Foot and Ankle Assessment-Investigations and Tests

Original Editor - Rachael Lowe

Top Contributors - Ewa Jaraczewska, Admin, Kim Jackson, Lucinda hampton, Samuel Adedigba, Nikhil Benhur Abburi, Jess Bell, Shejza Mino, Rachael Lowe, Kai A. Sigel, Simisola Ajeyalemi, Khloud Shreif, Evan Thomas, Rucha Gadgil, Wanda van Niekerk and Pinar Kisacik

Subjective (Patient Intake)

Patient Intake

• History of present condition (HPC) (Was there trauma or was it insidious onset? Mechanism of Injury?)
  

Special Questions (Region‐specific historical examination)

• Any back or leg pain? (Is pain in a dermatomal region - pain in the knee can be referred from the back)
• Is there hip or ankle pain? (Ankle pain can be referred from the hip or biomechanically affected by the ankle)
  
• Type of shoes ( wear patterns/age of shoes/proper design)

Additional Information

• Past Medical History (PMH) (Pre-existing medical conditions)
• Drug history (DH) (Any relevant medications?)
• Social History (SH) (Work/sports/hobbies affected?)

Investigations

• Radiological Considerations  - any previous X-Rays or scans
  
• Other investigations - any recent blood tests

Red Flags

These are the special questions which may indicate that something more sinister may be going on. If you suspect that the problem is not musculoskeletal and/or something sinister may be going on patients should be referred immediately back to their doctor with your concerns noted. 

• Bilateral pins and needles or numbness in the LL.
• Problems with bowel and bladder function where the patient is unable to feel themselves going to the toilet.
• Incontinence.
• Paraesthesia in the groin region.
• Loss of pulses in the LL (Vascular compromise).
• Obvious deformity.

If nothing sinister but the symptoms are more severe than you might expect ask a seniors advice on whether and A&E referral is more appropriate. Mechanism of Injury is important here, what force was exerted through the leg? Was it enough for a tibia/femur fracture? Loss of pulses in the foot may indicate vascular compromise.

Clinical Reasoning - What does the History tell you?

Knowing the history gives clues as to the structures affected. Mechanism of injury is extremely important. If you can work out the force of the injury this gives you clues on likely stretched/ damaged structures (Valgus force may indicate an MCL sprain, varus force may indicate an LCL sprain, foot planted and twisted may indicate an ACL sprain/rupture).

Make sure you rule out the back and hip unless there is a clear mechanism of injury as the knee can be a referred site of pain for both these areas. Immediate swelling and bruising usually indicates significant trauma and may require X-Ray to rule out tibial plateau fractures, bone bruises or an MRI to investigate integrity of the ligaments.

Go into your objective examination with a working hypothesis. Use your physical examination to identify dysfunction and special tests to prove or disprove your hypothesis.

Objective

The objective examination gives you quantifiable measures to rule out what structures are involved and to reassess after treatment to determine improvement/deterioration.

General Observation (in standing)

• Posture - foot posture in standing, arch posture
• Movement Patterns - see functional tests, calf flexibility (without subtalar joint/midfoot colapsing)
• Gait Analysis - walking normally, on insides and outsides of feet, walk on heels and toes, in a straight line, running (particularly if pain present on running)

Functional Tests

• Small knee bend
  
• Sit to stand
• Squat
• Double heel raise
• Jump
  
• Single leg stand
• Single knee bend
  
• Single heel raise
• Hop
• Running

Inspection & Palpation

Inspection

• Effusion
• Poor Alignment
• Muscle Wasting
  

Palpation 

• Medial and lateral ligaments
  
• Joint Line
• 
  

Neurologic Assessment

If neurological defecits or referral from lumbar spine are suspected you should perform a neurological assessment:

Reflexes

• Patella Ligament (L3/L4)
• Achilles Tendon (S1/S2)

Dermatomes

• L1 to S4

Myotomes

• L2      Hip Flexion
• L3      Knee Extension
• L4      Dorsiflexion
• L5      Big Toe Extension OR 4 Lesser Toes Extension
• L5/S1 Knee Flexion
• S1      Plantarflexion OR Foot Eversion
• S2      Toe Flexion
  

Other neurological testing includes: Babinski and Clonus

Movement Testing

• Clear lumbar spine, hip and knee with full AROM + overpressure
• AROM, PROM, and Overpressure - ankle, subtalar joint, midfoot and forefoot
• Specific joint mobility - Foot Mobilisation Technique tests each individual joint with a glide, compares with the other side and with what you know as normal 
• Lower limb muscle strength and length - particularly calf plus gluts, TFL and hip flexors promimally
  
• If lumbar spine suspected add passive intevertebral mobilisations (PA spinous processes, PA transverse processes).

Special Tests

Special tests are used to prove or disprove your working hypothesis and identify the dysfunctional structures.  See full list of ankle special tests

• Silfverskiöld test

MCL/LCL

• Valgus stress test

LCL

• Varus stress tests
•