Foot and ankle examination Flashcards
What is the general order in which you should examine the foot and ankle?
Look: Standing, gait, sitting
Feel: Temperature, pulse
Move: Active and passive
Sensation
Resisted movements/power
Special tests
How should you position the patient when looking at their foot and ankle whilst sitting?
Sitting on bed with foot and ankle overhanging edge
When the patient is sitting with overhanging foot and ankle, what surfaces do you examine?
Forefoot and toes
Plantar surface/sole
Shoes
Why do you need to examine the patient’s shoes, when they are sitting?
Abnormal or asymmetrical wearing of the sole or upper
For evidence of poor fit or the presence of special insoles, as this can cause fixed flexion deformities in toes
When the patient is standing, what 4 angles do you examine their foot and ankle from?
Anterior
Lateral
Posterior
Lateral
When the patient is standing, what do you look for on the anterior aspect of their foot and ankle?
Symmetry across both feet and ankles
Toe alignment and if they are touching the ground eg. fixed flexion deformities
Calluses
Unilateral/bilateral swelling in foot, toes or ankle joints
Psoriasis plaques/other skin changes
Nail changes
Lumps/nodules on their forefoot eg. rheumatoid nodules, gouty tophi
Bruising, erythema
Muscle bulk of lower calf muscles
Where do gouty tophi tend to present most commonly in foot and ankle, and describe their colour and texture?
Phalangeal joints in toes (mostly big toe)
Can also appear in midfoot and ankle, or any joints
Large, hard lumps, white/chalky colour
Where do rheumatoid nodules tend to appear in foot and ankle, and describe their appearance?
Balls of the feet, sides of the feet, on the toes, plantar surface
Rubbery surface, mobile, firm to touch
What are the 3 most common fixed flexion deformities of the lesser toes, and what conditions do they indicate?
Mallet toe: Mostly from wearing too narrow shoes
Claw toe: RA
Hammer toe: RA, maybe PsA
All can result from wearing narrow shoes and no pathology
What 2 conditions can bruising in the foot or ankle commonly indicate?
Recent trauma
Haemarthrosis due to clotting disorder or anticoagulant medication
What is hallux valgus/bunion and what condition is it a characteristic finding of?
Lateral angulation at metatarsophalangeal joint of great toe
Inflammatory conditions, mostly RA but can be PsA eg.
What is hallux varus, and what conditions cause it?
Medial angulation at metatarsophalangeal joint of great toe
Inflammatory conditions eg. RA, PsA
What do you look at on the foot and ankle from the lateral aspect?
Foot arch abnormalities
eg. flat feet: pes planus
eg. abnormally raised arch: pes cavus
Muscle bulk of lower calf muscles
If you see that someone has flat feet, what should you do to confirm this abnormality?
Ask them to stand on tiptoes and then see if their foot arch becomes normal
What do you look at on the foot and ankle from the posterior aspect?
Normal/abnormal heel alignment of hindfoot eg. varus, valgus deformity
Muscle bulk of lower calf muscles
Achilles tendon
On the posterior aspect of the foot and ankle, why is important to look for heel misalignment?
Can indicate ankle/subtalar joint disease
On the posterior aspect of the foot and ankle, what do you look for on the Achilles tendon?
Thickened tendon
Calcific tendinitis
Rupture
What does calcific tendinitis of the Achilles tendon look like?
Calcified mass in the distal Achilles tendon at its insertion site onto the posterior calcaneus.
Localized erythema and edema may be present along with an inflamed retrocalcaneal bursal sac
What does rupture of the Achilles tendon look like?
Loss of normal heel tone
Loss of tendon definition
Swelling
Erythema
What do you look for on the sole/plantar surface of foot?
Calluses
Where should you feel the temperature, in a foot and ankle examination?
Forefoot, midfoot, lower calf
Ankle joints and foot joints
Why is it important to feel the temperature of the joints in the foot and ankle?
Higher temperature can indicate infection, septic arthritis, inflammation of joint space
Along with redness, swelling
Which 2 pulses should you feel in the foot and ankle, and what do you compare between each leg?
Dorsalis pedis
Posterior tibial artery
Compare pulse strength
Why should you gently squeeze the MTP joints in the forefoot before palpating the rest of the joints?
If painful or tender, this can indicate synovitis that isn’t obviously palpable
What joints and bones in the foot and ankle should you palpate after the MTP squeeze?
Metatarsal and tarsal bones
Tarsal joint
Ankle joint
Subtalar joint
Calcaneum
Medial/lateral malleoli
Distal fibula
Why should you palpate the Achilles tendon?
Feel for tenderness, swelling, loss of definition as this indicates rupture or tendonitis
How do you ask a patient to show plantarflexion of the ankle joint?
Ask patient to point/push their feet downwards
‘Push down like you’re pressing on a pedal’
How do you ask a patient to show dorsiflexion of the ankle joint?
Ask patient to point their feet towards their head
“Extend your feet backwards, like you’re trying to point them up towards your head.”
How do you ask a patient to show foot/ankle inversion?
Ask patient to angle their feet to try to touch their soles together
How do you ask a patient to show foot/ankle eversion?
Ask patient to angle soles outwards as far as they are able to
How do you ask a patient to show toe flexion and extension?
Ask patient to curl toes as tightly as possible
Ask patient to point toes towards their head
When testing passive foot and ankle movements, where should you position your non-dominant hand and why?
Hold the heel to feel for crepitus in ankle joint
What special test should you do that can indicate Achilles tendon rupture?
Simmonds’ test
Ask the patient to kneel on a chair with their feet hanging over the edge, then squeeze each of the patient’s calves in turn.
Positive: No plantarflexion
Negative: Planterflexion happens
Which 7 nerves should you examine in the foot and ankle for sensory innervation?
Deep peroneal nerve
Lateral plantar nerve
Medial plantar nerve
Sural nerve
Saphenous nerve
Superficial peroneal nerve
Calcaneal nerve of tibial nerve
Where do you examine sensory innervation of the deep peroneal nerve?
1st toe webspace on foot dorsum
Where do you examine sensory innervation of the superficial peroneal nerve?
Middle of foot dorsum
Where do you examine sensory innervation of the saphenous nerve?
Medial aspect of foot up to metatarsophalangeal joint of great toe
Where do you examine sensory innervation of the sural nerve?
Lateral aspect of foot from inferior ankle to little toe
Where do you examine sensory innervation of the medial plantar nerve?
Planter surface under 1st toe webspace
Where do you examine sensory innervation of the lateral plantar nerve?
Planter surface under 4th toe webspace
Where do you examine sensory innervation of the calcaneal branch of the tibial nerve?
Plantar surface of heel
