture.
https\://app.geekymedics.com/osce-guides/clinical-examination/ankle-and-foot-examination/ 3/711/13/24, 6\:50 PM Guide | Ankle and foot examination

Feel

Ask the patient to lay on the clinical examination couch.

Temperature

Assess and compare ankle joint and foot temperature using the back of your hands.
Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis
or in

Pulses

Posterior tibial pulse
Palpate the posterior tibial pulse\:
The posterior tibial pulse can be located posterior to the medial malleolus of the tibia.
Palpate the pulse to con
Dorsalis pedis pulse
Palpate the dorsalis pedis pulse\:
The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over
the second and third cuneiform bones.
Palpate the pulse to con

Metatarsophalangeal joint squeeze

Gently squeeze across the metatarsophalangeal (MTP) joints and observe for verbal and non-verbal signs of discomfort.
Tenderness is suggestive of active in

Ankle and foot palpation

Palpate the ankle joints and the various joints/bones of each foot, noting any swelling, irregularity or tenderness\:
Metatarsal and tarsal bones
Tarsal joint
Ankle joint
Subtalar joint
Calcaneum
Medial/lateral malleoli
Distal

Achilles tendon palpation

Palpate the gastrocnemius muscle and the Achilles tendon\:
Note any focal tenderness or swelling suggestive of tendonitis.
Note any discontinuity in the tendon suggestive of rupture.
https\://app.geekymedics.com/osce-guides/clinical-examination/ankle-and-foot-examination/ 4/711/13/24, 6\:50 PM Guide | Ankle and foot examination
Assess the temperature of the joints

Move

The ankle joint and the joints of the feet should be assessed and compared.
If the patient is known to have an issue with a particular ankle or foot, you should assess the 'normal' ankle or foot
comparison.

Active and passive movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of
active movements to assess joint function. As the patient performs each movement, note any restrictions in the range of the
joint's movement and also look for signs of discomfort. It's important to clearly explain and demonstrate each movement you
expect the patient to perform to aid understanding.
Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and
allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move
the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of
movement.
Ask the patient to perform all of the below actively and then repeat the movements passively.
Foot plantar
Normal range of movement\: 0-50°
Instructions\: " P u s h y o u r f e e t d o w n w a r d s , l i k e y o u a r e p r e s s i n g a c a r p e d a l .
"
Foot dorsi
Normal range of movement\: 0-20º
Instructions\: " E x t e n d y o u r f e e t b a c k w a r d s , l i k e y o u' r e t r y i n g t o p o i n t t h e m u p t o w a r d s y o u r h e a d .
"
Toe
Instructions\: " C u r l u p y o u r t o e s a s t i g h t a s y o u c a n .
"
Toe extension
Instructions\: " E x t e n d y o u r t o e s b a c k w a r d s , l i k e y o u' r e t r y i n g t o p o i n t t h e m t o w a r d s y o u r h e a d .
"
Ankle/foot inversion
https\://app.geekymedics.com/osce-guides/clinical-examination/ankle-and-foot-examination/ 5/711/13/24, 6\:50 PM Guide | Ankle and foot examination
Normal range of movement\: 0-35º
Instructions\: " T r y t o t o u c h t h e s o l e s o f y o u r f e e t t o ge t h e r .
"
Ankle/foot eversion
Normal range of movement\: 0-15º
Instructions\: " T r y t o a n g l e t h e s o l e s o f y o u r f e e t o u t w a r d s a s f a r a s y o u a r e a b l e t o .
"

Passive movement only

The movements of the following joints need to be assessed passively as they are di
Subtalar joint
Midtarsal joint
Assess ankle plantar

Special tests

Simmonds' test

Simmonds' test is used to assess for clinical evidence of Achilles tendon rupture\:
1. Ask the patient to kneel on a chair with their feet hanging over the edge.
2. Squeeze each of the patient's calves in turn.
Interpretation
In healthy individuals, the foot should plantar
muscle and the subsequent pulling force transmitted via the Achilles tendon.
There will be no movement of the foot if the Achilles tendon is ruptured due to loss of continuity between the gastrocnemius
and the foot.
https\://app.geekymedics.com/osce-guides/clinical-examination/ankle-and-foot-examination/ 6/711/13/24, 6\:50 PM Guide | Ankle and foot examination
Squeeze the patient's calf

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r s S m i t h , a 3 2- y e a r-o l d f e m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t ,
w i t h n o s t i g m a t a o f m u s c u l o s k e l e t a l d i s e a s e . T h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
" T h e a n k l e s a n d f e e t a p p e a r e d n o r m a l o n i n s p e c t i o n a n d t h e p a t i e n t' s g a i t w a s u n r e m a r k a b l e . T h e r a n g e o f m o v e m e n t
t h r o u g h o u t t h e a n k l e s a n d f e e t w a s n o r m a l .
"
" I n s u m m a r y , t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Neurovascular examination of both lower limbs.
Examination of the knee and hip joint.
Further imaging if indicated (e.g. X-ray and MRI).

Reviewer

Mr Tejas Yarashi
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/clinical-examination/ankle-and-foot-examination/ 7/7