Ankle and foot

1. CLINICAL EXAMINATION OF
ANKLE&FOOT
Dr.SAJITH KURIAN PG M.S Ortho,
Department of orthopaedics
COIMBATORE MEDICAL COLLEGE

2. TITLES
 HISTORY
 GENERAL EXAMINATION
 LOCAL EXAMINATION
1)INSPECTION
2)PALPATION
3)RANGE OF MOTION
4)MEASUREMENTS

3. HISTORY
 1)Age:CTEV present since birth,TEV secondry to polio,neural tube
defects etc.appear later.CVT noticed at walking age around 1 year
 2)SEX:CTEV common in boys
 ASSOCIATED DISEASES :fever with myalgia and weakness of limbs in
polio

4. PAIN
 1)site,
 2)radiation,
 3)type,
 4)character
 5)aggravating factors
 6)relieving factors
 7)diurnal variation
 8)postural variation

5. SWELLING
 Duration
 Onset
 Progress
 aggravating factors,relieving factors
 effect of any treatment received
 diurnal and postural variation
 associated with deformity in other foot

6. LIMP
 onset
 Duration
 painless or painful
 progressive or not

7. INSTABILITY
 duration
 Onset
 unilateral or bilateral
 on even or uneven surfaces

8. DEFORMITY
Onset(at birth (CTEV)OR appeared later (aquired
clubfoot)appears at around 1 year in CVT,after an episode
of fever and myalgia with weakness of limbs and muscles
polio,progress ,any treatment received,response to any
such treatment

9. GENERAL EXAMINATION
Examine hip and spine for congenital hip
dislocation,myelomeningocele
spinal dysraphism,
Arthrogryposis multiplex congenita

10. INSPECTION
 Foot examination should always start with patients
footwear
 look for Shoe upper deformation & sole wear (it can tell
about severity and chronicity of foot deformity or
neuromuscular imbalance especially in assymetrical
cases
 It can tell about the expectations of the paients

11.  Inspection has three major aspects
 1)standing inspection
 2)gait assessment
 3)sitting inspection

12. STANDING INSPECTION
 Imp: some critical deformities wiil be appreciated only
while standing
 Digree of hallux valgus and pronation,
 Lesser toe deformity in particular deviation between the
2nd and 3rd toes in comparison to asymptomatic side
 Forefoot abductus and adducts
 And arch height

13.  Ask the patient to turn to opposite side
 Look for alignment of heel relative to leg
 Look for abnormal visualisation of digits laterally(the “
TOO MANY TOES” sign seen in pes planus with
forefoot adductus)

14. GAIT ASSESSMENT
 Avoidance patterns associated with HALLUX
RIGIDUS(no great toe extension after heel off)
 Toe walking:plantar fascitis,heel pain syndrome or stress
frscture (to avoid heel wt bearing)
 External rotation gait:ankle arthodesis

15. SITTING INSPECTION
 Patient must be sitting at the edge of the table with
legs hanging freely
 Entire lowerlimb should be examined
 Neurological examination should be done as
defecits produce different deformities of foot and
toes

16. INSPECTION OF ANTERIOR ASPECT
 1)alignment:
great toe(hallux valgus/varus)other
toes(claw,hammer,mallet)
Relations of forefoot,midfoot,hindfoot w.r.t
each other and lower leg
 2)Condition of skin:
any discolouration,ulcers,dialated veins

17. 3)TOES
 notice transverse skin crease at I-P joint(lost in polio)
 Thickened cornified skin over dorsum(heloma durum)
seen in toe deformities
 Toe nail deformities in fungal infections.
 Paronychia ,ingrowing toe nail
 Osteophytes medially over 1st MTP joint is BUNION
and lateral aspect of 5th MTP joint is called
BUNIONETTE

18. 5)TENDON
tendons of EHL andEDL are visible over foot and
anterior aspect of ankle by active contraction of muscles
6)Relation of medial and lateral malleoli:normally lateral is
below and posterior to medial malleoli
7)Any swelling over malleoli:seen in trauma,
tendinitis ,bursitis
8)Anterior crest of tibia and subcutaneous border may
show swelling,deformities

19. INSPECTION OF LATERAL ASPECT
Visualise lateral malleolus ,5th MT base ,tendo achilles and
peroneus brevis tendon,look for any swelling

20. INSPECTION OF POSTERIOR ASPECT
1)Alignment : varus/valgus,too many toes sign
2)heel:size,pattern and position
3)Tell the patient to stand on tips of toes(windlass effect-
inversion and incresed height of medial arch)
4)Plantar fat pad,calcaeneal tuberosity(abnormally
increased prominenece of superior aspect is hagelund
deformity or pump-bump)

21. 5)Retro-calcaneal bursa:bursitis
6)Achilles tendon :tendinitis,rapture,swelling at the level of
malleoli is seen in tendinitis and over whole length is seen
in rapture
7)Calf atrophy(compared to normal):Residum of CTEV,TA
rupture or prolonged immobilisatiion

22. INSPECTION OF MEDIAL ASPECT
 Medial longitudinal arch:cavus or planus or rocker
bottom deformity(in diabetes or improperly treated
CTEV
 Bony prominences :medial malleolus,head of 1st
MT,calcaneal tuberosity and navicular
tuberosity(prominent accessory in accessory navicular)

23.  Tibialis posterior tendon made visible by active
contraction .structures underneath flexor retinaculum of
ankle-tibialis posterior,flexor digitorum longus,posterior
tibial artery,posterior tibial nerve and flexor hallucis
longus

24. INSPECTION OF PLANTAR ASPECT
 Callosity suggests point of weight bearing.Normally seen
over metatarsal heads and lateral margin of foot.painful
calluses over MT heads are seen in claw toe and hammer
toes
 Corns are localised thickening of skin over pressure
areas.Two types hard and soft
 Ulcerations:Diabetes,abnormal bony prominences
 Warts and fungal infections

25. PALPATION
 PALPATION OF ANTERIOR ASPECT
 1)Local rise of temperature
 2)Tenderness :over the anterior tibial crest (in stress
fracture ).
 Over the talar dome: palpated anterolaterally with
maximal passive plantar flexion at ankle (in OCD).Over
talo-navicular joint in osteoarthritis
 Also palpate cuneiforms,metatarsals (stress
fractures,bunions,gout ,septic arthritis,frieberg infarction)

26.  Tenderness in interdigital spaces suggest Mortons
neuroma
 4)SWELLING:over stress fractures,osteophytes over
joints.effusion of joints –cross fluctuation can be
demonstrated between anterolateral and ateromedial
swellings in full plantar flexion.Also seen between
posterolateral and posteromedial swellings in full
dorsiflexion

27.  5)tendons (tautness,tenderness,ump or any gap,diffuse
swelling,crepitus)
 Toes palpate for corns ,ingrowing toe nails
 Tinels sign over deep peroneal nerve

28. PALPATION OF LATERAL ASPECT
 1)lateral malleolus ,anterior talo-fibular ligament
and calcaneo-fibular ligament for swelling and
tenderness
 2)Peroneal tendons
 3)calcaeneum in severs diseas
 4)over sinus tarsi in subtalar arthritis
 5)over fibular shaft :stress fractures

29. INSPECTON OF POSTERIOR ASPECT
 1)Over gastro soleus:In tendo achilles rupture tenderness
gap and swelling at 2-6 cm above TA insertion
 2) over posterior tuberosity of calcaneum:Tender
swelling in retro calcaneal bursitis

30. INSPECTION OF MEDIAL ASPECT
 Medial malleolus and subcutaneous border of tibia
 Head of talus
 Navicular tuberosity :tender swelling in accessory
naviculum
 4)tendons of FHL,FDL @TP
 Tinel sign over posterior tibial nerve and medial and
lateral plantar nerves

31. PALPATION OF PLANTAR ASPECT
 Callosities tendor
 Sesamoids for tenderness
 Plantar fascia tenderness ,tenderness on hyper
extending the toes,painfull nodues
 Plantar fat pad tenderness

32. RANGE OF MOTION
 Ankle : normal dorsi flexion and palntar flexion are 20
and 50 degrees each
 Ankle tested with fore foot in inversion and hind foot in
neutral with one hand gripped in such a way that any
movements of the the subtalar and mid tarsal joints are
excluded
 Assess the dorsiflexion in both knee flexion and
extension in cases of gastrocnemius contracture

33.  Subtalar joint :normal inversion-40 and eversion 20
degrees each
 Examined in prone position
 Hold dorsum of the foot with one hand such that head of
talus is stabilised between thumb and index,hold
calcaneum with thumb and index of other hand

34.  Forefoot :abduction and adduction(normal is jog)with
calcaneum stabilized in neutral postion

35. Great toe :MCP extension -70 flexion -45 digrees
IP-extension -0 and flexion-90 digrees
lesser toes :MCP flexion and extension are 90 & 0
IP 40 each
also test for adduction and abduction

36.  Muscles
 1)grossly ankle and plantar flexors are tested by toe
walking
 2)ankle dorsiflexors by toe walking
 3)evertors by walking on medial border
 4)invertors on walking on lateral border

37. MEASUREMENTS
 Longitudinal ;true and apparent limb length
 Heel length :from tip of medial malleolus vertically
down to point of heel
 Foot length :medial(from back of heel to tip of great toe)
and lateral(to tip of 5th toe)
 Circumferential :at thigh,calf and foot

38. DISTAL NEUROVASCULAR DEFICITS
 Look for ATA & PTA
 Complete neurological examination of ankle

39. SPECIAL TESTS
 All are done with leg hanging freely at the edge of table
 1)ANTERIOR DRAWER TEST:
tests for ant talo-fibular lig:
grasp just above the ankle with one hand and
hold heel with other.Gently pull heel forward with
an internal rotatory movement to foot.
Observe for ant translation and prominence of talar
head anteriolaterally
Difference of 3-5mm in laxity between two sides
with a soft end point or skin tenting anteriolaterally by
talar dome is significant

41.  INVERSION STRESS TEST(varus stress test):tests for
calcaneo-fibular ligament
 Maximally dorsiflex ankle and apply inversion stress test
to calcaneum.abnormal inversion of talus at ankle is
significant

42.  PERONEAL TENDON INSTABILITY TEST
 Rotate ankle from maximal dorsiflexion to eversion to
plantar plantar flexion to inversion
 Palpate posterior to lat malleolus .if peroneal tendons
subluxate or dilocate anterior to malleolus ,suggests
instability

43.  THOMSON TEST

44.  FIRST METATARSAL RISE TEST
 For tibialis posterior tendon
 Patient is made to stand.from behind of the patient ,rotate
leg into ext rotation.if 1st mt rises of the ground, it
suggests instability
 Opposite is Rose test

45.  Mortons test :compress 1st and 5th mt heads if neuroma
present patient will complaint pain I same space
 Homan test :pain in calf on passive dorsiflexion of ankle
seen in DVT