T h e Fo o t a n d A n k l e E x a m i n a t i o n

Dean N. Papaliodis, MDa,*, Maria A. Vanushkina, BSb,

Nicholas G. Richardson, BSb, John A. DiPreta, MDa

KEYWORDS
 Foot/Ankle physical examination  Structural abnormalities  Ottawa ankle rules
 Special tests

KEY POINTS
 Knowledge of common foot and ankle complaints can be diagnosed and managed effec-
tively in the primary care setting.
 Foot and ankle disorders require a thorough and structured history and physical examina-
tion with attention to the patient as a whole.
 Knowledge of foot and ankle anatomy and biomechanics is key in successful clinical eval-
uation and therapeutic considerations.

INTRODUCTION

Foot and ankle disorders (FAD) are highly prevalent in the general population and are
one of the leading motivations for primary care visits.1–4 Unfortunately, many physi-
cians consider FAD diagnostically challenging and the management daunting.5 On
initial approach, the goal is to establish a historical database to characterize the prob-
lem, infer the structures involved, and assess prognosis.6 A history should elucidate
symptoms, chronicity, pathomechanics, and relevant past medical conditions
(Box 1). Epidemiologic factors, such as age, gender, employment, and activities,
are of great diagnostic value and help individualize the history, physical examination,
and treatment.1 Physical examination findings should be interpreted in the context of
overall health, vital signs, and symptoms. A head-to-toe inspection is the first step.
Failing to expose the lower extremities sufficiently is a mistake; patients should be
in a gown with shoes and socks removed. Footwear patterns provide valuable infor-
mation and shoes should be evaluated for appropriate fit.7 A thorough physical exam-
ination examines structural integrity through palpation, mobility, and strength testing.
Many disorders mimic each other on initial presentation and provocative tests help

a
Division of Orthopaedic Surgery, Albany Medical Center, Albany Medical College, MC184,
1367 Washington Avenue, Suite 202, Albany, NY 12206, USA; b Albany Medical College,
MC184, 1367 Washington Avenue, Suite 202, Albany, NY 12206, USA
* Corresponding author.
E-mail address: [email protected]

Med Clin N Am 98 (2014) 181–204

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182 Box 1
Suggested historical evaluation

What are your goals regarding functional results after treatment?

Symptoms
Describe pain: Location, duration, radiation, intensity, and type
Describe swelling: chronicity, location, duration, color changes
Any new muscle weakness? Atrophy? Numbness, tingling, or burning?
Any foot or ankle instability? Feeling of giving way?
Have you tried rest, ice, compression, elevation, medications, hot packs?
What exacerbates symptoms?
How are the symptoms affected by physical activity? Rest?
Have you received any therapy for this injury? How much time passed since the onset before
you sought treatment? Why seek treatment now?
What activities have you been able to do since onset? Affecting activities of daily living?
Mechanism of injury
What type of activity lead to this injury?
How often and for how long do you engage in this activity?
If traumatic, describe mechanism: trip, fall, twist ankle, etc
What do you think happened? Did you injure anything else?
Did you have any sensation of popping or cracking at the time?
Were you able to walk (even with a limp) immediately after the injury?
Chronicity
Onset: acute, gradual, traumatic versus nontraumatic? Is this a recurrence?
Describe symptom progression over time.
Symptom severity correlated with time? AM, PM, activity?
Social history
What do you do for work? Does it involve physical activity?
What type of regular exercise do you perform?
Have you had changes in your activity level over the past 6 months: duration, intensity,
frequency, or equipment?
What type of shoes do you wear? How often do you change them?
Describe substance use: Tobacco/alcohol especially
Past medical history
Prior back, extremity injuries or disorders? When? Treatment?
History of diabetes/vascular disease? See a podiatrist?
Other endocrine, coagulation, vascular, systemic inflammatory, neuromuscular, nutritional,
kidney, or arthritic disorders?
Current medications? For what conditions? Recent antibiotic use?
Any past imaging studies? X-ray, CT, MRI, US
Are you up-to-date on immunizations? Last tetanus shot?

Data from Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and
risk assessment: a report of the task force of the foot care interest group of the American Dia-
betes Association, with endorsement by the American Association of Clinical Endocrinologists.
Diabetes Care 2008;31(8):1679–85.
 The Foot and Ankle Examination 183

differentiate similar or coexisting conditions.8 Evaluation should be performed in mul-

tiple positions, such as walking, standing, seated, and prone. The unaffected extrem-
ity should be used as a reference point for all examination findings. Many problems do
not require specialist referral and can be managed with protection, relative rest, ice,
compression, elevation, medications, or rehabilitation modalities (PRICEMR).9,10

SKIN EXAMINATION

Skin integrity should be assessed first. Hyperkeratotic lesions such as calluses and
corns can frequently form in areas of increased friction and pressure.1 Diabetes,
obesity, structural abnormalities, and poorly fitting shoes are common conditions
associated with increased pressure.11 In diabetic feet, these pressure points can
become sites of future ulceration. Aside from calluses, there are several common
soft tissue alterations in diabetic feet: increased thickness of plantar fascia, decreased
thickness of plantar soft tissue, accentuated hardness of the overlying skin, and a pro-
pensity for ulcer formation.12 Ulcers may be hidden by the overlying hyperkeratosis,
which should be debrided to relieve pain and allow proper assessment.13

Infections
Superficial conditions, such as tinea pedis, plantar warts, pitted keratolysis, and ony-
chomycosis, are obvious on inspection and eventually resolve on their own in healthy
patients but targeted topical treatments are often more expedient.14 Cellulitis and
erysipelas are common infections of the dermis and underlying soft tissue structures.
Both present as obviously red, hot, swollen, and tender expanses often without any
obvious breach in skin integrity. Poorly demarcated margins versus raised borders
and burning pain distinguish cellulitis from erysipelas. Normal skin flora such as Staph-
ylococcus or group A Streptococcus are the most common pathogens and are best
treated with empiric oral antibiotics, ibuprofen, and elevation. Purulent cellulitis should
be empirically covered for methicillin-resistant Staphylococcus aureus pending culture
and sensitivity. Cutaneous abscesses should be drained.15 Further studies are not
required unless there are signs of systemic toxicity or high suspicion for deep
infections.14
In the setting of any localized inflammation around a joint, septic arthritis should be
high on the differential. Joint sepsis is present in one-third of osteomyelitis cases.16
Adult patients should be assessed for predisposing factors, such as diabetes,
cirrhosis, cancer, traumatic joint damage, surgery, hemoglobinopathies, corticoste-
roids or immunosuppressants, HIV/AIDS, chronic joint disease, and alcohol and intra-
venous drug abuse.17 Signs of systemic infection, such as fever or lethargy, multiple
joint involvement, abnormal gait, limited range of motion (ROM), tenderness, skin le-
sions, and ulcers, should be assessed during a physical examination. Workup includes
arthrocentesis, blood cultures, Gram stains, erythrocyte sedimentation rate, and plain
films.16 Septic arthritis is more common in all children and is often unprovoked.18 Phy-
sicians should maintain high clinical suspicion for osteomyelitis of adjacent bones.
Osteomyelitis in children is classically thought to affect the metaphyseal regions of
long bones; however, a recent study found that bones of the foot are actually most
commonly involved.19 Bone biopsies are the gold standard for diagnosis.
Diabetic feet are especially susceptible to all infections. Dry skin with cracks and fis-
sures provides easy access to infections that progress rapidly without an adequate
immune system and vascular supply.12 There is a 15% lifetime chance of developing
a foot infection in this population.14 Infections are frequently coincident with ulcers,
but one is not necessary for the presence of the other. Foot ulceration is the most
184 Papaliodis et al

significant risk factor for amputation. Most nontraumatic amputations occur in dia-
betic patients and are preventable with vigilant screening (Table 1).7 For patients
with existing ulcers, the likelihood and severity of infection increase with any of the
following features: lesions measuring greater than 2 cm, grossly exposed or palpable
bone at ulcer site, erythrocyte sedimentation rate greater than 70 mm/h, and corrob-
orating radiologic abnormalities.14

STRUCTURAL ABNORMALITIES

Congenital and acquired variation in lower extremity form is common. In children, in-
toeing and flatfeet (FF) are especially prevalent structural disorders seen in the first
decade of life; both are usually asymptomatic, improve naturally with age, and have
a strong genetic component.20 Parents report a family history of the condition and
will worry about the psychosocial and functional implications of the deformity and
its treatment on the child.20 In most cases, reassurance is the only intervention neces-
sary. In adults, arch and digital deformities prevail and are more likely to be pathologic
and painful and lead to significant morbidity. Between 5% and 20% of adults have FF
and more than one-third of adults will develop a digital deformity, such as hallux valgus
(HVD).21,22 Unlike childhood abnormalities, adult-onset structural disorders can be
disabling and often require medical or surgical intervention.

Arch Disorders
FF have numerous causes; classification according to age of onset and foot flexibility
is the most informative for prognosis and treatment. Pediatric FF are present before
skeletal maturity and adult FF are present after. Flexible flatfeet (FFF) retain a normal
arch while in a dependent position and flatten on standing.23 Rigid flatfeet are

Table 1
Diabetic foot screening guidelines

Ulcer Risk Factors Historical Features Essential Physical Examination

PN Past medical history: Inspection
Foot deformity Ulceration, amputation, Skin
Foot trauma Charcot joint, vascular Color, thickness, dryness, cracking;
Previous amputation surgery, angioplasty, sweating; infection (check
Past foot ulcer history cigarette smoking between toes for fungal);
Peripheral vascular Neuropathic symptoms: ulceration; calluses/blistering
disease Burning, shooting, pain, (hemorrhage into callus?)
Visual impairment electrical, or sharp Musculoskeletal
Diabetic nephropathy sensations Deformity, such as claw toes,
Poor glycemic control Numbness, dead feet prominent metatarsal heads,
Cigarette smoking Vascular symptoms: Charcot joint, HVD; muscle wasting
Claudication, rest pain, (guttering between metatarsals)
nonhealing ulcer Neurologic assessment
Other complications: 10-g monofilament 1 1 of the
Renal, retinal following 4: Vibration using 128-Hz
tuning fork; pinprick sensation; ankle
reflexes; vibration perception
threshold testing
Vascular assessment
Foot pulses (ABI if indicated)

Data from Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes
Care 2011;34(9):2123–9.
 The Foot and Ankle Examination 185

characterized by a stiff, flattened arch on and off weight-bearing.20 On inspection, pa-

tients will have at least one of the following: forefoot supination, a depressed medial
arch, medial talar head prominence, hindfoot eversion, and a positive Helbing sign,
which is described as medial or inward deviation of the Achilles tendon (Fig. 1).22
More than the normal 1 to 2 toes will be visible on the lateral border when looking
from behind (see Fig. 1), referred to as the “too many toes sign.”24 Single leg heel rai-
ses (SHR) and Jack’s toe raises are diagnostic tests that look for reconstitution of the
arch.20 SHR is observed from behind with the patient’s hands against a wall for sup-
port.24 On single toe standing, normal feet and FFF will have heel inversion and a
visible arch (Fig. 2). Patients with normal subtalar joint motion and plantar flexor
strength are able to perform at least 10 SHR on each side. Jack’s toe raises uses
the same “windlass mechanism” as SHR. With the patient standing, the hallux is
passively extended to create an arch (Fig. 3).22

Digital Deformities
HVD is a heritable progressive deformity presenting with abduction and valgus rota-
tion of the great toe and a medially prominent first metatarsal head.25 HVD is the
most common digital deformity with a prevalence of 23% in adults aged 18 to
65 years.21 The prevalence is estimated at 35.7% in the elderly, where it increases
gait instability and fall risk.21,26 Even severe deformities may be asymptomatic; how-
ever, many patients with will report high self-perceived disability.27 Pain is usually

Fig. 1. Severe flatfoot deformity. This woman demonstrates (A) very excessive heel valgus
and the lateral bow of the tendo-Achilles known as the positive Helbing sign as well as
excessive toes visible on the lateral border known as the Too Many Toes sign; (B) the classic
medial collapse of the foot; and retained ability to perform a double heel raise, but a
marked lack of supinatory varus in the heel. (From Lee MS, Vanore JV, Thomas JL, et al. Diag-
nosis and treatment of adult flatfoot. J Foot Ankle Surg 2005;44(2):78–113; with permission.)
186 Papaliodis et al

Fig. 2. Examination of hindfoot movement. In normal feet as well as in patients with flex-
ible flatfoot, the valgus heel (A) in stance changes to a varus (B) position with the clinical
maneuver of SHR, showing the flexible nature and the reducibility of the deformity.
(From Harris EJ, Vanore JV, Thomas JL, et al. Diagnosis and treatment of pediatric flatfoot.
J Foot Ankle Surg 2004;43(6):341–73; with permission.)

associated with inflammation of the overlying soft tissue structures exacerbated by

inappropriately fitting footwear,13 usually referred to as a bunion. There are multiple
associated conditions such as hammer toes, calluses under the second metatarsal,
metatarsal pain, and ingrown toenails. ROM at the first metatarsophalangeal (MTP)

Fig. 3. Jack’s toe raise test (A). An arch is created in the weight-bearing FFF by the windlass
action of the great toe and the plantar fascia (B). (From Evans AM. The pocket podiatry guide:
pediatrics. Edinburgh (Scotland): Churchill Livingstone; 2010. p. 107–37; with permission.)
 The Foot and Ankle Examination 187

joint, normally confined exclusively to the sagittal plane, may include oblique deviation
such as abduction and eversion during dorsiflexion.25 To test hallux ROM, the midfoot
is stabilized with one hand and the other is used to extend and flex the great toe maxi-
mally. The MTP joint is capable of 0 to 70 of extension and 0 to 45 of flexion.28 Loss
of motion, most significantly extension, in the MTP is critical and results in an abnormal
gait characterized by foot supination and lateral border walking24 as well as compen-
satory hyperextension at the hallucal interphalangeal joint. This condition is referred to
as hallux rigidus, a progressive degenerative joint disease secondary to biomechan-
ical disturbance or arthritic pathologic abnormality that ultimately results in ankylosis
of the joint. Hallux rigidus can present insidiously or posttraumatically with pain, stiff-
ness, and a dorsal bunion localized at the first MTP joint. Symptoms are associated
with activities that require extension of the first MTP, such as squatting, stooping,
or high-heeled shoe wear.26
Deformities of the lesser digits are classically referred to as hammer toes, claw toes,
and mallet toes (Fig. 4). These conditions may be congenital, acquired, or a compo-
nent of other disorders. Like HVD, lesser toe deformities may be asymptomatic or pre-
sent with varying degrees of pain secondary to bursitis, calluses, contracture, or shifts
in pressure. Trauma such as fractures should be ruled out especially in an acute pre-
sentation of pain. Arthritic conditions may manifest with symptoms affecting the lesser
digit joints, especially rheumatoid, and should be considered. A full evaluation in-
cludes gait assessment, ROM testing for flexibility, and palpation. Applying direct dor-
sal and plantar stress to the MTP joints will assess for instability often associated with

Fig. 4. Three common digital deformities. In general, they can be described as the combina-
tion of joint contractures at the digital segments: (A) hammer toes have flexion at the prox-
imal interphalangeal joint (PIPJ) with extension at the metatarsophalangeal joint (MPJ) with
a neutral or hyperextended distal interphalangeal joint (DIPJ), (B) claw toes have flexion at
both the PIPJ and the DIPJ combined with extension at the MPJ, (C) mallet toes have flexion
at the DIPJ. (From Thomas JL, Blitch EL, Chaney DM, et al. Diagnosis and treatment of fore-
foot disorders. Section 1: digital deformities. J Foot Ankle Surg 2009;48(2):230–8; with
permission.)
188 Papaliodis et al

claw toes.13 Radiographs can be used to gauge severity and degeneration and
monitor progression of all digital deformities.25 PRICERM is the first-line treatment.

VASCULAR FUNCTION

Pulses are assessed by using the pads of the index and middle fingers to apply the
lightest possible pressure to avoid compressing the vessels. The posterior tibial artery
pulse can be palpated in the tarsal canal in the groove between the medial malleolus
and the Achilles tendon.27 It is best felt when the foot is completely relaxed. The ante-
rior tibial artery is renamed the dorsalis pedis artery (DPA) after it crosses the ankle.
Only 3% of patients have a congenitally absent DPA.29 The DPA is found along the
dorsum of the foot lateral to the extensor hallucis longus tendon and medial to the
extensor digitorum longus tendon. Starting at the navicular tuberosity, gently
palpating across an arc over the dorsum of the foot toward the lateral malleolus in a
posterior-lateral direction can help detect the pulse. Plantarflexion of the foot is
avoided because this decreases sensitivity of palpation.27

Peripheral Vascular Disease

Diminished or absent pulses, temperature changes, bluish nail beds, and shiny or atro-
phied skin are significant signs of peripheral artery disease (PAD). Subtle changes in
temperature can be appreciated by moving the dorsal surface of the hand proximally
from the toes.30 PAD affects 10% of the population and is a marker for general arther-
osclerotic disease. Intermittent claudication—pain reproduced by exercise and
relieved by rest—is the classical presentation of PAD seen in 30% to 40% of all cases.
Foot claudication can result from occlusion of the tibial or peroneal artery, although
this is less common than proximal (eg, popliteal) artery stenosis.31 The diagnosis of
PAD may be confounded by comorbidities that present with similar pain. It may be
confused with neurogenic claudication because of spinal stenosis. A key distinction
between vascular and neurogenic claudication is forward bending—this enlarges
the spinal canal and improves the symptoms of neurogenic but not vascular pain.28
In diabetics, PAD increases both morbidity and mortality. It rarely leads to ulcerations
directly, but once ulceration develops, it will heal poorly because of decreased perfu-
sion. Subsequent infections are difficult to eradicate because of inadequate oxygen-
ation and antibiotic delivery.12

Swelling
Fluid extravasation presenting as swelling is common following traumatic and inflam-
matory tissue disturbance. Swelling may be extensive, affecting the entire lower ex-
tremity or localized at a joint. It is frequently accompanied by rubor, pain, and
limited ROM. Most cases of unilateral swelling result from acute inflammatory pro-
cesses.18 Cellulitis, deep vein thrombosis, compartment syndrome, and acute Char-
cot foot (CN) may all present with diffuse lower extremity swelling. Bilateral swelling
is common in patients with venous insufficiency, which is frequently accompanied
by stasis dermatitis, pain, blisters, and ulceration. Pulmonary hypertension and early
heart failure are other possible causes of bilateral edema seen frequently in older
individuals.32
The ankle and first MTP joints are the most common sites of swelling. Septic effu-
sions should remain on the differential of any acute monoarticular inflammation until
definitively ruled out.18 In the ankle, fluid may pool around both malleoli and the dorsal
foot in response to traumatic damage, such as sprains, or systemic conditions, such
as gout or rheumatoid arthritis.24 Swelling associated with HVD may be confused with
 The Foot and Ankle Examination 189

gouty inflammation because both affect the first MTP joint. Gout is common in older
men with a positive family history or prior attack and does not have the characteristic
valgus deviation of HVD unless the conditions are superimposed. It is aggravated by
trauma, surgery, alcohol, dietary factors, or dehydration.18 Gout and pseudogout are
diagnosed by the presence of crystals in the synovial fluid obtained by joint aspiration.
Arthrocentesis is often necessary for assessment of other conditions as well. Normal
synovial fluid is clear with a slight yellow tinge. Aspirated fluid that looks purulent or
blood-tinged requires urgent attention. The characteristic appearance of purulent fluid
is due to an increased white blood cell count (greater than 50,000/mm3) and is usually
a response to infection. Blood-tinged synovial fluid is referred to as hemarthrosis. A
traumatic tap or history of anticoagulant use or hemophilia may explain the presence
of blood.28 Hemarthrosis may also be suggestive of an intra-articular fracture or a lig-
ament tear. If fat droplets are seen on microscopic analysis, joint fracture is even more
likely. Aspirated fluid should be sent for analysis that includes a total leukocyte count
with differential, Gram stain, cultures and special stains, sensitivities, glucose, and
crystal examination.18 In cases of septic arthritis, antibiotics can be adjusted or dis-
continued after culture results are available.
Arthrocentesis is simple to perform in an office setting. Consent and proper sterile
technique should not be forgotten. A 25-gauge needle is used for small joints. The
ankle is aspirated from an anteromedial approach by palpating the depression be-
tween the medial malleolus and anterior tibial tendon. The needle is inserted to a depth
of 1 to 3 cm, aiming toward the middle of the ankle joint. Aspiration of the first MTP
joint is done using a medial approach to help avoid tendons and neurovasculature.
With the joint in 15 of flexion, the needle is inserted straight in at the depression be-
tween the 2 bones. Aspiration may be used therapeutically to decompress any joint in
the absence of relative contraindications, such as clotting disorders and infection of
the surrounding tissue.18

NEUROLOGIC ASSESSMENT

Proprioception should be universally assessed with the Romberg test as a part of gen-
eral evaluation—especially in patients with prior ankle injuries or peripheral neuropa-
thies (PN). Starting with the unaffected side, patients should stand on one foot for at
least 5 seconds with their eyes open and then with eyes closed.1 Mechanoreceptors
located in ligaments provide most of the proprioceptive information. Any damage will
compromise normal function, leading to chronic ankle issues, such as instability,
further injuries, and falls in the elderly.33 Inability to hold the position with eyes closed
for the appropriate time is an indication for rehabilitation.

Neuropathies
PN is commonly seen in a primary care setting. There is a long list of broadly grouped
causes including genetic disorders, substance toxicity, inflammatory diseases,
vitamin deficiencies, and traumatic injury. Diabetic PN is by far the most likely cause
in America; a classic history may include symmetric weakness in toes and distal sen-
sory loss in a stocking and glove distribution. The sensory or motor arc of the deep
tendon reflexes can be diminished or completely absent in any PN.28 Reflexes are
tested by stretching the tendon with a brisk tap of a reflex hammer and observing
the immediate muscle contraction. Reflexes are best tested in a sitting position with
the patient relaxed and not thinking about the procedure. Multiple samples of the re-
flex should be taken to assess reactivity. Normal reflexes confirm appropriate cuta-
neous and motor innervation as well as normal cortical input into the tested spinal
190 Papaliodis et al

nerve segment.34 There is also normal variation in deep tendon reflexes and dimin-
ished or increased reflexes without other clinical findings are usually not pathologic.
Constant vigilance is required when caring for diabetic patients and physicians
should be current on all appropriate screening techniques.7 Unfortunately, patient
education on foot care does not produce clinically relevant reduction in complica-
tions.35 The lifetime risk of developing foot ulcers is as high as 25% in diabetics and
PN is the universal predisposing factor.7 In addition to neuropathy, vascular disease
is a factor in up to 45% of diabetic ulcerations.12 Approximately 1% of diabetics will
develop an inflammatory neuropathic arthropathy known as Charcot Neuroarthrop-
athy (CN) due to a lack of protective sensation, which leads to damage and degener-
ation of weight-bearing joints.36 A history of injury is unreliable because more than half
of the patients have decreased or absent pain perception. There is a significantly
increased risk of severe traumas or infections that may go unnoticed for prolonged
periods.14 The acute clinical presentation of CN usually includes a swollen, erythem-
atous lower extremity with bounding pedal pulses and a temperature differential.36
The associated hyperemia increases bone reabsorption. Gross deformities may be
subtle in early stages.12 Chronic CN presentation includes the hallmark midfoot struc-
tural collapse referred to as a rocker bottom foot (Fig. 5).36 CN is limb threatening and
requires prompt treatment to reduce the swelling. Acute CN is often misdiagnosed
with other conditions common in diabetics, such as cellulitis, deep vein thrombosis,
or osteomyelitis. Plain films are appropriate initial studies but magnetic resonance
imaging (MRI) is the most accurate. Rubor associated with CN is dependent and
will resolve within 10 minutes of foot elevation but erythema associated with infection
will not.37

Fig. 5. CN with collapse of the internal arch. The deformity can occur abruptly and usually
without any relevant preceding trauma. Late-stage CN often presents a rocker-bottom
deformity. (From Hartemann-Heurtier A, Van GH, Grimaldi A. The Charcot foot. Lancet
2002;360(9347):1776–9.)
 The Foot and Ankle Examination 191

Nerve Entrapment Syndromes

PN from nonsystemic causes is usually due to stretching, entrapment, or compression
of nerves and tends to be unilateral (Table 2).38 The diagnosis is clinical.39,40 Classic
symptoms of include pain worsened by weight-bearing, deep burning, paresthesias,
and numbness in the nerve’s distribution distal to the site of damage. Weakness
and atrophy of intrinsic muscles of the foot are very late findings. Stretching- or
tension-related nerve disorders occur from acute ankle sprains or inappropriate foot
mechanics.38,40 External pressures from improper footwear and space-occupying
masses, such as scar tissue, bone spurs, varicose veins, or focal swelling, are the
usual culprits responsible for nerve compression or entrapment.38
Tinel sign is a sensitive but not specific finding elicited by gentle percussion over the
nerve path useful for diagnosing neuropathies.41 A positive sign involves tingling as
well as pins and needles in the nerve distribution (Fig. 6).24 In the case of tarsal tunnel
syndrome, a positive test is 88% to 93% predictive of excellent postsurgical out-
comes.41 However, there is significant inter- and intra-examiner variability in technique
and the amount of force applied. The “single finger technique”—5 strikes using only
the middle finger of the dominant hand—produces relatively minimal intragroup vari-
ability (Fig. 7).42 The triple compression stress test is most diagnostic with a sensitivity
and specificity of 85.9% and 100%, respectively.43 A compressive force held for
30 seconds on the posterior tibial nerve with the foot in plantarflexion and inversion
should elicit pain and numbness if the test is positive (Fig. 8).
Baxter neuropathy, entrapment of the motor branch of the lateral plantar nerve, is
responsible for 20% of chronic heel pain but is frequently overlooked.38 Diagnosis
is based on the pathognomonic MRI finding of selective fatty atrophy of the abductor
digiti minimi. Imaging studies are not required for other PNs but can be used to deter-
mine cause or rule out other pathologic abnormalities if surgery is planned.44 MRI is
very accurate39,45 but diagnostic ultrasound is gaining popularity because of lower
costs.46 Electrodiagnostic studies have high false positive and negative rates and
are not diagnostically superior to provocative tests.43
PN that presents in late childhood or early adulthood is suspicious for congenital
causes. Charcot-Marie-Tooth disease is one of the most common hereditary nervous
system conditions. It is heterogeneous with variable inheritance. It can be recessive so
a negative family history does not exclude the diagnosis. Charcot-Marie-Tooth pre-
sents with muscle weakness, foot deformity (foot drop, high arches, hammer toes),
or sensory loss.47 Other causes of PNs should be excluded. Definitive diagnosis is
made by nerve biopsy or genetic testing.48

PALPATION OF STRUCTURES

Most patients with foot and ankle complaints present with regional pain or discomfort.
Reproduction of symptoms through provocation is necessary to make a diagnosis.
The foot has a minimum of 26 key bones in addition to at least 2 sesamoids, many lig-
aments stabilizing the joints, fascia, as well as intrinsic and extrinsic musculature.28
Pain, swelling, and dysfunction can originate from disruption of any of these compo-
nents. Knowledge of anatomy is crucial. Many disorders can be noticed clinically by
pairing relevant historical findings with localization of a specific point of tenderness
(Fig. 9). Palpation of skin and subcutaneous tissues is performed by applying varying
degrees of pressure with finger pads. Deeper structures require firm pressure and may
be better appreciated when the foot is manipulated or actively moved. Deformity,
asymmetry, crepitus, tenderness, elasticity, and texture of the palpated structures
should be noted. When performing a complete assessment, palpation should be
 192
Papaliodis et al
Table 2
Nerve impingement syndromes in the foot

Diagnostic Tests (Sensitivity/

Location of Compression External Landmarks Presentation Specificity)
Tarsal tunnel syndrome Beneath flexor retinaculum Posterior to medial Onset: Insidious  Tinels sign
Nerve: tibial or its on medial aspect of ankle malleolus; medial to talus Symptoms: Pain directly over  Triple compression stress
divisional branches and calcaneus the tarsal tunnel; radiation test: (85.9%/100%)
to longitudinal arch,  MRI: (83%)
plantar foot and heel. Can
be worse at night
Aggravated by: Standing,
walking
Baxter’s neuropathy Between inferior margin of Anterior to medial calcaneus; Onset: Insidious  MRI: selective fatty atrophy
Nerve: inferior calcaneal abductor hallucis (AbH) almost in line with medial Symptoms: Chronic heel pain; of abductor digiti minimi is
and quadratus plantae malleolus can be confused with or a unique finding
accompanied by plantar
fasciitis; radiation to
inferomedial heel and
medial ankle. Can be worse
in the morning
Jogger’s foot Passage between AbH and Plantar, one thumb breadth Onset: Immediately after  Tinel sign
Nerve: medial plantar the knot of Henry distal to navicular running  Passive foot eversion
tuberosity Symptoms: Burning heel and  MRI: denervation changes
medial arch pain; sensory in muscles supplied
disturbance over plantar
surface behind first and
second toes
 Morton’s neuroma Fibrosis due to chronic Plantar forefoot over third Onset: Usually insidious  Tinel sign: (62%)
Nerve: interdigital impingement against distal and fourth metatarsals and Symptoms: Paroxysmal pain  Web space tenderness
branches of medial edge of plantar in third web space in plantar foot, toes, and (95%)
plantar intermetatarsal ligament dorsal web space; radiates  Squeeze test: (88%)
from metatarsal heads to  MRI: (87%/100%)
third and fourth toes;
altered sensation in less
than half
Aggravated by: All shoes,
high heels
Anterior tarsal tunnel Under superior edge of Level of talonavicular joint, Onset: Acute or chronic if  Tinel sign
syndrome inferior retinaculum lateral to the drosalis pedis caused by tight fitting  Ultrasound >>MRI
Nerve: deep peroneal artery shoes
Symptoms: Pain of
dorsomedial midfoot;
minimal weakness of
extensor hallucis brevis
(EHB); sensory disturbance
in first webspace. Worse at
night or at rest

Data from Refs.10,16–19,24

The Foot and Ankle Examination

193
194 Papaliodis et al

Fig. 6. Typical sensory innervation of the foot and ankle. (A) Superior view (B) Posterior view
and (C) Inferior view. (From Young CC, Niedfeldt MW, Morris GA, et al. Clinical examination
of the foot and ankle. Prim Care 2005;32(1):105–32; with permission.)

done systematically starting proximally above the ankle and moving distally through
the hindfoot, midfoot, and forefoot. Areas of reported pain should be assessed last
to avoid patient discomfort.

Ottawa Foot and Ankle Rules

In the setting of any suspected foot or ankle injury, patients should be evaluated
following the Ottawa Ankle Rules (OAR) to exclude fractures and avoid unnecessary
radiography (Fig. 10). To apply the rules correctly, the physician should palpate the
entire distal 6 cm of the fibula and tibia; remember the importance of medial malleolar
tenderness; palpate the entirety of the navicular, with special attention to the relatively
avascular nickel-sized area at the central region of the proximal dorsal surface termed
the “N” spot; palpate the fifth metatarsal focusing on the base; note verbal and
nonverbal pain responses; observe the patient ambulate for at least 4 steps. Tender-
ness at these locations is an indication for radiographs. Standard imaging includes
 The Foot and Ankle Examination 195

Fig. 7. Demonstration of the single finger percussion technique. (From Owens R, Gougoulias
N, Guthrie H, et al. Morton’s neuroma: clinical testing and imaging in 76 feet, compared to a
control group. Foot Ankle Surg 2011;17(3):197–200; with permission.)

anterior to posterior, lateral, and ankle mortise views. There are 11 important sites to
assess when evaluating patients for low-energy fractures (Fig. 11).49
These rules have been validated in multiple clinical settings with varying prevalence
of fractures, in adult patients, and in children greater than 5 years of age.50 If a patient
has negative findings following the OAR, there is less than a 2% chance that this is a
false negative.51 Limited knowledge of OAR may preclude implementation in prac-
tice—in a study, 99.2% of providers were aware of the rules but only 30.9% were
able to recall all the components correctly. In patients with repeat injuries, chronic
or worsening symptoms, or a difficult clinical assessment, radiographs should be
obtained regardless of the rules.52 Specificity of palpation is limited by extensive
soft tissue edema.24 If a grossly swollen ankle prevents proper palpation of bony
structures, radiographs should be obtained.52

Overuse Injuries
Running is the common denominator in many foot and ankle injuries. Sudden in-
creases in training volume or a history of prior injuries are major risk factors for all
running-based injuries. Variables such as gait, incline, pace, interval training, and

Fig. 8. The triple compression stress test involves 3 steps: (A) place ankle in plantar flexion,
(B) invert the heel and foot, and (C) compress the tibial nerve where it runs posterior to the
medial malleolus. (From Abouelela AA, Zohiery AK. The triple compression stress test for
diagnosis of tarsal tunnel syndrome. Foot (Edinb) 2012;22(3):146–9. Elsevier Ltd; with
permission.)
196 Papaliodis et al

Fig. 9. Important palpation landmarks. (B) Lateral foot and ankle—typical locations of injury
symptoms and selected anatomic structures: (A) Jones fracture; (B) avulsion fracture of the
fifth metatarsal; (C) anterior ankle impingement; (D) anterior talofibular ligament; (E) sinus
tarsi; (F) calcaneofibular ligament; (G) posterior ankle impingement; (H) retrocalcaneal
bursitis; (I) Achilles tendon rupture; (J) Achilles tendonitis; (K) calcaneal apophysitis (Sever
condition) and “pump bump.” (C) Medial foot and ankle—typical locations of injury symp-
toms and selected anatomic structures: (A) Achilles tendon rupture; (B) Achilles tendonitis;
(C) calcaneal apophysitis (Sever condition) and “pump bump”; (D) retrocalcaneal bursitis;
(E) tarsal tunnel syndrome; (F) medial ankle sprain; (G) entrapment site of first branch of
lateral plantar nerve; (H) master knot of Henry, entrapment site of medial plantar nerve.
(A) Dorsal foot and ankle—typical locations of injury symptoms and selected anatomic struc-
tures: (A) anterior ankle impingement; (B) osteochondritis dissecans of the lateral talar dome;
(C) the N spot—NSF; (D) Lisfranc sprain; (E) anterior tarsal tunnel syndrome; (F) bunionette;
(G) bunion; (H) hallux rigidus; (I) avascular necrosis of second metatarsal head (Freiberg
infarction); (J) interdigital neuroma (Morton neuroma); (K) paronychia. (D) Plantar foot—
typical locations of injury symptoms and selected anatomic structures: (A) plantar fat pad;
(B) plantar fasciitis; (C) avulsion fracture of the fifth metatarsal; (D) Jones fracture; (E) stress
fracture of the third metatarsal; (F) stress fracture of the second metatarsal; (G) metatarsalgia;
(H) sesamoiditis. (From Young CC, Niedfeldt MW, Morris GA, et al. Clinical examination of the
foot and ankle. Prim Care 2005;32(1):105–32; with permission.)
 The Foot and Ankle Examination 197

Fig. 10. Ottowa ankle rules. (From Bachmann LM, Kolb E, Koller MT, et al. Accuracy of
Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ
2003;326(7386):417; with permission.)

Fig. 11. Radiological assessment template for the ankle. A standard radiographic series of
the ankle has a minimum of 3 views including an anterior-posterior view (A), a mortise
view (B), and a lateral view (C). There are 11 target sites that represent vulnerable areas
where fractures occur including the medial (1) and lateral (2) malleoli, anterior tibial tuber-
cle (3) and posterior tibial malleolus (4), talar dome (5), lateral talar process (6), tubercles of
the posterior talus process (7), dorsal to the talonavicular joint (8), anterior calcaneus pro-
cess (9), calcaneal insertion of the extensor digitorum brevis (10), and the base of the fifth
metatarsal bone (11). (From Yu JS, Cody ME. A template approach for detecting fractures in
adults sustaining low-energy ankle trauma. Emerg Radiol 2009;16(4):309–18; with
permission.)
198 Papaliodis et al

shoes have not been conclusively linked to injuries.53 Ankle sprains are acute and the
most frequent injury sustained by young athletes, but most injuries in general are due
to chronic overuse.8 Despite a typically insidious onset, overuse injuries may become
abruptly aggravated and misdiagnosed as an acute trauma. Damage occurs from rela-
tive overload due to an increased tissue demand but inadequate recovery. Single
events are not significant enough to cause acute problems but the culmination of
microscopic damage from repetitive application of force will eventually result in a
serious injury. All tissue types are susceptible to this mechanism; some common ex-
amples include navicular, calcaneal, or metatarsal stress fractures, apophysitis,
plantar fasciitis, and Achilles tendinopathies.28 Underlying medical conditions may in-
crease injury risk. Female patients should be evaluated for “the Triad” of anorexia,
amenorrhea, and osteoporosis. This constellation is usually seen in young, thin women
and requires intervention to prevent other significant morbidities and potential mortal-
ity.28 The elderly are also at increased risk for injuries such as stress fractures due to
osteopenia or osteoporosis.54
Most overuse injuries lead to chronic localized pain.55 Patients will often attempt to
continue activity but this only leads to symptom progression: the pain will occur
earlier, last longer, and eventually lead to complications, such as arthritis, nonunion,
and structural deformity.56 A very common injury that is frequently missed or misman-
aged is the navicular stress fracture (NSF). The navicular is the point of maximal stress
and impingement during repetitive foot strikes.57 NSF symptoms include a gradual
onset of vague, aching pain in the dorsal midfoot that radiates to the medial arch.
Edema and ecchymosis are usually absent. Patients will experience increased pain
with passive eversion, active inversion, toe hopping, and toe standing. Tenderness
localized to the “N” spot is present in 81% of patients and is an indication for imaging
according to the OAR. However, plain films are only sensitive in 33% of acute cases
and a follow-up foot MRI is appropriate.58 Treatment involves non-weight-bearing
cast immobilization for 6 to 8 weeks. Many physicians default to PRICEMR, which
is inappropriate for this pathologic abnormality and results in the dismally poor cure
rate of 26%.55
Similar to NSF, calcaneal stress fractures are overuse injuries that present shortly
after an increase in frequency or intensity of activity.59 They are classically descried
in new military recruits or long distance runners.54 The most common site of injury
is immediately inferior to the posterior facet of the subtalar joint and presents as
tenderness of the lateral wall of the calcaneus.59 Pain elicited by the calcaneal
compression test—compression of the heel in a transverse plane by both palms
(Fig. 12)—is highly suspicious.59 Vibration applied to the calcaneus using either a
128-cps tuning fork or ultrasound can cause discomfort.24 Onset of symptoms pre-
cedes radiographic findings but 3-phase bone scans or MRIs are nearly 100% sensi-
tive as early as 1 to 2 days after injury.53 Treatment is the same as NSF.

RANGE OF MOTION
Terminology
To evaluate and understand disorders of the foot and ankle, an understanding of the
planes of motion and positions of the foot are essential to assess these disorders and
effectively communicate pertinent findings when referring to health providers.
The upper surface of the foot is the dorsum of the foot and the bottom or weight-
bearing surface is the plantar aspect. The medial side of the foot is the side closest
to the midline. The lateral side is furthest away from the midline. Medial and lateral
may also be described as the tibial and fibular borders, respectively. There are 3 basic
 The Foot and Ankle Examination 199

Fig. 12. Calcaneal compression test. (From DiGiovanni, BF, Dawson, LK, Baumhauer, JF.
Plantar Heel Pain. In: Coughlin, MJ, Saltzman, CL, Anderson, RB, editors. Mann’s Surgery of
the Foot and Ankle. 9th edition. Philadelphia, PA: Elsevier; 2014. p. 685–701; with permission.)

planes of motion involving the foot and ankle complex. There are sagittal, frontal, and
transverse planes of motion. Dorsiflexion and plantarflexion are considered sagittal
motions. A fixed position would be described as either plantarflexed or dorsiflexed.
Inversion and eversion occur along frontal plane. Inversion occurs when the foot is
rotated toward the midline; eversion is rotation of the foot away from the midline.
The foot when it is in a fixed position would be described as being in varus; the foot
fixed in an everted position would be in valgus. Transverse motion is described as
adduction and abduction. Motion toward the midline is adduction; motion away
from the midline is abduction. Fixed position in the transverse plane is adduction
and abduction. Supination and pronation, while often used to describe foot patterns,
more specifically represents composite motion in all 3 planes. Supination is adduction,
inversion, and plantarflexion of the foot. Pronation involves abduction, eversion, and
dorsiflexion of the foot.
Ligament and articular geometry are the primary determinants of available ROM, but
all structural components play a vital role in normal function.60 Resisted ROM is often
used clinically to gauge muscle strength; the physician exerts a force against the mus-
cle being tested using personal strength as a gauge for normality while the lower ex-
tremity is stabilized to avoid substitution by proximal muscles.28 Strength is best
evaluated in functional weight-bearing positions and during ambulation if possible—
patients should walk on heels, toes, as well as lateral and medial borders of the
foot.1 Passive ROM is used for assessing the integrity of joints and their supporting
structures. Normal joints should move smoothly and the end point should be firm.61
Pain, laxity, catching, locking, or inappropriate end point quality are pathologic. Pas-
sive ROM requires patient cooperation; the procedure should be explained and the
patient asked to allow movement without active resistance.62 The hindfoot is capable
of complex triplanar motion through action at the ankle and subtalar joints. The lateral
ligament complex and the medial deltoid ligament play a large role in stabilizing the
hindfoot and preventing excessive translation.8 The lateral ligament complex includes
the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talo-
fibular ligament and damage to these structures results in pathologic joint movement.
The ankle or “mortise” is a synovial hinge joint, involving the articulation between the
tibia, fibula, and talus. This joint is responsible for sagittal movement and the average
patient is capable of 20 dorsiflexion and up to 50 of plantarflexion.28 Bone spurs or
200 Papaliodis et al

accessory bones such as the os trigonum can cause painful impingement syndromes
that limit ROM at the ankle. Symptoms can be reproduced by sharp dorsiflexion or
plantarflexion resulting in pain at the anterior or posterior joint line, respectively.24
The subtalar joint is a synovial, bicondylar compound joint that consists of the anterior,
middle, and posterior articulation surfaces between the talus and the calcaneus. There
is great variability in subtalar motion, but the average individual should have an inver-
sion range of 5 to 40 and an eversion range of 5 to 20 . Ankle ROM should be
assessed with the knee flexed and then extended. The hindfoot should be in a neutral
position and the forefoot locked in inversion. Although one hand stabilizes the heel, the
other should use the midfoot as a lever to maximally dorsiflex and plantarflex the joint.
In the same position, subtalar ROM can be tested by slowly turning the heel in and
out.28 Most of the remaining articulations are relatively static and their ROM is not
routinely assessed. The individual bones of the midfoot, for example, are only capable
of minimal independent motion because of numerous ligaments that bind the struc-
tures together; this is functionally crucial for shock absorption during ambulation.63

GAIT ASSESSMENT

Patients rarely present with gait disturbance as a chief complaint but difficulty walking
is a common secondary problem.64 Gait assessment is arguably the most important
aspect in the clinical evaluation of FAD. Normal gait requires the coordination between
the nervous and musculoskeletal systems and relies heavily on intact sensory informa-
tion from the visual, vestibular, and proprioceptive systems. There are many ways to
evaluate gait using sophisticated equipment; however, visual observation is quick and
can give much information in a cost-effective manner.1 Ambulation should be system-
atically assessed from the front, side, and back. The stance phase takes up about
60% of the gait cycle and the swing phase takes up the remaining 40%. The overall
pattern of body movement should be evaluated first for posture, symmetry, fluidity,
temporal parameters, cadence, stance, and step length.65 Next, the motion at individ-
ual joints should be observed from the feet upward to help differentiate a focal prob-
lem in the lower extremity from a generalized movement disorder.64 Calcaneal motion
can be monitored by marking the midline of the rear foot and watching the movement
through the entire gait cycle.1 Increasing the pace may bring out subtle disorders. Ant-
algic gait can be caused by any painful condition in the lower extremity, such as
arthritis, ankle sprains, and stress fractures of the foot. The characteristic limp is a
result of decreased time in the stance phase of the affected limb in an attempt to mini-
mize pain with weight-bearing and can be recognized as a decrease in step length of
the uninjured side and overall decrease in velocity.64 The ability to ambulate for at least
4 steps regardless of gait is a criterion in the OAR.

Gait and Falls in the Elderly

There are many causes and patterns for gait disturbances, especially in the elderly
population. Up to 15% of patients older than 64 years and more than 40% of patients
over 85 years have a gait abnormality. Balance and gait impairment nearly double the
risk for falling, which can result in serious soft tissue injuries and fractures.64 Other risk
factors, such as the use of sedatives, environmental hazards, and excessive medica-
tion, should be modified.28 Not all abnormal gaits are concerning. Nonpathologic age-
related changes include shorter and broader-based steps, decreased velocity, and
decreased step length.65 Pathologic movement disorders in the elderly are most
commonly due to cerebral infarcts, arthritic pain, spinal spondylopathy, Parkinson dis-
ease, and cerebellar degeneration.64
 The Foot and Ankle Examination 201

Sensory ataxia is a gait pattern that results from disruption of afferent pathways in
the visual, vestibular, or proprioceptive systems. The patient loses awareness of limb
position but muscle strength remains intact. The most common cause in America is
likely diabetes-related polyneuropathy with visual disturbances. This gait is character-
ized by a wide stance and a forceful slap on contact with the floor to increase sensory
feedback. Patients are often vigilantly watching the ground during ambulation and will
have dramatic instability in the darkness or when asked to perform the Romberg test.
The slap associated with sensory ataxia may be confused with the slapping of foot
drop from deficits in strength of the ankle dorsiflexors, but other clinical findings easily
distinguish the 2 patterns. There are numerous causes for foot drop including acquired
or hereditary peripheral neuropathies, peroneal nerve injuries, radiculopathy at L4, or
loss of motion at the ankle.64 A steppage gait with excessive hip and knee flexion is
used to help the toes clear the ground during the swing phase.24 Toes will make con-
tact with the ground before heel strike, producing the characteristic slap.
Special Consideration in High-Energy Falls
Fall-related injuries can be intentional, such as a suicide attempt, accidental, such as
falling off the roof, or simply poor judgment, such as a teenager jumping out of a win-
dow.28 Falls are emergencies because of the high potential for soft tissue injuries and
fractures of the pelvis, thoracolumbar spine, and skull base.66 The physical examina-
tion should include assessment of the skin for open wounds, neurovascular integrity,
and a thorough musculoskeletal evaluation.67 Feet-first impact is the most common
falling mechanism resulting in calcaneal fractures.67 Patients present with varying de-
grees of heel tenderness, swelling, ecchymosis, and loss of heel contour but still may
be able to bear weight.68 Many other fracture sites and patterns exist.

SUMMARY

Most FAD can be diagnosed after a proper clinical examination and managed in a pri-
mary care setting. It is important to assess the patient as a whole because age,
gender, athletic involvement, and pre-existing medical conditions determine which
common conditions are common in a given patient population. A broad differential
should include disorders of bones, joints, muscles, neurovasculature, and surrounding
soft tissue structures. Physical examination should localize the area of maximal
tenderness and assess the effect of the problem on ROM, strength, and gait. Symp-
tom reproduction is often fundamental to making a diagnosis. Imaging should be used
only when the potential findings are likely to change the diagnosis or management to
limit unnecessary expense and radiation.

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