Ankle and Foot Examination – OSCE Guide
geekymedics.com/ankle-and-foot-examination/
Posted by Dr Lewis Potter | Clinical Examination , March 4,
Musculoskeletal 2014
Ankle and foot examination can occasionally appear in OSCEs, so it’s important you’re
familiar with it.
Check out the ankle and foot examination mark scheme here.
Check out our foot and ankle anatomy guide here .
Introduction
Wash hands
Introduce yourself – state your name and role
Confirm patient details – name and DOB
Explain examination:
“I’d like to examine your ankles and feet. This will involve having a look and feel of these joints,
in addition to assessing the joints’ movement”
Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with
the exam?”
Gain adequate exposure – both legs should be exposed from the knee down
Position patient – ask patient to stand up straight with their feet aligned facing forwards
Look
Gait
Is the patient demonstrating a normal heel strike/toe off gait?
Is each step of normal height? – increased stepping height is noted in foot drop
Is the gait smooth and symmetrical?
Examine the patient’s shoes – evidence of asymmetrical wearing may indicate abnormal
gait
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Ask the patient to walk on their tip-toes, then on their heels – problems with this may
point to multiple problems such as arthritis, muscle strength in the calf muscles which help in
plantarflexion and anterior muscles of the lower leg which help in dorsiflexion
Inspect from the front
Symmetry of feet and ankles
Toe alignment – hallux valgus of the big toe may be noted
Bunions – locatedat the 1st metatarsal phalangeal joint (MTP) joint
Deformities of the toes (claw/mallet/hammer toes)
Scars – suggestive of previous injury / surgery
Calluses – may indicate foot/gait deformity or poorly fitting footwear
Swelling or erythema of the foot or ankle – may suggest injury /
inflammatory arthritis / septic arthritis / cellulitis
Inspect from the side
Foot arches – observe for evidence of flat feet (pes planus) or high arched feet (pes
cavus)
If patient has flat feet ask to stand on tiptoes – supple flat feet will correct / rigid flat
feet will not
Inspect from the back
Foot/ankle symmetry – heel alignment – valgus or varus deformity?
Achilles tendon – deformity / discontinuity / swelling (may suggest Achilles tendonitis) /
erythema
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Inspect the patient's gait
Ask the patient to walk on their tip-toes
Ask the patient to walk on their heels
Inspect the patient from the front
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Inspect the patient from the side
Inspect the patient from behind
Feel
Ask the patient to lay on a bed
Assess temperature and compare between legs – ↑ temperature may
indicate inflammatory pathology / septic arthritis / cellulitis
Assess pulses in both feet – posterior tibial and dorsalis pedis
Palpate the achilles tendon:
Position the patient kneeling on a chair
Palpate the gastrocnemius muscle and achilles tendon
Note any focal tenderness or swelling – achilles tendonitis
Note any apparent gaps in the tendon – suggestive of rupture
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Palpate the joints and bones
Work distal to proximal – assess for tenderness / swelling / irregularity
Squeeze MTP joints – observe patient’s face for discomfort
Metatarsal and Tarsal bones
Tarsal joint
Ankle joint
Subtalar joint
Calcaneum
Medial/lateral malleoli
Distal fibula
Assess and compare temperature of the ankle/foot joints
Palpate the dorsalis pedis pulse
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Palpate the posterior tibial pulse
Palpate the Achilles tendon
Squeeze across the metatarsophalangeal (MTP) joints
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Palpate the tarsal bones
Palpate the calcaneus
Palpate the medial malleoli
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Palpate the lateral malleoli
Palpate the distal fibula
Move
Active and passive assessment
Assess each of the following movements actively and passively, feeling for
crepitus(excluding toe flexion/extension)
Foot plantarflexion – “push your feet downwards, like pushing a car pedal” – 0-50º
Foot dorsiflexion – “point your feet towards your head” – 0-20º
Toe flexion – “curl up your toes”
Toe extension – “point your toes towards your head”
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Ankle/foot inversion – 0-35º
Ankle/foot eversion – 0-15º
Passive assessment only
Assess the passive movement of:
Ankle joint
Subtalar Joint
Mid-tarsal joint
Metatarsal-phalangeal and Interphalangeal joints (proximal and distal)
Active ankle plantarflexion (0-50º)
Active ankle dorsiflexion (0-20º)
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Active toe flexion
Active toe extension
Ankle/foot inversion (0-35º)
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Ankle/foot eversion (0-15º)
Passive ankle plantarflexion
Passive ankle dorsiflexion
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Passive sub-talar eversion
Passive sub-talar inversion
Passive mid-tarsal eversion
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Passive mid-tarsal inversion
Passive hallux flexion
Passive hallux extension
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Passive toe flexion
Passive toe extension
Special tests
Simmonds’ test
Simmonds’ test is used to assess for rupture of the achilles tendon
1. Ask patient to kneel on a chair with their feet hanging off the edge
2. Squeeze each calf in turn
3. Normally the foot should plantarflex
4. If the achilles tendon is ruptured there will be no movement of the foot
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Ask the patient to kneel on a chair and squeeze their calf
The absence of plantarflexion upon squeezing the calf is suggestive of achilles
tendon rupture
To complete the examination
Thank patient
Wash hands
Suggest further assessments and investigations
Examine the knee and hip joint
Full neurovascular examination of the lower limbs
Further imaging of the relevant joints if indicated (Xray / CT / MRI)
Further reading
Arthritis research UK provides some excellent free guides to musculoskeletal
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examination and history taking [LINK]
REVIEWED BY
Mr Tejas Yarashi
Trauma & Orthopaedic Surgeon (ST7)
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