Foot & Ankle Examination PDF

FOOT & ANKLE EXAMINATION (According to UMMC video) PROFESSIONALISM 1. Wash hands and introduce yourself 2. Obtain consent 3. Exposure of the patient a. Ensure patient is standing with no footwear, expose from mid thigh and below b. The sound ankle...

FOOT & ANKLE EXAMINATION (According to UMMC video) PROFESSIONALISM 1. Wash hands and introduce yourself 2. Obtain consent 3. Exposure of the patient a. Ensure patient is standing with no footwear, expose from mid thigh and below b. The sound ankle (normal ankle) must also be exposed for comparison c. If patient is unable to stand, then ask patient to be in recumbent position (on their back), or sitting on a couch LOOK (GENERAL) 1. Inspection the attitude of the lower limb first a. Inspect for genu valgus/valgum, varus or external rotation of the lower limb b. Inspect for skin changes; bruising, redness, dry skin, ulcer, scars, sinuses, swelling, or muscle wasting c. Do this anteriorly and laterally d. Note: the video did not show inspection from the posterior aspect but you may do so GAIT 1. Assess patient’s gait and note for normal toe off, swing, heel strike, and stance phases 2. Observe for any abnormal lateral or medial loading of the foot, or varus thrust of the ankle joint 3. Certain abnormal gaits include; antalgic gait, short limb gait, high stepping gait LOOK (2ND TIME - FOOT & ANKLE) 1. Ask patient to stand and realign the lower limbs with the patellar facing forwards before commenting on the attitude of the foot and ankle 2. Anteriorly; look for medial longitudinal arch, bilateral hallux valgus, lesser toe deformities, ankle deformities, peek-a-boo heel sign 3. Posteriorly; look for hindfoot varus or valgus deformities, too many toes sign (indicating forefoot abduction) 4. Other examples of foot deformities include; pes planovalgus deformity (loss of medial longitudinal arch of the foot, clawing of toes, hindfoot valgus, too many toes sign), hallux valgus, overriding toes, and clawing of toes 5. Perform a double heel raise test a. Ensure there is an examination chair or couch for support b. Ask the patient to stand on their toes while you observe from behind c. Note that the hindfoot goes into varus and the medial longitudinal arch of the foot reconstitutes (which is normal) 6. Perform a single heel raise test (when suspecting an isolated posterior tibialis tendon deficiency) a. Ask patient to stand on the toes of only one foot and raise their other leg b. Note that the hindfoot goes into varus and the medial longitudinal arch of the foot reconstitutes (which is normal) c. Compare with the other leg FEEL 1. Ask patient to sit 2. Feel the plantar aspect of the foot for any callosities or ulcers 3. Examine for any increase in local temperature of the feet and ankles a. Palpation should always start at non-tender regions 4. Palpate lateral ankle for any tenderness a. Start at the tip of the fibula or lateral malleolus b. The anterior talofibular ligament (ATFL) footprint c. The calcaneofibular ligament (CFL) footprint d. The peroneus tendons e. Up the lateral malleolus  5. Palpate medial ankle for any tenderness a. Start at the tip of medial malleolus b. Deltoid ligament c. Medial joint line d. Talocrural joint 6. Palpate posterior ankle for any tenderness a. Start at the Achilles tendon b. Along midsubstance of the tendon c. Retrocalcaneal bursa region 7. Palpate midfoot for any tenderness a. Start at the talonavicular joint b. First tarsometatarsal joint c. Subsequent tarsometatarsal joints 8. Palpate plantar area for any tenderness a. Start at the metatarsal heads b. Plantar fascia until its insertion into the calcaneum c. Heel fat pad MOVE 1. Test for active range of motion a. Ankle dorsiflexion (normal is up to 20 degrees of movement) b. Ankle plantarflexion (normal is up to 45 degrees of movement) c. Supination of the foot d. Pronation of the foot 2. Test for passive range of motion a. Start when there is limitation present b. If patient had normal active range of movement, proceed by assessing movement of subtalar joint (as this can only be done passively)  i. Hold and fix the talus in position while cupping the calcaneum with your other hand ii. Perform passive inversion and eversion of subtalar joint 3. If ankle dorsiflexion is limited, proceed with Silfverskiold test a. Passively dorsiflex the ankle joint with the knee in extension b. Note the angle c. Then, flex the knee d. If the ankle is able to dorsiflex an extra 10-15 degrees, it denotes a positive Silfverskoild test (indicating gastrocnemius tightness) 4. Perform anterior drawer test (to assess lateral ankle instability - for ATFL laxity: ankle in 10 degrees plantarflexion) a. Rest the forefoot on your forearm while cupping the heel with your hand b. Stabilize the talus and tibia with your other hand c. Hold the foot in 10 degrees plantarflexion d. Pull the foot forward (to draw the talus forward in the ankle mortise) e. A positive test is when there is a suction sign indicating laxity in the ATFL 5. Perform anterior drawer test (to assess lateral ankle instability - for CFL laxity: ankle in neutral position) a. Rest the forefoot on your forearm while cupping the heel with your hand b. Stabilize the talus and tibia with your other hand c. Hold the foot in neutral position 6. Perform Thompson test (to assess integrity of Achilles tendon) a. Ask patient to lie prone b. Flex the knee joint c. Observe the resting position of the ankle joint and compare it to the contralateral side d. Subsequently, squeeze the calf i. If the ankle joint moves into more plantarflexion, it indicates intact Achilles tendon ii. Be careful of false negative finding in cases of a partial rupture of Achilles tendon CONCLUSION 1. Conclude the examination by inspection of the patient’s footwear for any abnormal wear 2. Note also if the patient uses any orthosis, special shoes or walking aids