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:
Calcaneus, medial malleolus, sustentaculum tali, talar head, navicular tub, 1st cuneiform, 1st metatarsal, 1st metatarsal-phalangeal joint.
Lateral malleolus, sinus tarsi, calcaneus, peroneal tub, cuboid bone, styloid process, 5th metatarsal, 5th metatarsal-phalangeal joint.
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
Deformities or atrophy
Anatomical differences compared with the healthy side
Dorsal side of the foot
Plantar side of the foot
The examiner will palpate the foot to determine:
Changes in temperature
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.
Head of 1st metatarsal bone
Pathology e.g. gout, hallux valgus
Zone 2 - Medial foot
Navicular tubercle and talar head
Zone 3 - Medial malleolus
Palpate - Deltoid ligament on the medial side
Palpate the area between posterior aspect of medial malleolus and Achilles tendon including:
Tibialis posterior tendon
Flexor digitorum longus tendon
Flexor hallucis longus tendon
Posterior tibial artery and tibial nerve
Zone 4 – Dorsum of foot between malleoli
The examiner palpates the dorsal foot from the medial to the lateral side, along three major tendons and one artery across the malleoli:
Extensor hallucis longus
Extensor digitorum longus
Dorsal pedal artery
Zone 5 – Lateral ankle – lateral foot
The examiner palpates the ligaments of the lateral side of the ankle joint. From anterior to posterior, they are:
Anterior talo-fibular ligament
Posterior talo-fibular ligament
Zone 6 - Sinus tarsi
This region is often damaged in ankle sprains.
Zone 7 - Head of 5th metatarsal
Checking the peroneus brevis tendon at the base of the 5th metatarso-phalangeal joint to test for tailor’s bunion
Zone 8 - Calcaneus
Palpationat the insertion of the Achilles tendon and the posterior side of the calcaneus is useful to detect pathologies of the retrocalcaneal bursa and calcaneal bursa and bone spur growth
Zone 9 - Plantar surface
A gentle pressure is put on the metatarsal heads (sesamoids), along the metatarsal bones (Morton’s neuroma) and through the plantar aponeurosis orfascia
Zone 10 - Toes
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°
Inversion: Twisting movement of the foot inward
Eversion: Twisting movement outward.
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.
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°
PIPJ, proximal interphalangeal joint, Toes II to V
Flexion / Extension
Range: 35° - 0°- 0°
DIPJ, distal interphalangeal joint, Toes II to V
Flexion / Extension
Range: 60° - 0°- 30°
Analysis of gait cycle
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.
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.
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
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.
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.
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.
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.
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.
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.
The neurological status of the limb must be assessed at examination.
The specific examination is performed to determine changes in:
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.
Tibialis Anterior (Deep Peroneal Nerve L4)
Extensor Hallucis Longus (L5)
Extensor Digitorum Longus (L5)
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)
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
L5 Big Toe Extension or Lesser Toes Extension
L5/S1 Knee Flexion
S1 Plantar flexion or Foot Eversion
S2 Toe Flexion
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)
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.
A thorough vascular examination is required to detect any damage to the veins and arteries of the lower limbs. Vascular tests ascertain the integrity of the circulatory system and perfusion of the foot and ankle by examining:
Distal pulses (images)
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.