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, Khloud Shreif, Rachael Lowe, Kai A. Sigel, Simisola Ajeyalemi, Pinar Kisacik, Evan Thomas, Rucha Gadgil and Wanda van Niekerk

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 foot and ankle can be referred from the back)
• Is there hip or knee 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 a deltoid ligament sprain, varus force may indicate injury to the ATFL and/or CFL).

Make sure you rule out the back unless there is a clear mechanism of injury as the ankle 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 fractures 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 collapsing)
• 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
• Star Excursion Balance Test

Inspection & Palpation

Inspection

• Deformity - is there any deformity present such as bunions, hammer toes, claw toes, calluses
• Effusion
• Muscle Wasting

Palpation

• Joint Lines
• Medial and lateral ligaments
• Achilles tendon, peronei and other extrinsic muscles

Neurologic Assessment

If neurological deficits 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

Vascular Assessment

If it is suspected that the circulation is compromised, the clinician palpates the pulses of the dorsalis pedis artery. The state of the vascular system can also be determined by the response of symptoms to positions of dependence and elevation of the lower limbs.

Movement Testing

• Clear lumbar spine, hip and knee with full AROM + overpressure
• AROM, PROM, and Overpressure - ankle, subtalar joint, midfoot, forefoot and toes
• Specific joint mobility - test each individual joint with a glide, compare 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 proximally
  
• If lumbar spine suspected, add passive intervertebral 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 special tests for the foot and ankle

• Ottawa Ankle Rules - to determine if a radiograph needs to be ordered
• Ankle ligament stress tests
  • Talar tilt test
  • Anterior Draw of the Ankle
  • Eversion stress test
• Muscle tests - are the intrinsic and extrinsic muscles functioning
• Silfverskiöld test
• Squeeze test
• Windlass test
• Impingement sign ankle
• Navicular Drop Test

Biomechanical Evaluation

Foot assessment is a common approach in clinical practice for classifying foot type with a view to identifying possible etiological factors relating to injury and prescribing therapeutic interventions.

See detail on the Biomechanical Assessment of the Foot and Ankle page