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English captions by Jade Cheng from the University of Michigan

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To ensure a thorough assessment, it is best[br]to perform the musculoskeletal exam of the

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ankle and foot in a systematic way.

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The following is a suggested order of examination[br]that incorporates the common techniques for

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diagnosing ankle and foot injuries.

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Begin with the standing evaluation of the[br]foot anatomy.

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Look for muscular atrophy, skin changes, or[br]anatomic variance, such as pes planus, pes cavus,

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or bunion formation.

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From a posterior view, observe for more than[br]two toes laterally, also called the 'too-many-toes'

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sign, which can indicate overpronation or[br]an abducted foot.

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Have a patient perform a toe raise and evaluate[br]for heel positioning.

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Normally the heel should change from a neutral[br]to a varus position.

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Observe gait as the patient walks away from[br]and towards the examiner.

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Look for an antalgic gait or excessive pronation[br]or supination.

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Next evaluate active range of motion.

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If pain or limitation exists, repeat passive[br]range of motion.

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First check dorsiflexion, plantarflexion,[br]inversion, eversion, great toe dorsiflexion,

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and great toe plantarflexion.

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Now check resisted strength with dorsiflexion,[br]plantarflexion, inversion, eversion, great

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toe dorsiflexion, and great toe plantarflexion.

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Palpate anatomic landmarks for tenderness:[br]the calf belly; the Achilles tendon for Haglund's

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deformity; along the tibia, checking for any[br]areas of tenderness; the medial malleolus;

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the deltoid ligament; the tarsal tunnel; the[br]posterior tibial muscle and tendon; the navicular

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bone and tubercle; the fibula, including the[br]fibular head; the lateral malleolus; the anterior

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talofibular ligament; calcaneofibular ligament[br]and posterior talofibular ligament; the peroneal

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tendon; the talar dome; the calcaneus and[br]calcaneal fat pad; the plantar fascia; the

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metatarsal heads; the base of the fifth metatarsal;[br]the sesamoid bones; and the phalanges, or

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toes.

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Specific testing for the ankle and foot to[br]evaluate for injuries may include, but is

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not limited to, the following tests.

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The squeeze test evaluates for a syndesmotic[br]ankle injury. With the foot dorsiflexed, the

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tibia and the fibula are squeezed together.

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Pain is a positive test.

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Kleiger's test also evaluates for a syndesmotic[br]injury. With the knee fixed, the foot is dorsiflexed

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and externally rotated.

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Pain is a positive test.

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The anterior drawer test is for anterior talofibular[br]ligament stability. With the foot slightly

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plantarflexed, brace the shin and pull the[br]heel anteriorly.

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Laxity or poor endpoint is a positive test[br]and indicative of anterior talofibular injury.

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The talar tilt test assesses for both anterior[br]talofibular ligament and calcaneofibular ligament

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stability.

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With the foot slightly plantarflexed, brace[br]the heel and invert the foot.

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Repeat on the opposite side and compare degrees[br]of inversion.

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Inversion of more than twenty three degrees,[br]or more than five degree difference, is a

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positive test and indicative of anterior talofibular[br]and calcaneofibular ligament injury.

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The calcaneal squeeze test evaluates for calcaneal[br]injury, such as a stress fracture.

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Apply a compressive force on the calcaneus.

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Pain is a positive test.

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The midfoot torsion test assesses for midfoot[br]injuries, such as Lisfranc sprain.

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Stabilize the hind foot and rotate the midfoot.

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Pain is a positive test.

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Mulder's test evaluates for Morton neuroma.

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The first and fifth metatarsal heads are grasped[br]and squeezed together.

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Pain or paresthesia is a positive test.

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If an audible click is heard, it's called[br]a Mulder's sign and indicative of a fibrotic

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neuroma.

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Perform a Tinel's over the tarsal tunnel,[br]attempting to reproduce pain, numbness, or

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tingling caused by tarsal tunnel syndrome.

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In a prone position, Achilles tendon stability[br]can be assessed using Thompson's test.

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Flex the knee to ninety degrees, squeeze the[br]calf, and observe for plantarflexion of the

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foot.

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Absence of plantarflexion indicates Achilles[br]tendon rupture.

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In concluding the ankle and foot exam, it's[br]important to document neurovascular.

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Here we demonstrate dorsalis pedis pulse,[br]posterior tibial artery pulse, and capillary refill.

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Further neurovascular exam may be indicated[br]by history.

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Acknowledgement: The Japanese translation of this video was made as part of Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM) Project supported by Shizuoka Prefecture and funded by the Community Healthcare Revival Fund.