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Ankle and foot examination can occasionally appear in OSCEs, so it’s important you’re familiar with it. Check out the ankle and foot examination mark scheme here.

Check out our foot and ankle anatomy guide here.



Introduction

Wash hands

Introduce yourself – state your name and role

Confirm patient details – name and DOB

 

Explain examination:

“I’d like to examine your ankles and feet. This will involve having a look and feel of these joints, in addition to assessing the joints’ movement”

 

Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with the exam?”

Gain adequate exposure – both legs should be exposed from the knee down

Position patient – ask patient to stand up straight with their feet aligned facing forwards


Look

Gait

Is the patient demonstrating a normal heel strike/toe off gait?

Is each step of normal height?increased stepping height is noted in foot drop

Is the gait smooth and symmetrical?

Examine the patient’s shoes – evidence of asymmetrical wearing may indicate abnormal gait 

Ask the patient to walk on their tip-toes, then on their heels – problems with this may point to multiple problems such as arthritis, muscle strength in the calf muscles which help in plantarflexion and anterior muscles of the lower leg which help in dorsiflexion

Inspect from the front

Symmetry of feet and ankles

Toe alignment – hallux valgus of the big toe may be noted

Bunions – located at the 1st metatarsal phalangeal joint (MTP) joint

Deformities of the toes (claw/mallet/hammer toes)

Scarssuggestive of previous injury / surgery

Calluses – may indicate foot/gait deformity or poorly fitting footwear

Swelling or erythema of the foot or ankle – may suggest injury / inflammatory arthritis / septic arthritis / cellulitis 

 

Inspect from the side

Foot arches – observe for evidence of flat feet (pes planus) or high arched feet (pes cavus)

If patient has flat feet ask to stand on tiptoes – supple flat feet will correct / rigid flat feet will not

 

Inspect from the back

Foot/ankle symmetry – heel alignment – valgus or varus deformity?

Achilles tendon – deformity / discontinuity / swelling (may suggest Achilles tendonitis) / erythema

  • Inspect GAIT
    Inspect the patient's gait

Feel

Ask the patient to lay on a bed

Assess temperature and compare between legs – ↑ temperature may indicate inflammatory pathology / septic arthritis / cellulitis

Assess pulses in both feet – posterior tibial and dorsalis pedis 

 

Palpate the achilles tendon:

  • Position the patient kneeling on a chair
  • Palpate the gastrocnemius muscle and achilles tendon
  • Note any focal tenderness or swelling – achilles tendonitis
  • Note any apparent gaps in the tendon – suggestive of rupture

 

Palpate the joints and bones

Work distal to proximal – assess for tenderness / swelling / irregularity  

  • Squeeze MTP joints – observe patient’s face for discomfort
  • Metatarsal and Tarsal bones
  • Tarsal joint
  • Ankle joint 
  • Subtalar joint
  • Calcaneum
  • Medial/lateral malleoli
  • Distal fibula
  • Assess ankle and foot joint temperature
    Assess and compare temperature of the ankle/foot joints

Move

Active and passive assessment

Assess each of the following movements actively and passively, feeling for crepitus (excluding toe flexion/extension)

Foot plantarflexion – push your feet downwards, like pushing a car pedal” 0-50º

Foot dorsiflexion – “point your feet towards your head”0-20º

Toe flexion – “curl up your toes”

Toe extension – “point your toes towards your head”

Ankle/foot inversion – 0-35º

Ankle/foot eversion – 0-15º

Passive assessment only

Assess the passive movement of:

  • Ankle joint
  • Subtalar Joint
  • Mid-tarsal joint
  • Metatarsal-phalangeal and Interphalangeal joints (proximal and distal)
  • Active ankle plantarflexion
    Active ankle plantarflexion (0-50º)

Special tests

Simmonds’ test

Simmonds’ test is used to assess for rupture of the achilles tendon

1. Ask patient to kneel on a chair with their feet hanging off the edge

2. Squeeze each calf in turn

3. Normally the foot should plantarflex

4. If the achilles tendon is ruptured there will be no movement of the foot

  • Simmond's test
    Ask the patient to kneel on a chair and squeeze their calf

To complete the examination

Thank patient

Wash hands

 

Suggest further assessments and investigations

  • Examine the knee and hip joint 
  • Full neurovascular examination of the lower limbs
  • Further imaging of the relevant joints if indicated (Xray / CT / MRI)

Further reading

Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [LINK]


REVIEWED BY 

Mr Tejas Yarashi

Trauma & Orthopaedic Surgeon (ST7)


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