Foot and ankle history and clinical examination: A guide to everyday practice

Table 1 Correlations between the anatomical site of the pain and the possible underlying causes[6]

Location of pain	Common possible pathology
Anterior ankle pain	Degenerative disease	Impingement
		Ankle joint capsule injury ex. Sport injury with maximum ankle joint plantar flexion
Medial pain below the medial malleolus	Sinus tarsi syndrome Subtalar degenerative changes Tarsal coalition of mid facet	Spring ligament or deltoid ligament pathology Tibialis posterior pathology or medial impingement
Postero-medial pain	Tibialis posterior tendonitis	Flexor hallucis longus Tarsal tunnel syndrome
Posterior pain	Achilles tendinopathy Posterior impingement	Os trigonum pathology
Postero-lateral pain	Peroneal tendon
Lateral pain	Stress fracture of distal fibula ATFL injury Lateral impingement	Sinus tarsi syndrome Subtalar pathology Calcaneal fracture malunion
Heel pain	Plantar fasciitis Calcaneal stress fracture Entrapment of first branch of lateral plantar nerve	Fat pad atrophy/contusion Tarsal tunnel syndrome Foreign body reaction Plantar fascia rupture
Mid foot pain	Degenerative disease Post traumatic arthritis	Tarsal bones stress fracture Ligament injury ex Lisfranc injury Insertional tendinopathy of peroneal brevis
Forefoot pain	Metatarsalgia Morton neuropathy Stress fracture Freiberg disease	Metatarsophalangeal joint synovitis Nail pathology
Forefoot pain - big toe	Hallux valgus/rigidus Inflamed bunion	Sesamoiditis Sesamoid fracture
Forefoot pain - 2nd, 3rd and 4th toe	Claw toe Hammer toe	Mallet toe
Forefoot pain - little toe	Inflamed bunionette

ATFL: Anterior inferior tibiofibular ligament.

Table 2 Important points not to miss during the history taking[6]

Important key points not to be missed in general medical history
Age
Occupation
Participation in sports
History of lower back pain
History of problems with other joints (for example, hip and knee)
Diabetes
Peripheral neuropathy
Peripheral vascular disease
Inflammatory arthropathy
Rheumatoid arthritis
Vasculitis

Table 3 Correlations between the different gait patterns and the functional assessment

Examination of gait	Assessing the following aspects
Tiptoe walking	Ankle flexibility Posterior impingement Achilles/tibialis post function Midfoot function MTPJ problems Fractures (Stress) S1/2 function
Heel walking	Ankle mobility Anterior impingement Tibialis anterior function L4/5 EHL/EDL function Plantar fasciitis/heel problems
Inner borders (inversion)/outer borders (eversion) foot walking	Sub talar mobility Tibialis posterior function Peroneal tendons function 5th ray problems Medial and lateral gutter impingement 1st ray problem

Table 4 Different types of abnormal gaits

Type of the gait	Physical findings and observations	Possible cause
Antalgic gait	Short stance phase of the affected side Decrease of the swing phase of the normal side	Pain on weight bearing could be any reason from Back pathology to toe problem, e.g., degenerative hip joint
Ataxic (stamping) gait	Unsteady and uncoordinated walk with a wide base	Cerebral cause Tabes dorsalis
Equinus (tiptoes) gait	Walking on tiptoes	Weak dorsiflexion and/or plantar contractures
Equinovarous gait	Walking on the out border of the foot	CETV
Hemiplegic (circumductory) gait	Moving the whole leg in a half circle path	Spastic muscle
Rocking horse (gluteus maximum) gait	The body shift backward at heel strike then move forward	Weak or hypotonic gluteus maximum
Quadriceps gait	The body leans forward with hyperextension of the knee in the affected side	Radiculopathy or spinal cord pathology
Scissoring gait	One leg crosses over the other	Bilateral spastic adductors
Short leg (Equinus) gait (more than 3 cm)	Minimum: Dropping the pelvis on the affected side Moderate: Walks on forefoot of the short limb Severe: Combination of both	Leg length discrepancy
Steppage gait (high stepping - slapping - foot drop)	No heel strike The foot lands on the floor with a sound like a slap	Foot drop Polio Tibialis anterior dysfunction
Trendelenburg (lurching) gait	Trunk deviation towards the normal side When the foot of the affected side leaves the floor, the pelvis on this side drops	Weak gluteus medius
Waddling gait	Lateral deviation of the trunk with an exaggerated elevation of the hip	Muscular dystrophy

Table 5 Movements of the ankle joint and possible causes of restrictions[3,9]

Movement	Normal range of motion	Possible causes of restriction
Dorsiflexion	0-20 degrees	Tight Achilles tendon Tightness of the posterior ligaments Loss of flexibility in the ankle syndesmosis Impingement of anterior soft tissue or osteophytes
Plantar flexion	0-50 degrees	Anterior capsule/ligaments contractures Posterior impingement
Inversion	0-35 degrees	Tension in the joint capsules and the lateral ligaments1
Eversion	0-15 degrees	Tension in the joint capsules and the medial ligaments1

¹Inversion and eversion is mostly the motion of subtalar joint, the most common causes of restriction including subtalar arthritis, tarsal coalitions or calcaneal fracture malunion.

Table 6 Examination techniques of muscles functions[3]

Muscle	Ankle position	Manoeuvre of the test
Tibialis Anterior	Maximum Dorsiflexion and inversion	Try to plantar flex the ankle with your hand and ask the patient to resist, use your second hand on the tendon to feel the contraction (Figure 1)
Tibialis posterior	Plantar flexion and inversion	Patient inverts the foot in full plantar flexion whilst the examiner pushes laterally against the medial border of the patient’s foot (in an attempt to evert the foot). The examiner needs to use second hand on the tendon to feel the contraction (Figure 2)
Peroneal longus and peroneal brevis	Plantar flexion and eversion	Patient everts the foot in full plantar flexion and the examiner pushes medially against the lateral border of the patient’s foot (in an attempt to invert the foot) (Figure 3)
Extensor hallucis longus	Neutral	Patient extends the great toe and the examiner try to planter flex it (Figure 4)
Extensor digitorum longus	Neutral	Patient extends the lesser toes toe and the examiner try to planter flex it1 (Figure 5)
Flexor hallucis longus and flexor digitorum longus	Neutral	Patient curls the toes downward and the examiner tries to dorsiflex them1

¹It can be difficult to neutralize the intrinsic muscles completely.

Table 7 Examination techniques of performing the foot and ankle special tests[2,3,9,10]

Name of the test	Purpose of the test	Maneuver
Anterior drawer test	Lateral ligament complex	The leg hangs loosely off the table The examiner hold the patient’s leg just above the ankle joint with one hand The examiner uses the other hand to hold the ankle in plantar flexion and try to gently to pull the ankle forward - anterior translation (Figure 6) Look at the skin over the anterolateral dome of the talus to watch for anterior motion of the talus with this maneuver - sulcus sign
Inversion stress test	Stability of the lateral ankle ligaments (ATFL)	The knee is flexed 90 degree With one hand perform inversion stress by pushing the calcaneus and talus into inversion while holding the leg form the medial side with the other hand (Figure 7) The test is positive when there is excessive inversion and/or pain
Calf compression or “squeeze” test	Syndesmotic injury	The leg hangs loosely off the table - knee flexed The examiner uses both hand to squeeze at midpoint of the tibia and fibula Pain caused by this maneuver indicates Syndesmotic injury
External rotation stress	Syndesmotic injury	The leg hangs loosely off the table - knee flexed and foot fully dorsiflexed The examiner uses one hand to stabilize the lower leg With the other hand they externally rotate the foot Pain caused by this maneuver indicates Syndesmotic injury
Coleman block test	To assess the flexibility of the hindfoot, i.e., whether the cavus foot is caused by the forefoot or the hindfoot	A block is placed under the lateral border of the patients foot The medial forefoot is allowed to hang over the side The first metatarsal will be able to drop below the level of the block, i.e., eliminate the contribution by the first ray (Figure 8) With a flexible hindfoot, the heel will fall into valgus or neutral termed forefoot-driven hindfoot varus In case of rigid hindfoot or hindfoot-driven hindfoot varus the heel will remain in varus, and no correction will be happen
Semmes-weinstein monofilament test	To assess the degree of sensory deficit	Pressure testing using a 10 g Semmes-Weinstein mono- filament. Especially useful in diabetic charcot feet (Figure 9)

Table 8 Examination techniques of performing the foot and ankle special tests[2,3,9,10]

Name of the test	Purpose of the test	Manoeuvre
Silfverskiold test	Differentiate between a tight gastrocnemius and a tight soleus muscle	The leg hangs loosely off the table - knee flexed Dorsiflex the ankle to the maximum Patient should then extend their knee Repeat the ankle dorsiflexion (Figure 10) If there was more ankle dorsiflexion with the knee flexed then there is gastrocnemius tightness
Thompson’s test	Achilles’ tendon rupture	Patient lies is prone on the bed or kneel on a chair The examiner gently squeeze the gastrocsoleus muscle (calf) If the tendon is intact, then the foot passively plantar flexes when the calf is squeezed
Test for tarsal tunnel syndrome	Compressions of the posterior tibial nerve underneath the flexor retinaculum at the tarsal tunnel	Tap inferior to the inferior to the medial malleolus to produce Tinel’s sign
Test for flat foot	Differentiate between flexible vs rigid	Ask patient to stand on tiptoes If the medial arch forms and heel going into varus then it is flexible flat foot Beware of rupture tibialis posterior tendon or tarsal coalition
Test for stress fractures	Stress fractures	Place a tuning fork onto the painful area If it increases the pain, then it is positive Other test: One spot tenderness on palpation with finger
Babinski’s response	Upper motor neuron disease	Scratch the lateral border of the sole of the foot A positive response is dorsiflexion of the great toe
Oppenheim’s test	Upper motor neuron disease	Run a knuckle or fingernail up the anterior tibial surface A positive response is dorsiflexion of the great toe
Mulder's test	Morton’s neuroma	A mass felt or audible Click is elicited by palpating (grasping) the forefoot (web space) with the index finger and thumb of the examiner

Table 9 Three common pathologies and the related necessary clinical tests[7]

Special pathology	Required tests
Pes cavus	Claw toes Examine peroneal tendons Tibialis anterior and posterior Coleman block test Examine the Achilles tendon Full lower and upper limb neurological examination Hand - inspect for muscle wasting Spine
Pes planus	Single leg sustained tip toe test Testing tibialis posterior power Too many toes sign Examine the Achilles tendon
Hallux valgus/ rigidus	Dorsal osteophyte Passive ROM Grind tests Correct the deformity Examine the Achilles tendon

Table 10 Medical Research Council scale to assess the strength of muscle[8]

Grade	Description
Grade 0	No contraction
Grade 1	Flicker or trace of contraction
Grade 2	Active movement with gravity eliminated
Grade 3	Active movement against gravity
Grade 4	Active movement against gravity and resistance
Grade 5	Normal power