Ankle & Foot Exam

Question 1

What are some things to look for in terms of general observation?

Answer 1

• standing vs. seated vs. ambulating
• asymmetry, varus/valgus
• hyperpronation
  hypersupination

Question 2

What are some key landmarks of the ankle/foot?

Answer 2

• medial and lateral malleoli
• navicular
• cuneiforms (1-3)
• deltoid ligament (primary stabilizer of medial ankle)
• medial longitudinal arch (talus, navicular, cuneiforms 1-3, metatarsals 1-3)
• posterior tibial artery pulse
• calcaneus
• cuboid
• lateral longitudinal arch (calcaneus, cuboid, metatarsals 4-5)
• anterior talofibular ligament
• calcaneofibular ligament
• posterior talofibular ligament
• metatarsals/MTP joints
• phalanges
• transverse distal tarsal arch
• dorsalis pedis pulse
• plantar fascia
• achilles tendon
• posterior tibialis tendon, flexor digitorum longus, flexor hallucis longus - all pass thru tarsal tunnel
• extensor hallucis longus tendon
• extensor tendons
• peroneus (fibularis) tendon

Question 3

Capillary refill testing

Answer 3

• compress digits between index and thumb to cause blanching - then release pressure and note time to regain color
• normal is 3 seconds or less

Question 4

Monofilament test

Answer 4

• test is performed on the plantar aspect of foot
• doctor asks patient to close their eyes
• monofilament is placed on first and fourth pad of toes and at base of 1st, 3rd and 5th plantar MTP joints with enough pressure to cause slight bend of monofilament
• if (+): if patient cannot feel monofilament
• imp component of diabetic foot exam

Question 5

ROM of ankle: dorsiflexion

Answer 5

15-20 deg

Question 6

ROM of ankle: plantarflexion

Answer 6

50-65

Question 7

ROM of ankle: subtalar inversion

Answer 7

20-30

Question 8

ROM of ankle: subtalar eversion

Answer 8

10-20

Question 9

ROM of ankle: metatarsophalangeal flexion and extension

Answer 9

N/A

Question 10

ROM of ankle: forefoot adduction and abduction

Answer 10

N/A

Question 11

ROM of ankle: pronation

Answer 11

dorsiflexion, abduction and eversion of calcaneus

Question 12

ROM of ankle: supination

Answer 12

• plantarflexion, adduction, inversion of calcaneus

Question 13

What are the dorsiflexors and their innervation?

Answer 13

tibialis anterior (primary) - deep peroneal n (L4/5) 
extensor hallucis longus - deep peroneal n (L5) 
extensor digitorum longus - deep peroneal n (L5)

Question 14

What are the plantar flexors and their innervation?

Answer 14

gastrocnemius/soleus (primary) - tibial n (S1/2)
peroneus longus/brevis - superficial peroneal n (L5)
Flexor digitorum longus - tibial n (L5)
Tibialis posterior - tibial n (L5)

Question 15

What is the reflex at the ankle?

Answer 15

Achilles tendon - S1

Question 16

What are the spinal contributions to the dermatomes of the ankle/foot?

Answer 16

L4,5,S1

Question 17

Anterior drawer test

Answer 17

• Doc grasps posterior calcaneus with one hand and cups distal tibia/fibula with the other hand, monitoring anteriorly at the anterior talus.
• Provide anterior force on calcaneus while stabilizing the distal tibia/fibula. Normal springing of calcaneus back to neutral should occur
• if (+): pain, no springing, excessive motion
• indicates anterior/laxity - ATF ligament pathology/tear

Question 18

Talar tilt test

Answer 18

• doc grasps distal tibia/fibula with one hand and the inferior calcaneus with the other, blocking motion of the calcaneus on the talus
• invert the talus to evaluate ROM
• if (+): laxity, increased ROM or pain
• indicates calcaneofibular ligament pathology/tear and some ATFL

Question 19

Eversion test

Answer 19

• Doc grasps distal tibia/fibula with one hand and grasps the
  midfoot from the plantar surface of the foot with the other hand.
• Doc everts the foot to evaluate ROM.
• if (+): laxity, increased ROM or pain
• indicates deltoid ligament pathology

Question 20

Squeeze test

Answer 20

• for high ankle sprain
• Doc wraps hands around leg proximal to the ankle, contacting the distal tibia/fibula with both thenar eminences.
• Squeeze for 2-3 seconds then rapidly release.
• if (+): pain at syndesmosis
• indicates syndesmosis pathology

Question 21

Cross leg test

Answer 21

• for evaluation of high ankle sprain
• patient seated
• patient crosses affected leg over opp knee
• patient then applies pressure to proximal fibula of affected leg
• if (+): pain at distal ankle
• indicates syndesmosis injury

Question 22

Thompson test

Answer 22

• patient prone with foot off the table
• doc squeezes calf
• if (+): absence of plantar flexion
• indicates achilles tendon rupture

Question 23

Homan’s sign

Answer 23

• Indicates thrombophlebitis or acute venous thrombosis
• pt laying or seated with knee extended
• doc dorsiflexes foot (sometimes add lateral compression of calf as well)
• if (+): pain with dorsiflexion
• indicates venous thrombosis in presence of edema, erythema, and increased warmth of skin of lower leg
• need to get a venous doppler to rule out clot

Question 24

Moses sign

Answer 24

• indicates deep vein thrombosis of posterior tibial veins
• pt seated or supine
• physician induces an anterior compression on the gastrocnemius mm into the posterior aspect of the tibia (compresses the calf towards the tibia)
• if (+): pain with anterior compression (NOT lateral compression)

Question 25

Inversion ankle sprain (lateral sprains)

Answer 25

- Accounts for 80-85% of all ankle sprains - Ankle inversion with plantar flexion - Ligaments Involved: - Anterior talofibular (ATF=always tears first) - Calaneofibular - Posterior talofibular - Swelling and ecchymosis over involved area

Question 26

High ankle sprain

Answer 26

- Accounts for 10% of all ankle sprains - Ankle Eversion and rotation (some dorsiflexion) - Ligaments Involved: - Anterior Inferior tibiofibular - Syndesmosis - Pain more common on medial aspect with minimal swelling - Pain worse with weight bearing

Question 27

Plantar fasciitis

Answer 27

- Inflammation of origin of plantar aponeurosis - Worse with first steps, improves through day - Pt will complain pain is worst when they get out of bed in morning - Point tenderness of calcaneous - Causes: tight calves, repetitive impact activities, high arches, obesity, new/changes in activities - You already know a way to treat this!!

Question 28

Morton's neuroma

Answer 28

- Inflammation and thickening of tissue that surrounds the nerve between toes. - Most commonly between 3rd and 4th toes. - Patient reports feeling like they are walking on a marble - Palpable in web space, which will replicate pain

Question 29

Turf toe

Answer 29

- Inflammation and Pain at base of 1st MTP - Presents as pain and bruising at base of great toe - Caused by hyperextension of great toe causing damage to the joint capsule. - Severe cases can damage sesamoids and flexor tendon - Common due to activities performed on hard surface

Question 30

Achilles tendonitis

Answer 30

- Inflammation at Achilles tendon - Presents as sharp heel pain and stiffness at mid-achilles tendon to insertion - Worse with strenuous exercising, better with walking - Micro tears in tendon causes swelling and thickening - Causes: tight calf muscles, sudden change in activity, poorly fitting shoes, incorrect running technique