Complete Musculoskeletal Exam of the Foot and Ankle

This video demonstrates a complete foot and ankle examination. View the complete foot and ankle examination learning module at https://sites.google.com/a/umich.edu/fammed-modules/

Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition.

CC: BY-NC University of Michigan Family Medicine Residency Program. This material is licensed under a Creative Commons Attribution - Noncommercial 3.0 License http://creativecommons.org/licenses/by-nc/3.0/.

English captions by Jade Cheng from the University of Michigan

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

ankle and foot in a systematic way.

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

diagnosing ankle and foot injuries.

Begin with the standing evaluation of the
foot anatomy.

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

or bunion formation.

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

sign, which can indicate overpronation or
an abducted foot.

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

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

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

Look for an antalgic gait or excessive pronation
or supination.

Next evaluate active range of motion.

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

First check dorsiflexion, plantarflexion,
inversion, eversion, great toe dorsiflexion,

and great toe plantarflexion.

Now check resisted strength with dorsiflexion,
plantarflexion, inversion, eversion, great

toe dorsiflexion, and great toe plantarflexion.

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

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

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

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

talofibular ligament; calcaneofibular ligament
and posterior talofibular ligament; the peroneal

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

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

toes.

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

not limited to, the following tests.

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

tibia and the fibula are squeezed together.

Pain is a positive test.

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

and externally rotated.

Pain is a positive test.

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

plantarflexed, brace the shin and pull the
heel anteriorly.

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

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

stability.

With the foot slightly plantarflexed, brace
the heel and invert the foot.

Repeat on the opposite side and compare degrees
of inversion.

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

positive test and indicative of anterior talofibular
and calcaneofibular ligament injury.

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

Apply a compressive force on the calcaneus.

Pain is a positive test.

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

Stabilize the hind foot and rotate the midfoot.

Pain is a positive test.

Mulder's test evaluates for Morton neuroma.

The first and fifth metatarsal heads are grasped
and squeezed together.

Pain or paresthesia is a positive test.

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

neuroma.

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

tingling caused by tarsal tunnel syndrome.

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

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

foot.

Absence of plantarflexion indicates Achilles
tendon rupture.

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

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

Further neurovascular exam may be indicated
by history.

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.