Landmarks

Anatomical landmarks represent a guide in the examination of a specific region of the body that may be compromised by injury or degenerative conditions.

The examiner uses the protruding surfaces of the joints of the ankle and foot. The landmarks are located in the:

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Medial aspect

Calcaneus, medial malleolus, sustentaculum tali, talar head, navicular tub, 1st cuneiform, 1st metatarsal, 1st metatarsal-phalangeal joint.

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Lateral aspect:

Lateral malleolus, sinus tarsi, calcaneus, peroneal tub, cuboid bone, styloid process, 5th metatarsal, 5th metatarsal-phalangeal joint.

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Inspection

The inspection begins with a visual observation of the affected area, which is compared to the contralateral,healthy side. The hallmarks of any pathology are pain, redness(erythema), swelling, increased warmth, deformity, neurological symptoms and changes in gate function.

The examiner investigates possible morphological alterations in the anatomy of the ankle and foot including:

Scars, rashes, or other lesions

Asymmetry

Deformities or atrophy

Anatomical differences compared with the healthy side

Dorsal side of the foot

Plantar side of the foot

Arthritic changes

Palpation

The examiner will palpate the foot to determine:

Changes in temperature

Local tenderness

Palpation in specific areas: metatarso-phalangealjoints, mid-foot, ankle

Sole, medial, lateral and tendons, ankle joint, forefoot

Palpation of the foot is set in different zones corresponding to different areas of the foot.

Zone1

Head of 1st metatarsal bone

Pathology e.g. gout, hallux valgus

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Range of motion

Analysis of the range of motion is performed during passive movement, active mobilisation and power function/action.

Dorsiflexion: raise the foot upwards; range of movement 10° to 30°

Plantar flexion: Lower the foot downward; range 20° to 50°

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Inversion: Twisting movement of the foot inward

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Eversion: Twisting movement outward.

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Flexion - extension of the big toe 1st metatarsal phalangeal joint motion

To assess the movement of the big toe the examiner stabilises the foot. The movement of the 1st interphalangeal joint of the big toe is measured from flexion to extension.

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The movements of the toes II to V. The movement of the joints of the other toes varies as follows:

MPJ, metatarso-interphalangeal joint, Toes  II to V

Flexion / Extension

Range: 40° - 0°-  60°/ 80°

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PIPJ, proximal interphalangeal joint, Toes II to V

Flexion / Extension

Range: 35° - 0°-  0°

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DIPJ, distal interphalangeal joint, Toes II to V

Flexion / Extension

Range: 60° - 0°-  30°

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Analysis of gait cycle

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Contact/Heel Strike: The beginning of the gait cycle the heel contacts the ground.

Forefoot contact: The entire forefoot contacts the ground, to stabilise the foot and body.

Midstance: When the weight of the body is directly over the foot. The opposite foot is swinging from the rear of the body towards the front of the body.

Heel off: the heel lift from the ground, and the weight shifts to the front of the foot.Simultaneously the opposite foot contacts the ground.
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Propulsion/Push off: the foot pushes off the ground and begins to swing from the back to the front of the body).

Anterior drawer test - ligamentous ankle instability

Anterior drawer (and talar tilt tests) is used to assess ankle instability of the capsule and anterior talofibular ligament. The patient's knee is flexed to relax the gastro soleus complex and the foot kept in 10° flexion. The examiner holds the heel while pulling the foot forward (anteromedially) and pressing the front of the tibia with the other hand in opposite directions.

With lax joints, the drawer test is positive with a movement over 2 mm, or better over 4 mm, compared to the contralateral, uninjured ankle. If a depression appears over the anterior talofibular ligament during anterior translation, it is a sign of ligament compromise especially if associated with pain. The anterior drawer test is not always reliable, because muscle tension may mask the damage to the ligaments.

Talar tilt test

The talar tilt test, or inversion stress maneuver, is performed to diagnose excessive ankle inversion. The patient is supine or sitting with the foot relaxed. The knee is flexed to relax the gastrocnemius. The talus is twisted from side to side into adduction and abduction. The normal degree of tilt ranges from 0 to 23°. If abduction exceeds this range compared to the opposite ankle, it indicates damage to the calcaneo-fibular ligament or CFL. It is difficult to perform this test if the ankle is swollen and tender.

Squeeze test - ligamentous ankle stability

The syndesmosis is the joint made of ligaments situated above the ankle, which connects and stabilises the tibia and fibula. The fibular compression test, or squeeze test, is used for the diagnosis of asyndesmotic or fibular injury. The examiner places the thumb on the tibia and the fingers on the fibula at the midpoint of the calf and then squeezes both bones together. The test is positive when pain is triggered at the distal syndesmosis, just above the ankle, but not where the pressure is applied. A positive test indicates injuries to the syndesmosis and tibiofibular ligaments in high ankle sprain, or with a Maisonneuve fracture of the proximal fibula.

External stress rotation test (Kleiger’stest)

The external rotation test is used to diagnose rotational injuries to the deltoid ligament and tibiofibular syndesmosis, typical of ankle sprains. The patient sits with the knee flexed to 90°. The examiner holds the foot from the medial side with one hand while supporting the lateral fibula and tibia with the other. Then the foot is rotated laterally with the ankle locked in neutral position (ERT) or in maximal dorsiflexion (Kleiger’s).

The test is positive for damage to the deltoid ligament if there is medial joint pain at neutral position. The test is positive for syndesmos is damage if pain is felt in the anterolateral ankle, at the distal tibiofibular syndesmosis.

Thompson test for Achilles tendon rupture

Thompson test is used to detect a partial or complete rupture of the Achilles tendon. The patient lies in a prone position with the feet placed beyond the edge of the examining table. The examiner squeezes the calf muscle and observes the reaction of the foot. Flexion of the foot plantar indicates a normal or partially torn Achilles tendon. Absence of foot movement indicates a complete rupture of the Achilles tendon.

Test for Achilles pathologies

The examiner asks the patient to walk on the toes with the heels off the ground.The test is positive for a Achilles pathology if this task causes pain. Then the patient walks on heels while lifting the toes. The test is positive for Achilles pathology when pain is felt on the tendon. When both tasks cause pain, it is a sign of Achilles tendinitis.

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Examination of footwear

Observation of the footwear provides a good indication of biomechanic dysfunction demonstrated by abnormal wear of the sole.

Asymmetry of sole wear is also a sign of altered weight-bearing, and can arise from low extremity deformities but also problems to the pelvis and spine resulting in abnormal gate pattern.

The examiner will focus on:

Distortion of shape - rigid deformity of the foot

Wrinkling of footwear – heel varus, deep wrinkles on inner aspect of heel

Bulging out thinning

Sole deformity

Clubfoot weight kept on the outside of the heels

Wear on the lateral sole is indicative of fixed supination, or tibial varum/knee varum (bowlegged).

Excessive wear at the front of the sole indicates a "forefoot striker" in runners, or increased pressure from the metatarsal heads, with arch collapse.

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Tibial torsion test

Tibial torsion test is used to assess whether excessive internal rotation of the tibia is the cause of toeing. In normal anatomy, the imaginary line between the malleoli is slightly rotated externally relative to the centre line along the tibia. With excessive rotation of the tibia, the line between the malleoli is exactly perpendicular to the tibial line.

Forefoot adduction correction test

The fore foot adduction correction test helps determine whether forefoot adduction, often found in children, requires treatment. The examiner holds the child’s foot and corrects the adduction by pushing the foot to neutral position. If the foot position into neutral is achieved no treatment is necessary. Otherwise if only partial neutral position is achieved, it may require correction with a cast.

Coleman block test

The Coleman block test is used to determine the flexibility of the hindfoot and the pronation of the forefoot, when the foot shows increased medial-longitudinal arch and heel varus.

The patient stands with the foot on a wood block (1 inch thick) by keeping the heel and lateral edge of foot on the block, while the 1st metatarsal hangs off the block to allowfor plantar flexion.

The hindfoot is flexible if heel varus is corrected to neutral position with the block indicating that varus deformity is caused by flexion of the 1st metatarsal. If the hindfoot varus persists, the hindfoot has a fixed inversion deformity.

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Fracture test

The patient lays in supine having the feet at the end of the table. The examiner grasps the foot around the mid–shaft. He/she then squeezes the metatarsals or compresses the bones from one end to the other and rotates the bones. The test is positive when the manoeuvre triggers pain or crepitus indicative of possible metatarsal fracture.

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Windlass test for plantar fasciitis

The windlass test consists in a strong stretch of the plantar aponeurosis when thebody weight is transferred to the balls of the feet, the hallux is dorsiflexedand the heel is raised. It is used for the diagnosis of plantar fasciitis. The test can be performed in both sitting position with the foot elevated from the ground or in standing position whereby the foot is placed on a block and the metatarsal joints on the edge. The windlass test determines whether passive dorsiflexion of the toes causes painto the heel.

Hallux valgus - hallux rigidus

The severity of the hallux valgus deformity is assessed by measuring the size of the medial eminence and by examining the skin condition including the presence of callouses and infections. With passive range of movement of 1st metatarsal, the examiner tries to correct the deformity by abducting the big toe in the correct position. If the joint position does not correct spontaneously it may indicate soft tissue contracture, congruent joint or arthritis of the MTP joint.

Grind test. With axial compression of the big, the examiner determines the occurrence of pain, caused by arthritis to the 1st MTP joint.

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Varus/Valgus Stress Test of the MTP

The patient lies supine or sitting with the knees extended. With one hand the examiner stabilises the medial foot close to the MTP. The distal 1st metatarsal of the big toe is moved laterally (valgus) or medially (varus). The test is positive when increased or decreased laxity occurs and pain is felt,all of which is indicative of a collateral ligament sprain.

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Morton’s test for interdigital neuroma

With the patient in the supine position, the examiner uses a stick or pencil to apply pressure to the intermetatarsal space. The test is positive for interdigital neuroma when symptoms (e.g. pain) are enhanced.

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Neurological testing

The neurological status of the limb must be assessed at examination.

The specific examination is performed to determine changes in:

Motor function

Sensory function

Reflexes

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Motor function

The examiner investigates the function of different muscles of the ankle and foot to determine the integrity of the nerves controlling the movement of each component. In brackets is the responsible nerve.

Extensors:

Tibialis Anterior (Deep Peroneal Nerve L4)

Extensor Hallucis Longus (L5)

Extensor Digitorum Longus (L5)

Flexors:

Peroneus Longus and Brevis (Superficial peroneal Nerve, S1)

Gastrocnemiusand soleus (Tibial Nerve, S1 S2)

Flexor Digitorum Longus (Tibial Nerve L5)

Tibialis Posterior (Tibial Nerve L5)

Sensory function

The sensory and motor function of the ankle and foot are controlled by the nerves of the lumbar and sacral spine.

The examiner is testing touch, pin prick, vibration (using a tuning fork), and is looking for joint position sense (proprioception). The examiner will also focus on dermatomes, which are skin and muscle areas innervated by specific nerves. Any deficits such as pain, numbness, and muscular atrophy/loss of strength of the ankle and foot can arise from a pathology to the lower spine and revealed by examining the corresponding dermatomes.

Also each muscles can be assigned to a specific nerve which is named myotome. The nerves departing from each vertebra are listed below to the corresponding muscular function.These are the myotomes

L2     Hip Flexion

L3     Knee Extension

L4     Dorsiflexion

L5     Big Toe Extension or Lesser Toes Extension

L5/S1 Knee Flexion

S1     Plantar flexion or Foot Eversion

S2     Toe Flexion

Reflexes

The reflexes of nerves controlling the the ankle and foot include the following tests:

Ankle jerk, calcaneal - Achilles tendon (S1, S2)

Plantar reflex (S1 root and tibial nerve) - deep fibular nerve (when damaged causes foot drop)

Sensation

Tinel's sign

The patient lies supine with the hip of the affected side externally rotated and the foot slightly turned inward. The examiner taps over the tarsal tunnel with a hammer. The test is positive for a tarsal tunnel syndrome when pain radiates to the foot and toes.

Vascular examination

Besides the pulses, the examiner is testing for capillary refill and looking for oedema, cyanosis, clubbing and lymphatics.

The patient pulses are taken in various regions of the limb from the inguinal area to the foot. There are multiple pulses on the lower extremity are:

Femoral pulse at the groin, popliteal pulse at the popliteal fossa taken with the leg partially flexed, posterior tibial pulse on the back of the knee, anteriortibial pulse just above the inner ankle.

Vascular tests are also employed to monitor the vascular status.

Doppler: If the examiner is unable to feel the pulse due to severe oedema, a Doppler device can be used to locate the artery.

The ankle-brachial index is used to test for peripheral artery disease. It compares the blood pressure measured at the ankle with that measured at the arm. A low index indicates a blockage or narrowing of the arteries.

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