Foot and Ankle Assessment

Original Editor - Ewa Jaraczewska based on the course presented by Helene Simpson

Top Contributors - Ewa Jaraczewska, Kim Jackson, Jess Bell, Lucinda hampton, Aminat Abolade, Nupur Smit Shah, Robin Leigh Tacchetti and Robin Tacchetti  

Assessment Goal

The goal of the assessment is to:

• Determine the extent of the injury
• Identify what has been injured
• Establish a framework that can be negotiated with the patient regarding:
  • Timeline
  • Further referral
  • Treatment plan
  • Treatment strategy

Subjective

Patient Intake

Gathering information during the history provides the clinician with clues as to what structure is likely affected, further guiding the physical examination. For example, the mechanism of injury is important as it provides information on what forces went through what structure, and in what direction. This will further provide information on what tissues and/or structures are likely stretched or damaged.

Example: a valgus force may indicate a deltoid ligament sprain, whereas a varus force may be suggestive of injury to the anterior talofibular ligament (ATFL) and/or calcaneofibular ligament (CFL).

The patient's history should include questions related to:

• The time of the injury (acute vs subacute vs chronic)
• The mechanism of the injury and forces involved in the injury (loose vs locked position)
• The activity that leads to the injury (an athletic event vs recreational activity vs activity of daily living)
• Contributing factors (shoes, terrain, medical history, medications, general health)
• Training history
• Previous treatment (successes vs failures)

The results from the interview should assist with establishing risk factors and precautions during the objective assessment.

"At the end of the patient's interview, the physiotherapist must have a good idea of what needs to be examined objectively. The clinician must later determine if the results of the assessment match the subjective signs and symptoms the patient complained about." Helene Simpson

Special Questions

Red flags are signs and symptoms found in the patient history and clinical examination that may be suggestive of serious pathology. If serious pathology is suspected, immediate referral to a medical doctor is indicated and the physiotherapist's concerns should be noted.

Red Flags specific to foot and ankle assessment:

• Unable to bear weight: rule out fracture (Ottawa Rule)
• Bilateral pins and needles or numbness in the lower limbs
• Bowel and bladder dysfunction (i.e. the patient is unable to feel themselves going to the toilet)
• Urinary Incontinence
• Paraesthesia in the groin region
• Loss of pulses in the lower leg (vascular compromise)
• Obvious deformity
• Joint dislocation
• Positive Babinski sign
• Unable to calf raise: rule out Achilles tendon rupture

Yellow Flags specific to foot and ankle assessment:

• Severity of symptoms do not match the subjective information→more tests
• Pain preventing objective assessment→detailed assessment delayed

Objective

Observation

• Observation
  • Perform with the patient in supine, sitting or standing
  • Watch for the presence of swelling
  • Assess skin colour
  • Check skin temperature
  • Watch for signs of muscle wasting
  • Notice foot and toes deformities: bunions, hammertoes, claw toes, calluses

• Posture assessment
  • If the patient is able to stand: observe in quiet stance and assess weight-bearing distribution; pay attention to foot arches; observe walking with or without assistive device: watch for back deformity: scoliosis, lordosis, kyphosis; observe gait pathology, eg., Trendelenburg; notice any changes in the lower leg alignment: knee valgus or varus, foot pronation or supination; observe gait cycle: heel strike, toe-off.
  • If the patient is unable to stand: observe in sitting, feet flat on the floor, assess the weight-bearing distribution and the patient's ability to take a load while preparing for a sit to stand transition

Squeeze test

External rotation test

Anterior Drawer Test

Functional Tests

The choice of functional tests is based on the patient's signs and symptoms and the physiotherapist's initial list of suspected pathologies. It may include:

• Sit to stand
• Squat: defines the integrity of the syndesmosis joint
• Deep squat
• Tandem stance
• Lounge position
• Step forward and backwards: weight transfer
• Single leg stance: assess postural and balance control
• Step-up
• Step down + step overs
• Knee to wall test - knee extended might relate more to the range of dorsiflexion in gait: helps to assess ankle dorsiflexion range of motion
• Squeeze test: helps to diagnose the syndesmotic ankle sprain
• External rotation test: assesses the integrity of the syndesmotic ligaments
• Anterior drawer test: defines ankle mechanical instability

For high-level performance athletes, additional tests may include a jump or a hop.

Additional details can be found on the Foot and Ankle Assessment-Investigations and Tests page.

Balance Assessment

The results of the balance assessment in the foot and ankle injury help to develop a sensory targeted rehabilitation programme that stimulates sensory receptors. The following are the examples of balance tests:

• Static postural control :
  • Balance Error Scoring System (BESS)
  • Airplane balance test

• Dynamic postural control
  • Star Excursion Balance Test (SEBT)

Palpation

Palpation can be performed in supine, prone and or seated position. The clinician checks for points of tenderness:

• On the medial, lateral, posterior and anterior part of the lower leg and the around calcaneus

• Along joint lines
• At the attachments of the medial and lateral ligaments
• At the Achilles tendon, peronei and other extrinsic muscles

Neurologic Assessment

The neurologic assessment can assist the clinician to identify a potential neurological aetiology for the observed ankle or foot pathology. It includes peripheral neuropathy or central nervous system impairment.

The complete neurological examination should include:

• Inspection
• Reflex testing
  • Achilles Tendon (S1)
  • Patella Ligament (L3/L4)
• Muscle tone assessment
• Sensory testing (proprioception, light touch, sharp/dull)
• Plantar response (also known as the Babinski response)
• Clonus

This video demonstrates the anatomy of the dermatomes of the lower extremities. The sensory testing needs to be performed when pathology or referral from the lumbar spine is suspected:

Vascular Assessment

If compromised circulation is suspected, the clinician should palpate to assess pulses of the dorsalis pedis artery. The state of the vascular system can also be assessed by the response of symptoms to positions of dependence and elevation of the lower limbs.

Movement Testing

• When assessing ankle and foot active range of motion (AROM) and passive range of motion (PROM), all testing positions must be comfortable for the patient. For example, ankle dorsiflexion and plantarflexion are assessed when the patient is prone. If the patient cannot get into the desired position, the clinician can modify the position and document this for future testing. When an ankle fracture is ruled out, but the patient cannot fully participate in the range of motion assessment because of pain, the best option is to immobilise the ankle joint and delay the examination for a few days until the pain subsides.

• The following are the basic range of motion testing in foot and ankle injury:
  • Plantarflexion(PF)/ dorsiflexion (DF)
  • Toe extension/ flexion
  • Pronation/supination
  • Big toe extension/ flexion

This video demonstrates a complete foot and ankle ROM assessment:

• Joint mobility: test each individual joint with a glide and compare to the contralateral side and to normal values

These videos demonstrate specific joint mobility assessments:

• Muscle Strength: Specific active muscle tests (isometric and through range): Gastrocnemius, soleus, tibialis posterior, tibialis anterior, extensor hallucis longus and brevis/flexor hallucis brevis, intrinsics. The strength of toe or digital purchase can be evaluated using the paper pullout test.

This video demonstrates manual muscle testing of the lower extremities:

Biomechanical Evaluation

A foot assessment can be used to classify foot type, as well as to identify possible aetiological factors relating to injury in order to properly prescribe therapeutic interventions.

Details can be found on the Biomechanical Assessment of the Foot and Ankle page.

Additional Testing

Patient-Reported Outcomes (PROs)

Patient-reported outcome measures allow clinicians to prioritise the outcomes most important to patients. In the foot and ankle assessment, it has been determined that physical performance and pain interference were at the top of the patients' priorities when assessing their satisfaction with treatment.

Patient Reported Outcome Measure: Pain Interference

Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI)

One PRO is the Patient-Reported Outcomes Measurement Information System (PROMIS) which takes information from multiple domains to assess patient-reported outcomes. Pain and function are two domains measured by PROMIS PI, a patient-reported outcome measure that defines patients' satisfaction with foot and ankle treatment in response to improvement with these two domains. PROMIS PI detects pain at lower levels than the Visual Analogue Scale, a standard patient-reported pain scale. .

Visual Analogue Scale (VAS)

The Visual Analogue Scale (VAS) is a generic patient-reported pain scale that is used to assess the patient's perception of pain only. The scale may not be reliable in the assessment of the elderly population presenting with mild cognitive deficits or who show difficulties in understanding the instructions for the VAS.

Foot and Ankle Ability Measure (FAAM)

The Foot and Ankle Ability Measure (FAAM) is a self-report outcome instrument developed to assess physical function for individuals with foot and ankle related impairments. This self-report outcome instrument is available in English, German, French and Persian. The Foot and Ankle Ability Measure is a 29-item questionnaire divided into two subscales: the Foot and Ankle Ability Measure, 21-item Activities of Daily Living Subscale and the Foot and Ankle Ability Measure, 8-item Sports Subscale.

Detailed information is available on the Foot and Ankle Ability Measure page.

Conclusion

What→ so what→ now what

At the end of the examination, the clinician should return to the initial list of potential problems/suspected diagnoses and choose the three most likely diagnoses.

The foot and ankle assessment is completed when the clinician is able to provide a response to the following questions:

• What has happened?

• What were the consequences of the incident?

• How are the consequences of the incident going to be treated?
  • What is the treatment plan?
  • What is the treatment strategy?
  • What are the short and long term goal?
  • What is the timeline for goal completion?

Virtual Foot and Ankle Assessment

Telehealth is a well-established alternative to in-person visits as a response to the COVID pandemic and beyond. Development of objective assessment tools for telehealth is a priority in order to demonstrate the outcome of treatments provided via telehealth.

Virtual assessments for foot and ankle pathology have been developed and tested. The following is the guideline for the virtual examination.

Pre-Visit

Prior to the virtual visit, the patient should obtain a pre-visit form and information regarding wardrobe expectations and the camera set up during the examination. The pre-visit form needs to be completed by the patient or the caregiver and it consists of the questions regarding:

• Patient's chief complaint and reason for the visit
• Patient's past and present medical and surgical history
• Medication and allergies
• Social history

Additional information may include biometrics (height and weight) and vital signs (HR, blood pressure, body temperature).

Virtual Assessment

The foot and ankle examination includes:

1. Inspection
   • Patient in standing and seated
   • Camera set up to provide front, side and back view of the foot and ankle
   • The elements of inspection are as follows: alignment, muscle atrophy, joint deformity, incisions, scarring, rash, swelling, ecchymosis, erythema. In addition, the plantar aspect of the foot must be examined for ulcers, abrasions, and skin breakdown.
2. Palpation
   • Patient uses one finger to point to the area of maximal pain or discomfort
3. Range of motion testing
   • Use a web-based goniometer
   • Performed actively (patient's own muscle power) and passively (family member manipulates the joint)
4. Strength testing
   • Assisted by the family member
   • Exam performed on both sides at the same time and differences reported
5. Functional assessment
   • Gait observation
6. Neurovascular assessment
   • Patient touches the skin on both sides and reports differences, however sensory feedback from the patient’s own fingers touching the skin is a limitation.

Additional tests for flatfoot, cavovarus foot, hallux rigidus, and Achilles rupture may be added if the pathology is suspected.