Foot and Ankle Examination

The foot and ankle form one of the most complex biomechanical units in the human body. Together, they provide stability, mobility, and shock absorption during walking, running, and balance activities. A thorough clinical examination of this region is crucial for identifying injuries, dysfunction, or compensatory movement patterns that may contribute to pain or impaired function.

Clinical Anatomy Overview

The foot and ankle consist of 28 bones, 33 joints, and over 100 muscles, tendons, and ligaments, all working together to maintain alignment, stability, and efficient gait mechanics.

• Bony Structures:The ankle (talocrural joint) is formed by the tibia, fibula, and talus, creating a hinge joint that allows plantarflexion and dorsiflexion.The subtalar joint (between the talus and calcaneus) enables inversion and eversion, critical for adapting to uneven surfaces.

• Ligaments:Stability is primarily maintained by the lateral ligament complex — consisting of the anterior talofibular (ATFL), calcaneofibular (CFL), and posterior talofibular (PTFL) ligaments — and the medial deltoid ligament. The syndesmosis between the tibia and fibula supports rotational and axial stability.

• Muscles and Tendons:Dynamic control is provided by muscle groups such as the gastrocnemius-soleus complex (plantarflexion), tibialis anterior (dorsiflexion), peroneal muscles (eversion), and tibialis posterior (arch support).The Achilles tendon, the strongest tendon in the body, transmits force from the calf muscles to the heel.

• Neurovascular Supply:The tibial, deep peroneal, and superficial peroneal nerves innervate most of the structures, while arterial supply derives from the posterior tibial and dorsalis pedis arteries.

Purpose of the Foot and Ankle Examination

A complete foot and ankle examination aims to:

• Identify the source of pain and mechanical dysfunction.

• Evaluate joint integrity, ligament stability, and muscle strength.

• Detect abnormal gait mechanics or compensations.

• Guide rehabilitation and return-to-sport decisions.

The examination typically follows a structured format that integrates subjective history, observation, palpation, range of motion testing, manual muscle testing, and special tests.When necessary, imaging studies such as X-ray, ultrasound, MRI, or CT are used to confirm the diagnosis and assess the extent of injury.

Clinical Examination Components

1. Observation

Inspect for deformities, asymmetries, swelling, bruising, scars, or calluses.Common findings include valgus or varus alignment, arch collapse (pes planus), or high arches (pes cavus).

2. Palpation

Palpate key landmarks such as the malleoli, calcaneus, navicular, base of the fifth metatarsal, and the Achilles tendon.Assess for localized tenderness, temperature changes, or crepitus.

3. Range of Motion (ROM)

• Ankle joint: Dorsiflexion, plantarflexion

• Subtalar joint: Inversion, eversion

• Midfoot: Pronation, supinationCompare both sides for symmetry and end-feel.

4. Strength Testing

Manual muscle testing of dorsiflexors, plantarflexors, invertors, and evertors provides information on neuromuscular function and tendon integrity.

5. Special Tests

Used to identify specific injuries:

• Anterior Drawer Test: ATFL integrity

• Talar Tilt Test: CFL and deltoid ligament

• Squeeze Test / External Rotation Test: Syndesmotic injury

• Thompson Test: Achilles rupture

• Windlass Test: Plantar fasciitis

• Silfverskiöld Test: Gastrocnemius tightness

6. Functional Assessment

Observe gait, balance, and load-bearing tolerance using tests such as:

• Knee-to-Wall Test (dorsiflexion mobility)

• Star Excursion Balance Test (SEBT)

• Hop and landing tests for athletes returning to sport

7. Imaging Studies

When physical findings suggest deeper structural involvement, imaging can confirm the diagnosis and guide management.See detailed section: Imaging Modalities in Foot and Ankle Assessment (X-ray, Ultrasound, MRI, CT).

Clinical Significance

Foot and ankle pathologies are common in both athletic and general populations. Conditions such as Achilles tendinopathy, ankle instability, plantar fasciitis, and stress fractures require accurate diagnosis for effective treatment and rehabilitation.A systematic approach ensures all potential contributors — from joint alignment to muscle control and neuromechanical function — are addressed to restore optimal mobility and prevent recurrence.

Ottawa Foot and Ankle Rules

The Ottawa Rules are a set of criteria used to determine the need for radiographic imaging in acute ankle injuries. They are highly accurate for ruling out fractures of the ankle and midfoot, but have certain limitations:

• High accuracy within the first 10 days after injury: The test is most effective shortly after the trauma.

• High sensitivity in patients under 55 years: Sensitivity decreases in older patients, which may necessitate additional diagnostics.

Special Tests for the Foot and Ankle

Knee-to-Wall Test

DescriptionPurpose: Assesses ankle dorsiflexion range of motion.Indications: Recommended when evaluating conditions such as foot overpronation or plantar fasciitis.

Performance

• The patient starts with the toes touching the wall and gradually steps backward.

• The goal is to find the maximum distance between the toes and the wall at which the knee can still touch the wall without lifting the heel.

• Measure the distance with a ruler and record for future comparisons.

Clinical UseProvides a simple and reliable measure of dorsiflexion excursion, which is often reduced with ankle injury or dysfunction.[26]

Anterior Drawer Test

Description

Purpose: Assesses the stability of the anterior talofibular ligament (ATFL), commonly involved in ankle sprains.

Performance

• The patient sits or lies supine with the ankle relaxed.

• The examiner grasps the calcaneus with a “squeeze grip” and gently translates it anteriorly while stabilizing the tibia.

• Compare with the contralateral “normal” side to identify excessive anterior translation.

• Tip: Maintain a firm squeeze on the calcaneus to ensure effective talar motion.

Clinical Use

Routinely used to diagnose acute injury or chronic instability of the lateral ankle ligaments.

Squeeze Test

Description

Purpose: Identifies syndesmotic injury (high ankle sprain).

Performance

• The examiner compresses the tibia and fibula together at a point above the ankle, typically 5–10 cm proximal to the malleoli.

• Positive test: Reproduction of pain at the syndesmosis.

Use

Applied specifically to assess pain related to syndesmotic injury.

Bruk: Denne testen brukes spesifikt for å vurdere smerte relatert til syndesmoseskader.

External Rotation Test

Description

Purpose: Evaluates syndesmotic integrity by simulating the injury mechanism.

Performance

• The patient sits with the knee flexed to 90°.

• The examiner stabilizes the tibia with one hand and externally rotates the foot with the other.

• Positive test: Pain at the syndesmosis or above the ankle.

Clinical Use

Used to confirm syndesmotic injury, especially after trauma involving rotational or weight-bearing mechanisms.

Cotton Test

Description

Purpose: Assesses syndesmotic instability of the ankle.

Performance

• The patient is positioned relaxed in supine or sitting.

• The examiner applies a lateral translational force to the talus within the ankle mortise.

• The aim is to identify the degree of lateral talar movement.

• Positive test: Increased lateral translation compared to the contralateral side, indicating syndesmotic instability.

Clinical Use

Particularly useful for identifying syndesmotic lesions associated with high ankle sprains.[28]

Coleman Block Test

Description

Purpose: Evaluates hindfoot flexibility and the degree of forefoot-driven pronation/supination.

Performance

• The patient’s lateral forefoot is supported on a wooden block 2.5–4 cm thick.

• The examiner observes whether an inverted heel is driven by a forefoot malalignment or by a structural hindfoot problem.

• Positive test: If the heel corrects (becomes neutral) when the forefoot is supported, the issue is likely forefoot-driven; if the heel remains inverted, the problem may be in the hindfoot.

Clinical Use

Provides information on hindfoot flexibility and helps differentiate forefoot- from hindfoot-origin deformity.[29]

Other Tests for the Foot and Ankle

Ankle Ligament Stress Tests:Used to evaluate the integrity of the ankle ligaments.

Talar Tilt Test:Assesses the lateral ligament complex, particularly the ATFL and CFL.

Eversion Stress Test:Evaluates medial ligament integrity, especially the deltoid ligament.

Silfverskiöld Test:Assesses gastrocnemius flexibility and the difference between gastrocnemius and soleus length/constraint.

Windlass Test:Identifies plantar fasciitis by tensioning the plantar fascia.

Impingement Sign (Ankle):Assesses anterior impingement by applying dorsiflexion with compression.

Navicular Drop Test:Evaluates medial longitudinal arch height and degree of arch collapse.

Balance and Return-to-Sport Tests for the Foot and Ankle

Balance Tests

BESS (Balance Error Scoring System)Purpose: Assesses postural stability.Equipment: Two surfaces (firm and unstable), a stopwatch, and a scoring sheet.Performance: The patient performs balance tasks on different surfaces and in multiple stances.Use: Particularly helpful after ankle injuries and during sports rehabilitation. See the dedicated BESS page for details.

Star Excursion Balance Test (SEBT)Purpose: Measures dynamic balance and control by assessing reach in multiple directions without loss of balance.

Performance:The patient stands on one leg and reaches with the other in specified directions.Distances are recorded and compared over time.

Use: Tracks rehabilitation progress and is widely used as a screening tool for future injury risk.Variation: The Y-Balance Test is a simplified version focusing on fewer directions. See the dedicated SEBT page for details.[30]

Return-to-Sport Testing

Purpose of Return-to-Sport Tests

Determine readiness to resume high-level activity.Reduce risk of re-injury by assessing functional capacity.

Examples of Tests

Jump and Landing Control: Single-leg hop, double-leg hop, or “jump-to-stability” tests.Sprint and Change-of-Direction: Shuttle runs that simulate sport-specific demands.

Key Points

Tests should be tailored to the target sport (e.g., a jump-and-land task for a long jumper with prior ankle injury).There is no single gold-standard test; a battery of tests is preferable.Combine physical testing with patient-reported outcome measures and psychological readiness assessments for a comprehensive approach.[31]

Standardized Outcome Measures

Foot and ankle injuries are common, and robust outcome measures are essential for monitoring progress throughout rehabilitation. These tools help quantify functional gains and identify barriers to returning to sport or daily activities.

Common Outcome Measures

Foot and Ankle Ability Measure (FAAM)

Purpose: Assesses functional levels for the foot and ankle.

Use: Especially helpful for patients returning to sport or high-demand activity.

Oxford Ankle Foot Questionnaire

Purpose: Evaluates quality of life and function related to foot and ankle conditions.

Population: Frequently used in paediatrics and adolescents.

Foot and Ankle Disability Index (FADI)

Purpose: Assesses limitations in daily activities and sport.

Use: Widely used across physiotherapy for foot and ankle disorders.

Lower-Limb Tasks Questionnaire (LLTQ)

Purpose: Measures functional tasks and limitations across the lower limbs.

Scope: Covers activities from basic to complex.

Foot Function Index (FFI)

Purpose: Quantifies pain, function, and activity level.

Use: Commonly applied in chronic foot conditions such as plantar fasciitis or hallux valgus.

AAOS Lower Limb Core Score / Foot and Ankle Module

Purpose: Evaluates foot and ankle function and symptoms.

Strength: Suitable for patients post-surgery or following traumatic injury.

Ankle Joint Functional Assessment Tool (AJFAT)P

urpose: Assesses ankle stability and function after acute or chronic injury.

Use: Often used for athletes.

VISA-A Scale

Purpose: Specialized assessment of Achilles tendon–related symptoms.

Strength: Quantifies pain and function specific to the Achilles tendon.

Clinical Relevance

Outcome measures provide valuable insight into perceived function and recovery. By combining patient-reported outcomes with clinical evaluation, physiotherapists can tailor interventions to meet individual needs and goals.[32]

Imaging Examinations of the Foot and Ankle

X-ray Examinations

X-rays play a crucial role in diagnosing bone injuries and certain soft-tissue pathologies. However, they may be insufficient for detecting subtle or complex lesions. The following outlines the diagnostic applications of X-ray imaging in common foot and ankle conditions:

Diagnosis of Achilles Tendon Rupture

Radiographs can assist in confirming Achilles tendon rupture through five characteristic radiological signs visible on a lateral ankle X-ray. This projection has proven reliable for identifying tendon discontinuity and associated soft-tissue changes¹.

Fractures

Standard X-rays may not always reveal small malleolar or hairline fractures². If a patient experiences persistent pain and fails to progress during rehabilitation, repeat radiographs after six weeks are recommended to rule out osteochondral lesions or stress fractures.

For suspected ankle fractures, three views are advised: anteroposterior (AP), lateral, and mortise views. The mortise view is achieved by internally rotating the ankle by 15°. Whenever possible, weight-bearing images should be obtained, even with minimal loading, except in cases of open fractures or gross dislocations.

Lisfranc Injury

Malalignment at the second tarsometatarsal joint is a hallmark of Lisfranc fractures or dislocations. The AP view can reveal lateral displacement of the base of the second metatarsal and diastasis greater than 2 mm between the first and second metatarsals. Bilateral, weight-bearing radiographs are recommended for comparison³.

Heel and Hindfoot Malalignment

Hindfoot malalignment can lead to significant functional limitations. A long axial hindfoot view, taken bilaterally in a standing position, is recommended for both clinical and research purposes⁴.

Sesamoid Fractures

A sesamoid fracture appears as an irregular separation between bone fragments. Symmetrical division of the sesamoid bones, however, is considered a normal anatomical variant in approximately 10 % of the population.

Ligament Injuries

Only about 50 % of ligament ruptures are visible on initial radiographs, increasing to 66 % upon follow-up⁵. This underscores the limited sensitivity of X-rays in soft-tissue assessment.

Ottawa Ankle Rules

The Ottawa Ankle Rules are a validated clinical guideline for determining the need for X-ray imaging following ankle trauma. Their implementation can reduce unnecessary imaging and streamline diagnostics.

Clinical Significance of Radiographs

Radiographs remain essential for initial evaluation of bone and joint injuries but have limitations in assessing syndesmotic injuries² and osteochondral lesions. Follow-up or alternative imaging modalities are recommended when deeper pathology is suspected.

Diagnostic Ultrasound

Diagnostic ultrasound is a dynamic, non-invasive imaging technique ideal for examining soft-tissue structures of the foot and ankle. It is cost-effective, widely available, and often used as a first-line modality to identify ligament tears, tendinopathy, tenosynovitis, plantar fascia injuries, soft-tissue masses, or Morton’s neuroma⁶⁷.

Applications of Diagnostic Ultrasound

Ultrasound is highly effective in assessing the following conditions:

Fractures:Fractures of the fifth metatarsal and the medial and lateral malleoli can be detected in patients with foot or ankle sprains, although its sensitivity for navicular fractures is lower⁸.

Ligament Injuries:Ultrasound can distinguish between sprained and torn anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments⁹¹⁰¹¹.

Ankle Pain:Useful for evaluating lateral ligament pathology, tendon abnormalities, and joint effusions, though less effective for detecting posterior talofibular ligament (PTFL) injury¹².

Achilles Tendon Rupture:An accurate modality for diagnosing Achilles tendon tears¹³.

Syndesmotic Injury:Can identify syndesmotic damage when tibiofibular clear space is ≥ 6.0 mm¹⁴.

Primary Imaging for Fractures:Ultrasound may be considered as an initial diagnostic tool for certain foot and ankle fractures¹⁵.

Advantages of Diagnostic Ultrasound

Ultrasound allows real-time visualization of moving structures, making it uniquely suited for assessing tendon motion, ligament stability, and dynamic interactions between anatomical components. Its adaptability enables clinicians to tailor the examination to patient-specific symptoms, making it an indispensable adjunct to X-ray and other imaging modalities.

Magnetic Resonance Imaging (MRI)

MRI is the gold standard for diagnosing chronic pain and soft-tissue injuries of the foot and ankle. Owing to its superior soft-tissue contrast and spatial resolution, MRI provides detailed visualization of muscles, tendons, ligaments, cartilage, and bone marrow. However, it is costly and less accessible in some regions. Referral is typically reserved for complex or unresolved cases.

Clinical Indications for MRI

• Achilles Tendon Rupture: MRI remains the gold standard for confirming tendon injuries due to its exceptional accuracy¹.

• Persistent Post-Injury Pain: Recommended when pain persists at rest following ankle sprain, particularly when syndesmotic injury is suspected and clinical examination is inconclusive¹⁶.

• Preoperative Planning: Used to evaluate the anterior talofibular ligament (ATFL) before reconstructive surgery for chronic ankle instability¹⁷¹⁸.

• Ligament Examination: Weight-bearing MRI provides improved visualization of ligamentous structures in both transverse and coronal planes⁵.

• Post-Traumatic Ankle Pain: MRI demonstrates 96 % accuracy in detecting tendon lesions following trauma¹⁹.

• Occult Bone Injuries: Highly sensitive for identifying subtle fractures not visible on X-ray.

• Metatarsalgia: MRI is preferred for assessing sesamoid bones, the plantar plate, and adjacent tendon and muscle structures²⁰.

Advantages of MRI

• Superior Soft-Tissue Imaging: Excellent for evaluating tendons, ligaments, fascia, and cartilage damage.

• High Resolution: Enables detailed visualization of small or complex structures.

• No Radiation: MRI uses magnetic fields rather than ionizing radiation, ensuring patient safety.

While MRI offers unparalleled diagnostic accuracy, it should be used selectively based on clinical findings and patient needs. When appropriately indicated, MRI provides essential insights that complement physical examination and other imaging modalities.

Computed Tomography (CT)

CT provides high-resolution cross-sectional images and is particularly effective for evaluating the osseous anatomy of the foot and ankle. Weight-bearing CT (WBCT) enhances diagnostic precision by allowing assessment of joint alignment and deformity under load, making it invaluable for biomechanical evaluation and surgical planning.

Recommended Clinical Applications

• Ankle Fracture Assessment: CT is ideal for evaluating complex ankle fractures, particularly when X-rays are inconclusive².

• Syndesmosis Reduction Evaluation: WBCT has proven more reliable than conventional radiographs for assessing the adequacy of syndesmotic reduction after injury²².

• Prediction of Syndesmotic Injury: Subtle morphological changes on CT can indicate syndesmotic involvement, influencing treatment decisions²³.

• Hindfoot Alignment Characterization: CT determines the degree of translational correction required during calcaneal osteotomy²⁴.

• Detection of Subtle Lisfranc Instability: CT offers detailed visualization of the Lisfranc joint and can detect minor instabilities missed on X-rays²⁵.

Advantages of CT Imaging

• Exceptional Detail: Provides superior resolution for evaluating complex fractures and joint morphology.

• Speed and Efficiency: Rapid acquisition time allows use in acute and intraoperative settings.

• Dynamic Assessment: WBCT facilitates biomechanical analysis under physiological loading conditions.

CT remains a cornerstone in the comprehensive assessment of foot and ankle injuries, especially when standard radiographs or clinical examination fail to reveal sufficient diagnostic information. Combined with functional and clinical tests, CT contributes to accurate diagnosis and treatment planning.

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