ORIGINAL ARTICLES

Reliability and Validity of Current Physical Examination Techniques of the Foot and Ankle
James S. Wrobel, DPM, MS* David G. Armstrong, DPM, PhD*
Background: This literature review was undertaken to evaluate the reliability and validity of the orthopedic, neurologic, and vascular examination of the foot and ankle. Methods: We searched PubMedthe US National Library of Medicines database of biomedical citationsand abstracts for relevant publications from 1966 to 2006. We also searched the bibliographies of the retrieved articles. We identified 35 articles to review. For discussion purposes, we used reliability interpretation guidelines proposed by others. For the statistic that calculates reliability for dichotomous (eg, yes or no) measures, reliability was defined as moderate (0.40.6), substantial (0.60.8), and outstanding (> 0.8). For the intraclass correlation coefficient that calculates reliability for continuous (eg, degrees of motion) measures, reliability was defined as good (> 0.75), moderate (0.50.75), and poor (< 0.5). Results: Intraclass correlations, based on the various examinations performed, varied widely. The range was from 0.08 to 0.98, depending on the examination performed. Concurrent and predictive validity ranged from poor to good. Conclusions: Although hundreds of articles exist describing various methods of lowerextremity assessment, few rigorously assess the measurement properties. This information can be used both by the discerning clinician in the art of clinical examination and by the scientist in the measurement properties of reproducibility and validity. (J Am Podiatr Med Assoc 98(3): 197-206, 2008)

Foot problems are common, complex, and costly. Estimates from the National Health and Nutrition Examination Survey suggest that the prevalence of significant mobility problems in the United States affects more than one in six adults.1 This figure increases to nearly one in three for persons aged 60 years old or older. Lower-extremity maladies play a central role in these problems and have a substantial impact on quality of life and self-efficacy. Interest in the treatment of the lower extremity has yielded a host of proposed measurements and examination techniques designed to better quantify the degree of pathology. However, there has been comparatively little attention given to robust inquiry into the reliability and validity of these techniques.
*Scholls Center for Lower Extremity Ambulatory Research, Rosalind Franklin University of Medicine and Science, Chicago, IL. Corresponding author: James S. Wrobel, DPM, MS, Center for Lower Extremity Ambulatory Research, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL 60064. (E-mail: james.wrobel@rosalindfranklin.edu)

With this structured literature review we sought to evaluate aspects of the orthopedic, neurologic, and vascular examination of the foot and ankle.

Methods
We conducted a systematic literature search with PubMedthe US National Library of Medicines online database of biomedical citationsand searched abstracts available on the Internet. PubMed includes 16 million citations from more than 4,800 journals published in the United States and more than 70 other countries, primarily since 1966. We searched for foot exam and reliability, accuracy, or validity. Criteria for inclusion included a well-described patient population and sampling technique. The examiner description and training had to be well described, and the examination technique had to be described well enough to be reproduced in a typical clinical setting. Additional inclusion criteria included valid statistical techniques and presentation of the data. With these inclusion criteria, 27 studies were included

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from 133 potential studies for reliability, 19 studies were included from 120 potential studies for accuracy, and for validity, 5 studies were included from 75 potential studies. The searching sequence (reliability followed by accuracy followed by validity) affected our yield because studies with more than one search term were grouped under the first term searched and found. Relevant references from the included studies bibliographies were also considered for inclusion. Of the 51 included studies, findings from 38 studies are reported here. Both authors had complete access to the articles and met to agree for inclusion or exclusion of various studies. Reliability can take on many forms depending on the measure and its purpose. These include test-retest reliability and interitem consistency from the psychometric literature. Test-retest reliability tests concepts at different points in time when the underlying condition is not expected to change. Reliable items exhibit similar scores over this period. Interitem consistency tests the correlation of items within a conceptual domain to see if they agree with the overall concept. From the clinical perspective, reliability is commonly measured with intrarater reliability and interrater reliability form. Validity from the clinical perspective is commonly measured with predictive, criterion-related, and face validity.2 Predictive validity successfully predicts an outcome of interest. A prediction is sensitive if it detects differences important to the investigator. It is specific if it represents only the characteristic of interest. Criterion validity agrees with other approaches. Face or content validity makes intuitive sense.2 For measures of reliability, many advocate avoiding arbitrary cutoff points for the measures. For the purposes of our discussion, we used interpretation guidelines proposed by others so we could describe the current state of the foot examination measures. For the statistic that calculates reliability for dichotomous (eg, yes or no) measures, reliability was defined as moderate (0.40.6), substantial (0.60.8), and outstanding (> 0.8).3 For the intraclass correlation coefficient that calculates reliability for continuous (eg, degrees of motion) measures, reliability was defined as good (> 0.75), moderate (0.50.75), and poor (< 0.5).4 The SEM can roughly be interpreted as the number by which examiners will tend to vary.

of examination, the reliability, and the investigators conclusions. Intraclass correlations on the basis of the various examinations performed varied widely. The range was from 0.08 to 0.98, depending on the examination performed.

Discussion
Orthopedic Examination
The orthopedic examination was the most studied area of the clinical aspect representing 26 of 38 articles.5-25, 36-40 Visual estimation of the forefoot-to-rearfoot ratio may be more reliable than an estimate made with a goniometer. In a study of ten patients,11 examiner experience with the two methods did not seem to matter. The interrater reliability was poor with the goniometer and good with visual estimation. Conversely, measuring first-ray mobility as normal, hypomobile, or hypermobile with qualitative methods (n = 60)9 showed poor interrater reliability, as did using a ruler (n = 14)10 with a Glasoe device as the standard. Range-of-motion testing appears to demonstrate good reliability.5, 6, 8 In a study of 63 healthy Navy midshipmen, both active and passive range of ankle dorsiflexion was measured in the prone position. This method revealed a good intrarater reliability and moderate inter-examiner reliability with mean absolute differences of 2 and 3.5 These numbers compare favorably with a previous report, in which ankle dorsiflexion was measured in the supine position.8 Elveru et al6 investigated the reliability of ankle and subtalar joint motion for 50 patients of 14 physical therapists. They found ankle joint motion to have good intrarater reliability; however, subtalar joint positions and neutral were found to have poor reliability. Moderate interrater reliability was found with ankle motion. The authors also stated that the therapists had little or no experience in assessing a subtalar joint.6 When first metatarsophalangeal joint motion was measured in a weightbearing position, the average error found was 12 and 16 in the dorsiflexed and plantarflexed positions, respectively.7 This finding contradicts subsequent work that found good interrater reliability in first metatarsophalangeal joint dorsiflexion measured in a weightbearing position.8 Different examination methods could partially explain the findings; patients were asked to stand with one foot on the edge of a stool7 and on the floor in a relaxed, bipedal stance. This difference in technique may have added to the observed reliability differences.8 Manual muscle testing, including the supination resistance test, appears to demonstrate good reliability

Results
The previously defined search criteria resulted in the inclusion of 38 manuscripts described in Table 1. The table divides the studies into the type of examination performed, the number of examiners, the basic method

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Table 1. Reliability and Validity of Lower-Extremity Examination Method by Examination Technique Examination Technique Sample Size and Examiner Type Method Orthopedic Examination Ankle dorsiflexion, leg length discrepancy, medial talonavicular bulge, rearfoot angle, arch angle and foot type5 Ankle and subtalar joint motion6 n = 63 Navy midshipmen; physical therapy and athletic trainer examiners ICC = 0.650.97 with 88.8%94.4% agreement Results reliable when conducted on healthy individuals Reliability and Validity Authors Conclusion

n = 50; 15 physical therapist examiners

Intrarater ICC 0.74 for ankle; Intertester ICC: STJ inversion = 0.32, STJ eversion = 0.17, STJ neutral = 0.25, and 0.50 and 0.72 for ankle Dorsiflexion and plantarflexion Average error = 12 (dorsiflexion) and 16 plantarflexion Interrater reliability was 0.71 for ankle and 0.95 for first metatarsophalangeal joint

With the exception of ankle plantarflexion, measures cannot be considered reliable

First metatarsophalangeal joint mobility7

n = 20

Linear measurement more accurate than angular Good reliability for ankle and first metatarsophalangeal joint dorsiflexion

Ankle and first metatarsophalangeal joint mobility8

n = 10; two podiatrist examiners

Supine ankle dorsiflexion and weightbearing first metatarsophalangeal joint dorsiflexion Normal, hypomobility, and hypermobility versus Glasoe device

First-ray mobility9

n = 60; three clinician examiners

Interrater statistic = Poor agreement 0.143 for hypomobility (30% agreement); 0.063 for normal (34% agreement); not calculated for hypermobility (25% agreement) Device ICC = 0.98 (SEM = 0.15 mm) Ruler intratest ICC = 0.06 (SEM = 1.1 mm) Ruler intertest ICC = 0.05 (SEM = 1.2 mm) Average measurement error = 1.1 cm Poor reliability for ruler method

First-ray mobility 10

n = 14; three clinician examiners

Ruler versus mechanical device

Ball circumference7

n = 20

Linear measurement more accurate than angular Visual estimation may be more reliable

Forefoot-to-rearfoot assessment11

n = 10; two physical therapists and two student examiners

Visual and goniometer

Intrarater goniometer ICC of 0.08 to 0.78 Intrarater visual ICC of 0.51 to 0.76 Interrater goniometer = 0.38 Interrater visual = 0.81 statistics very good (0.611); however, when normals excluded, statistics were 0.55 to 0.88 (direct agreement, 11%41%)

Manual muscle testing12 n = 72, three examiners

Reliability could be improved with training. Only use manual muscle testing in pathology if agreement > 80%

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Table 1. continued Examination Technique Sample Size and Examiner Type Method Reliability and Validity Authors Conclusion

Orthopedic Examination (continued) Manual supination resistance test13 n = 44; four clinician examiners on 2 days Test-retest reliability; interrater ICC = 0.89, intrarater ICC of 0.78 to 0.82, two inexperienced clinicians ICC of 0.56 to 0.62 (poor) Correlation (r ) > .75 Supination resistance test may be clinically useful in prescription orthoses

Ankle laxity, stability, and strength14 Foot type15

n = 21

High correlation suggests reliability NH more sensitive to change and thus had a greater sensitivity to changes in calcaneal position

n = 20

SAI, CSI, and NH to represent foot type by calcaneal alignment as tested with footprint and changes in alignment over five test positions Five measures taken at 10% weightbearing and 90% weightbearing

SAI r = .5, CSI r =.6, NH r = .8. Change in degrees required to see change in index score, 20 for SAI, 15 for CSI, and 10 for NH Concurrent validity with radiographs; dorsum height at 50% of foot length divided by truncated foot length (ICC = 0.81 for 10% and 0.85 for 90%) Adults = 6 everted (SD = 2.71) Children = 5.6 everted (SD = 2.9)

Medial arch16

n = 51

The most reliable and valid was arch height at 10% and 90% weightbearing, dividing dorsum height at 50% of foot length by truncated foot length Resting calcaneal stance position was reliable; however, theoretical normal of 0 2 not observed Indirect limb-length measurement accurate; experience played no role All methods provide valuable information about medial longitudinal arch; NH most useful clinical measure

Resting calcaneal stance position17

n = 88 adults; n = 124 children

Limb-length discrepancy18

n = 66 with 17 examiners

0.5-cm boards for indirect measurement with orthoradiograms as standard Correlated with radiographs: NH, calcaneal inclination angle, and first metatarsalcalcaneal angle

Concurrent validity; 81% differed by 01.0 cm. No differences amongst experience Concurrent validity with x-ray positions (pronated, neutral, and supinated). NH r = .44, .53, .79; arch index r = .71, .68, .52; FPI r = .59, .36, .42 ICC children = 0.62, adolescents = 0.74, adults = 0.58; measurement error 11.5 points on 33-point scale

Arch index, NH, FPI19

n = 95

FPI20

n = 29 children; n = 30 adolescents; n = 30 adults

Reliability moderate to good

FPI21

n = 20

Derived measures from 119 papers; item reduction; six items compared with static and dynamic electromagnetic motiontracking system

Four-phase validation study of concurrent and predictive validity; sixitem FPI predicted more than 40% of variance ankle joint complex

Stronger association than most reports of static and dynamic measures

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Table 1. continued Examination Technique Sample Size and Examiner Type Method Reliability and Validity Authors Conclusion

Orthopedic Examination (continued) FPI22 Study 1: n = 31 Study 2: n = 12 Criterion validity of four criteria for FPI with radiographic criteria as standard Correlations poor (0.28 to 0.42); talonavicular angle significant; significant changes from supinated to resting position and from supinated to pronated Intratest-weighted statistic, 0.530.91 Intertest-weighted statistic, 0.430.86 Base and rearfoot ranges, 0.290.71 (intratest), 0.30.78 (intertest) ICC of 0.970.98 for angle and 0.980.99 for base of gait Data similar; both are useful clinical tools Criterion validity weaker than expected although significant correlation and change with foot manipulation for talar head palpation

Observational gait scale23

n = 20; two clinician examiners

Knee and foot position at mid-stance; base of support and rearfoot position with video

Angle and base of gait24

n = 25

Angle and base of gait measured with footprints and clinical tracings STJ neutral, maximum eversion, maximum inversion

One-legged stance25

n = 10 Rearfoot motion

Concurrent validity with electrogoniometer; ICC of 0.76, 0.37, 0.39, respectively; intratest ICC of one-legged stance = 0.92

Good interrater reliability for STJ neutral; rearfoot position one-legged stance may be used to approximate maximum eversion during gait

Neurologic Examination Bedsheet Babinski26 n = 20; 10 with neurologic disease and 10 without Toe response at the time feet are exposed Sensitivity, 80%; specificity, 90% Although small study, toe response at time of foot exposure frequently provides evidence of pyramidal tract dysfunction Self-administered sensory tests allow patients to participate in care but should not replace provider exam Reproducible VPT is inversely proportional to age and better for men Ability of Babinski sign to identify upper motor neuron lesion is limited. Slowness of toe tapping may be more useful sign

Patient use of monofilament27

n = 196 Nine centers, same-day self-screen and clinician examiner

Disagreed in 18 of 145 fair intertester reliability statistics = 0.73; disagreement associated with age Reliability coefficient for ICC of 0.89 (VPT) thermal sensitivity and and 0.54 (thermal VPT sensitivity) Babinski statistic fair (0.3); toe-tapping statistic substantial (0.73) Babinski agreement = 56%; toetapping agreement = 85%

Thermal sensitivity and VPT28

n = 39

Babinski29

n = 10 (8 with upper motor neuron lesion); 10 physician examiners

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Table 1. continued Examination Technique Sample Size and Examiner Type Method Reliability and Validity Authors Conclusion

Neurologic Examination (continued) Monofilament, ankle reflexes, pinprick, vibration, position30 n = 304; ten centers of internist and resident examiners Monofilament and ankle reflex statistic moderate (0.59); pinprick, vibration, and position statistics fair (0.280.36) Conventional clinical exam of diabetes mellitus feet had low reproducibility and correlated poorly with monofilament. Monofilament was reproducible, valid, and the procedure of choice

Vascular Examination Pedal pulse palpation31 n = 100 63% had systolic diastolic pressure 118 mmHG; 68% had ABI > 0.82; Predition ankle systolic sensitivity (66%) and specificity (91%) Palpable pulse suggests ankle systolic pressure 118 mmHG and ABI > 0.82

Pedal pulse palpation32

n = 229

Test-retest reliability; range of reproducibility = 68%81% for all four pulses statistics highest in vascular techs (0.68, good), vascular surgeons (0.38, fair). Best cutoff for ABI between palpable and nonpalpable = 0.76 underdiagnosed 30% ABI measured with continuous-wave Doppler versus automated oscillometry Concurrent validity with standard ultrasound; ankle systolic mean difference 2 mmHG ( 6.7); 3.1 mmHG ( 5.1 mmHG) Concurrent validity with standard ultrasound; correlation coefficient 0.78; mean difference 0.04 ( 0.01) and 0.06 ( 0.01)

Unacceptable variation with monofilament the best screening tool Pulses palpated under unhurried conditions; acceptable reproducibility and accuracy

Pedal pulse palpation33

n = 25; three vascular surgeon and three student examiners

ABI34

n = 246

Both methods fell within 1% error and 5% reproducibility

ABI35

n = 201

ABI measured with continuous-wave Doppler versus automated oscillometry

Automated ABI reliable

Abbreviations: ICC, intraclass correlation coefficient; STJ, subtalar joint; SAI, Staheli arch index; CSI, Chippaux-Smirak index; NH, navicular height; FPI, foot posture index; VPT, vibratory perception threshold; ABI, ankle-brachial index. Note: Intertest refers to reliability among examiners on same patient. Intratest refers to reliability for the same examiner and patient at different points in time.

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when used by experienced clinicians.12-14, 39 Ankle ligamentous laxity also appears to demonstrate good reliability.14 Relaxed calcaneal stance position appears to demonstrate good reliability. In a study of 212 patients with a two-arm goniometer and an electronic goniometer, the greatest mean difference within examiners (intrarater) was 0.5. Among examiners (interrater) the greatest mean difference was 1.23 for the twoarm goniometer.17 Torburn et al25 further assessed the reliability of rearfoot measures in ten patients. They found that subtalar joint neutral position demonstrated good reliability and that a relaxed, one-legged stance was not significantly different from the observed rearfoot eversion during gait.25 Other weightbearing measures demonstrated good reliability.5, 9, 13, 14 These measures include angle and base of gait, and limb-length discrepancy with a 0.5cm board. Observational gait analysis was studied in 14 patients with a three-point scale assessing rearfoot motion and was found to have poor reliability.38 In a subsequent observational gait scale study of 20 patients, investigators found acceptable reliability for the foot position in mid-stance, initial foot contact, and heel rise with weighted statistics ranging from 0.53 to 0.91 (intrarater) and 0.43 to 0.86 (interrater).23 The orthopedic examination is one of the most utilized in clinical podiatric practice. With the exception of one study (Resch et al7), range-of-motion testing at the ankle, subtalar joint, and first metatarsophalangeal joint seems to exhibit good to moderate intrarater reliability.5, 6, 8, 17, 25 The reliability of subtalar joint range of motion testing may be enhanced with additional training.6 Visual estimation of the forefootto-rearfoot relationship demonstrates good interrater reliability over goniometer or stratifying first ray into hypomobility, normal, or hypermobility.9, 11 Manual muscle testing and ankle stability appear to demonstrate good interrater reliability.12-14, 39 Assessing limblength discrepancy with boards and some aspects of visual gait analysis demonstrates good interrater reliability.5, 18, 23 Clinical measures for foot type and standing arch postures are two of the most studied areas of the orthopedic examination.15, 16, 19-22, 37 In general, these have been described in three categories: radiographic, anthropometric, and footprint measures.40 Mathieson et al15 studied various footprint measures in 20 patients positioned in five standardized positions. They investigated three foot type measures: the Staheli arch index, the Chippaux-Smirak index, and navicular height. The investigators examined the sensitivity of the three foot type measures to detect alterations in subtalar joint position as measured by calcaneal frontal plane alignment.15 The Staheli arch index and

Chippaux-Smirak index demonstrated moderate reliability, and navicular height demonstrated good reliability. Change required to observe a change in index score include 15 for Chippaux-Smirak index, 20 for Staheli arch index, and 10 for navicular height. Navicular height was more sensitive to change and thus had a greater sensitivity to changes in calcaneal position. Mathieson et al15 concluded that foot type measures derived from a static footprint exhibit limited responsiveness to changes in subtalar joint position. Anthropometric measures of foot type are probably the most clinically useful. Arch height has received much attention in the earlier literature. Williams and McClay16 looked at five measurements of arch height taken in two stance conditions, 10% and 90% weightbearing, in 51 patients. Reliability was good for dorsum height at 50% of foot length divided by truncated foot length (intraclass correlation coefficient, 0.81 for 10% weightbearing and 0.85 for 90% weightbearing). Dividing the dorsum height at 50% of foot length by the truncated foot length was the most reliable and valid of the five measures tested to clinically assess arch height at the two stances.16 Menz and Munteanu19 performed a concurrent validity study on 95 patients measuring navicular height, arch index, and foot posture index. They correlated these measures with radiographic angles of calcaneal inclination, calcaneal first metatarsal declination, and navicular height. They found that all three measures demonstrated significant correlations with the radiographic measures. The authors concluded that the three measures provided useful, but different, information about arch structure. Navicular height was believed to be most clinically useful because of its higher concurrent validity and low technical difficulty.19 One of the most studied anthropometric measures for foot type is the foot posture index.19-22 The original description attributed to Redmond21 consisted of eight criteria of talar head palpation, supralateral and infralateral malleolar curvature, Helbing sign, calcaneal frontal plane position, prominent talonavicular joint, congruence of the medial longitudinal arch, congruence of the lateral border of the foot, and abduction and adduction of the forefoot on the rearfoot. Each criterion is graded on a five-point Likert scale ranging from 2 to 2.20, Evans et al20 went on to study inter- and intrarater reliability of the foot posture index in children (n = 29), adolescents (n = 30), and adults (n = 30) with four raters. Normalized navicular height was the most reliable measure, except in children. Navicular drop, relaxed calcaneal stance position, and neutral calcaneal stance position demonstrated moderate to poor reliability. Forefoot-to-rearfoot relationship was moderate to poor but improved as

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the patient group became older. The SEM was 2, which is high for the range of measures but favorable compared with the other measures. None of the measures exhibited adequate reliability in children.20 The foot posture index underwent further criterion validity testing with radiographic measures as the standard in 31 patients.22 Correlations with radiographs were generally poor (0.28 to 0.42), although the talonavicular angle was significant. The responsiveness of the foot posture index was seen with significant changes from supinated to resting position and from supinated to pronated position. The authors concluded that criterion validity (with radiographic measures) was weaker than expected, although significant correlation and change with foot manipulation for talar head palpation was observed.22 The foot posture index was also studied for criterion validity with static and dynamic data from an electromagnetic motion analysis system and was able to predict 40% of the variance in dynamic ankle motion with walking.21 The authors studied 91 patients in the item-reduction phase, resulting in six of the eight original items being retained in the model (talar head palpation, supralateral and infralateral malleolar curvature, calcaneal frontal plane position, prominent talonavicular joint, congruence of the medial longitudinal arch, and abduction and adduction of the forefoot on the rearfoot). Twelve patients were then analyzed for the predictive validity phase with static and dynamic weightbearing. The six-item foot posture index was able to predict 40% of the variance in dynamic ankle motion with walking.21 The amount of variance described is higher than previous reports that describe static clinical measures predicting dynamic function.8 Foot type and standing arch postures appear to be used more for research purposes, rather than clinical care, and thus demand a higher level of reliability and validity. Navicular height demonstrated good reliability and more responsiveness to rearfoot change over the Staheli arch index and the Chippaux-Smirak index.15 The most reliable and valid measure of arch height at 10% and 90% weightbearing stances was obtained by dividing the dorsum height at 50% of foot length by the truncated foot length.16

Berger and Fannin26 also studied 20 inpatients and found the bedsheet Babinski had high sensitivity and specificity for detecting patients with neurological disease. Brandsma et al12 studied 72 patients with manual muscle testing. The interrater reliability was substantial to excellent. However, when normals were excluded, the interrater reliability was reduced to moderate to substantial levels.12 Smieja et al30 studied the interrater reliability of pinprick, vibration, deep tendon reflexes, position sensation, and monofilament testing in 304 patients in ten centers with internists and residents. They found the monofilament and ankle reflex examinations to have moderate reliability. The pinprick, vibration, and position sense examinations had fair reliability.30 Birke and Rolfsen27 studied the interrater reliability of the monofilament examination on 196 patients at nine centers and also found it to have substantial reliability.30 De Neeling et al28 studied the test-retest intrarater reliability of thermal and vibratory perception threshold examination in 39 patients and found good reliability with thermal sensitivity demonstrating moderate reliability. The neurologic examination demonstrated good test-retest reliability for vibratory perception threshold; moderate for thermal testing; and fair with pinprick, vibratory, and joint position testing.28, 30 Monofilament and ankle reflex testing demonstrated moderate reliability.27, 30 For predictive validity of upper motor neuron lesion, slowness of toe tapping had better interrater reliability and, along with the bedsheet Babinski, may predict disease better than the traditional Babinski sign.26, 29

Vascular Examination
In the vascular examination, pedal pulse palpation and ankle-brachial index were the most studied examinations for reliability.31-35 Lundin et al33 studied interrater reliability of pedal pulse palpation for vascular surgeons and students in 25 patients. They found vascular technicians to have substantial reliability and vascular surgeons to have fair reliability. The differences in results were attributed to hurried clinical conditions. Klenerman et al32 also found substantial test-retest intrarater reliability in pulse palpation in 229 patients studied. Raines et al34 (n = 246) and Beckman et al35 (n = 201) studied automated oscillometry for calculating ankle-brachial indexes and found the methods to be reliable. When looking at pedal pulse palpation, it seems the best cutoff for ankle-brachial index would range from 0.76 to 0.82.31, 33 These findings suggest there is a reservoir of peripheral arterial disease undetected by physical examination that might benefit from referral back to primary

Neurologic Examination
Several studies have investigated the reliability of the neurologic examination.12, 26-30, 39 Miller and Johnston29 observed ten patients and found the Babinski sign to have fair interrater reliability for five neurologists and five primary-care providers. Decreased speed of toe tapping had better reliability and agreement for identifying patients with an upper motor neuron lesion.29

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care should medical management not be optimal.41 Pedal pulse palpation demonstrated substantial reliability depending on clinician type and hurried clinical conditions.32, 33, 42 We have attempted to describe the reliability and validity of current foot examination. We understand that the needs of the examination may differ on the basis of application (clinical or research). Although hundreds of articles describe various methods of lower-extremity assessment, few have given rigorous attention to these measurement properties. We hope that future works in this area will include these critical measures to better guide the clinician in selecting examinations that can accurately assess the functional and physiological status of the lower extremity. The discerning clinician can then use this information to strike the delicate balance between the art of clinical examination and the science of reproducibility and validity. Financial Disclosures: None reported. Conflict of Interest: None reported.

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