Foot and ankle examination

Question 1

What is the general order in which you should examine the foot and ankle?

Answer 1

Look: Standing, gait, sitting

Feel: Temperature, pulse

Move: Active and passive

Sensation

Resisted movements/power

Special tests

Question 2

How should you position the patient when looking at their foot and ankle whilst sitting?

Answer 2

Sitting on bed with foot and ankle overhanging edge

Question 3

When the patient is sitting with overhanging foot and ankle, what surfaces do you examine?

Answer 3

Forefoot and toes

Plantar surface/sole

Shoes

Question 4

Why do you need to examine the patient’s shoes, when they are sitting?

Answer 4

Abnormal or asymmetrical wearing of the sole or upper

For evidence of poor fit or the presence of special insoles, as this can cause fixed flexion deformities in toes

Question 5

When the patient is standing, what 4 angles do you examine their foot and ankle from?

Answer 5

Anterior
Lateral
Posterior
Lateral

Question 6

When the patient is standing, what do you look for on the anterior aspect of their foot and ankle?

Answer 6

Symmetry across both feet and ankles

Toe alignment and if they are touching the ground eg. fixed flexion deformities

Calluses

Unilateral/bilateral swelling in foot, toes or ankle joints

Psoriasis plaques/other skin changes

Nail changes

Lumps/nodules on their forefoot eg. rheumatoid nodules, gouty tophi

Bruising, erythema

Muscle bulk of lower calf muscles

Question 7

Where do gouty tophi tend to present most commonly in foot and ankle, and describe their colour and texture?

Answer 7

Phalangeal joints in toes (mostly big toe)

Can also appear in midfoot and ankle, or any joints

Large, hard lumps, white/chalky colour

Question 8

Where do rheumatoid nodules tend to appear in foot and ankle, and describe their appearance?

Answer 8

Balls of the feet, sides of the feet, on the toes, plantar surface

Rubbery surface, mobile, firm to touch

Question 9

What are the 3 most common fixed flexion deformities of the lesser toes, and what conditions do they indicate?

Answer 9

Mallet toe: Mostly from wearing too narrow shoes
Claw toe: RA
Hammer toe: RA, maybe PsA

All can result from wearing narrow shoes and no pathology

Question 10

What 2 conditions can bruising in the foot or ankle commonly indicate?

Answer 10

Recent trauma

Haemarthrosis due to clotting disorder or anticoagulant medication

Question 11

What is hallux valgus/bunion and what condition is it a characteristic finding of?

Answer 11

Lateral angulation at metatarsophalangeal joint of great toe

Inflammatory conditions, mostly RA but can be PsA eg.

Question 12

What is hallux varus, and what conditions cause it?

Answer 12

Medial angulation at metatarsophalangeal joint of great toe

Inflammatory conditions eg. RA, PsA

Question 13

What do you look at on the foot and ankle from the lateral aspect?

Answer 13

Foot arch abnormalities

eg. flat feet: pes planus

eg. abnormally raised arch: pes cavus

Muscle bulk of lower calf muscles

Question 14

If you see that someone has flat feet, what should you do to confirm this abnormality?

Answer 14

Ask them to stand on tiptoes and then see if their foot arch becomes normal

Question 15

What do you look at on the foot and ankle from the posterior aspect?

Answer 15

Normal/abnormal heel alignment of hindfoot eg. varus, valgus deformity

Muscle bulk of lower calf muscles

Achilles tendon

Question 16

On the posterior aspect of the foot and ankle, why is important to look for heel misalignment?

Answer 16

Can indicate ankle/subtalar joint disease

Question 17

On the posterior aspect of the foot and ankle, what do you look for on the Achilles tendon?

Answer 17

Thickened tendon

Calcific tendinitis

Rupture

Question 18

What does calcific tendinitis of the Achilles tendon look like?

Answer 18

Calcified mass in the distal Achilles tendon at its insertion site onto the posterior calcaneus.

Localized erythema and edema may be present along with an inflamed retrocalcaneal bursal sac

Question 19

What does rupture of the Achilles tendon look like?

Answer 19

Loss of normal heel tone

Loss of tendon definition

Swelling

Erythema

Question 20

What do you look for on the sole/plantar surface of foot?

Answer 20

Calluses

Question 21

Where should you feel the temperature, in a foot and ankle examination?

Answer 21

Forefoot, midfoot, lower calf

Ankle joints and foot joints

Question 22

Why is it important to feel the temperature of the joints in the foot and ankle?

Answer 22

Higher temperature can indicate infection, septic arthritis, inflammation of joint space

Along with redness, swelling

Question 23

Which 2 pulses should you feel in the foot and ankle, and what do you compare between each leg?

Answer 23

Dorsalis pedis

Posterior tibial artery

Compare pulse strength

Question 24

Why should you gently squeeze the MTP joints in the forefoot before palpating the rest of the joints?

Answer 24

If painful or tender, this can indicate synovitis that isn’t obviously palpable

Question 25

What joints and bones in the foot and ankle should you palpate after the MTP squeeze?

Answer 25

Metatarsal and tarsal bones Tarsal joint Ankle joint Subtalar joint Calcaneum Medial/lateral malleoli Distal fibula

Question 26

Why should you palpate the Achilles tendon?

Answer 26

Feel for tenderness, swelling, loss of definition as this indicates rupture or tendonitis

Question 27

How do you ask a patient to show plantarflexion of the ankle joint?

Answer 27

Ask patient to point/push their feet downwards 'Push down like you're pressing on a pedal'

Question 28

How do you ask a patient to show dorsiflexion of the ankle joint?

Answer 28

Ask patient to point their feet towards their head “Extend your feet backwards, like you’re trying to point them up towards your head.”

Question 29

How do you ask a patient to show foot/ankle inversion?

Answer 29

Ask patient to angle their feet to try to touch their soles together

Question 30

How do you ask a patient to show foot/ankle eversion?

Answer 30

Ask patient to angle soles outwards as far as they are able to

Question 31

How do you ask a patient to show toe flexion and extension?

Answer 31

Ask patient to curl toes as tightly as possible Ask patient to point toes towards their head

Question 32

When testing passive foot and ankle movements, where should you position your non-dominant hand and why?

Answer 32

Hold the heel to feel for crepitus in ankle joint

Question 33

What special test should you do that can indicate Achilles tendon rupture?

Answer 33

Simmonds' test Ask the patient to kneel on a chair with their feet hanging over the edge, then squeeze each of the patient’s calves in turn. Positive: No plantarflexion Negative: Planterflexion happens

Question 34

Which 7 nerves should you examine in the foot and ankle for sensory innervation?

Answer 34

Deep peroneal nerve Lateral plantar nerve Medial plantar nerve Sural nerve Saphenous nerve Superficial peroneal nerve Calcaneal nerve of tibial nerve

Question 35

Where do you examine sensory innervation of the deep peroneal nerve?

Answer 35

1st toe webspace on foot dorsum

Question 36

Where do you examine sensory innervation of the superficial peroneal nerve?

Answer 36

Middle of foot dorsum

Question 37

Where do you examine sensory innervation of the saphenous nerve?

Answer 37

Medial aspect of foot up to metatarsophalangeal joint of great toe

Question 38

Where do you examine sensory innervation of the sural nerve?

Answer 38

Lateral aspect of foot from inferior ankle to little toe

Question 39

Where do you examine sensory innervation of the medial plantar nerve?

Answer 39

Planter surface under 1st toe webspace

Question 40

Where do you examine sensory innervation of the lateral plantar nerve?

Answer 40

Planter surface under 4th toe webspace

Question 41

Where do you examine sensory innervation of the calcaneal branch of the tibial nerve?

Answer 41

Plantar surface of heel