Clinical assessment and examination

Inspection

This should include the following:

1- Supine lying.
2- Prone lying.
3- Footwear.
Inspection should include assessment for swelling (including the ankle joint and the
Achilles tendon), muscle wasting (especially the calf), bone and joint deformity (such
as hallux abducto valgus, tibio varum, and accessory ossicles). On the undersurface
of the foot, the pattern of callus formation should be noted. This can be done by
comparing one foot to the other in order to determine if there are any differences
between the two.
Examination of a well worn shoe provides invaluable information on foot mechanics
and the assessment of footwear should include the wear pattern of the sole,
deformation of the toe box, deformation of the heel counter, and the asymmetrical
pattern between the two shoes.
The pointing sign

The patient should be asked to point with one finger to the site of the pain. (S)he will
point out the direction and distribution of the pain, which often conforms to the
anatomical alignment of the structure involved (e.g. pointing may follow the course of
the involved tendon, such as that of tibialis posterior or flexor hallucis longus, the
joint line of the involved joint, or the plantar fascia). This sign can be very helpful in
making a diagnosis in addition to alerting the physician to the site of maximum
tenderness. (Video 1, Video 2, Video 3, Video 4 , Video 5)
Palpation

This should be performed to assess tenderness and swelling, and will be influenced by
the ‘pointing sign’ and by the anatomical site of the proble
Tenderness may occur along the course of an inflamed tendon where there may be
associated swelling and/or crepitus. Achilles disorders are often associated with
nodular swelling of the tendon. Tenderness may occur along a joint line as a
reflection of joint injury or synovitis. (Video 1, Video 2) Point tenderness over a bone
may be a reflection of a stress fracture, e.g. navicular, tibia, fibular or metatarsal.
The metatarsal squeeze test can be used to assess for synovitis of any of the
metatarsophalangeal (MTP) joints and, if positive, should be followed up by palpating
each joint for tenderness. The web spaces between the MTP joints should be palpated
for tenderness to assess for neuromas (especially the third/ fourth web space).
Mulder's click test is a 'click' that can be felt due to the swollen nerve impinging
against the intermetatarsal ligament. The thumb and index finger are used to palpate
for the 'click' in the relevant intermetatarsal space, whilst the metatarsal heads are
squeezed together.
The Lachman toe translation test is a useful test to assess the stability of the plantar
ligaments of the MTP joints. If the plate is ruptured, the proximal phalanx can be
translated upwards. If capsulitis is present, there will be pain on the translation test.
The metatarsal is stabilized with the fingers of one hand, whilst the thumb and index
finger of the opposite hand of the examiner translate the proximal phalanx superiorly
and inferiorly. In capsulitis, the patient will experience pain on upward translation.
Abnormal movement or even a subluxation of the joint can be felt when the plantar
plate is completely ruptured

Passive movements

This should assess range of movement at the ankle, subtalar, midtarsal, and
metatarsophalangeal (MTP) joints.

Dorsiflexion at the ankle can be assessed more effectively on standing. Limitation of

dorsiflexion may be due to tightness of the Achilles tendon/calf muscles or due to a
bony block at the front of the ankle.

The passive range of movement of a single joint may vary depending on the position
of an adjacent joint. The range of movement of the subtalar joint is best assessed with
the ankle in maximal dorsiflexion. This locks the wider part of the talus into the ankle
joint. The range of movement of the ankle also depends on whether the ankle is
supinated or pronated.

The range of movement of the first MTP joint is dependent on the position of the
ankle joint. More dorsiflexion of the MTP joint occurs when the ankle is
plantarflexed. Maximal dorsiflexion of the first MTP joint (i.e. with the ankle
plantarflexed) should ideally be about 90 degrees for classical dancers and about 60
degrees for runners. Significant limitation of dorsiflexion in these two activities will
increase the risk of injury to the joint and elsewhere in the foot and leg
Active movements

Assessment should include the following movements:

1- Ankle plantarflexion and dorsiflexion.

2- Hindfoot inversion and eversion.

3-. Toe flexion and extension.

The terms 'supination' and 'pronation' refer to combined movements of the ankle,
subtalar, and midtarsal joints. The movements occur at the three joints and in three
dimensions. Supination of the foot with respect to the tibia implies:

1- Ankle plantarflexion.
2- Subtalar joint inversion.
3- Midfoot adduction.

Pronation of the foot implies:

1-. Ankle dorsiflexion.

2-. Subtalar joint eversion.

3- Midfoot abduction.

Resisted movements

Resisted movements should be tested as for active movements. Muscle power can be
measured according to the MRC (Medical Research Council) grading . Resisted
movements of tibialis posterior and tibialis anterior can be distinguished by varying
the position of the ankle.

Tibialis posterior is best tested with resisted inversion with the ankle plantarflexed.
Tibialis anterior is tested with resisted inversion with the ankle dorsiflexed. (Video)
© 2003 Primal Pictures Ltd.
Standing assessment

Assessment should be carried out from the front, back and sides, and the following
should be noted:
1- Toe deformities.
2. Alignment of forefoot relative to midfoot.
3. Alignment of midfoot relative to hindfoot.
4. Alignment of hindfoot relative to ankle and leg. (Video)
5-. Height of the medial longitudinal arch.
6-. Ability to dorsiflex the ankle.
7- Ability to perform both double and single heel raise. This will assess the
function of the ankle plantar flexors. In normal circumstances, the heel will invert
during this test. Athletes with tibialis posterior tendon dysfunction will be unable to
initiate a single heel raise and will also demonstrate lack of heel inversion during the
double heel raise. In normal people, the heel should invert and the arch should
become more prominent on heel rise.
Walking assessment

Assessment of the walking gait should include:

1-. Heel strike.
2-. Amount of hind foot eversion.
3- Amount of midfoot pronation.
4-. Foot alignment at toe off.
5- Ability to achieve a plantigrade foot.
Although these can be assessed by directly viewing the athlete from a posterior and
lateral position, a more detailed assessment can be achieved by filming the walking
gait from both these positions and then observing the video in slow motion. (Video 1,
Video 2, Video 3)
Functional tests
Proprioception
The patient stands on one leg, initially with the eyes open. Once stable, the patient is
asked to close their eyes and the degree of body sway and the time it takes before the
other leg has to be lowered to the ground are observed. This should be compared to
the opposite side. (Video 1, Video 2)
The test can be made more difficult by getting the patient to perform the test on tiptoe.
Heel raise

The patient should be observed performing a do double and single heel raise. This
will assess the function of the ankle plantar flexors. In normal circumstances, the heel
will invert during this test. Athletes with tibialis posterior tendon dysfunction will be
unable to initiate a single heel raise and will also demonstrate lack of heel inversion
during the double heel raise.
Jumping and hopping

Both the taking off and the landing are important when assessing the functional
integrity of the ankle and foot. The ability to perform the action and any associated
pain should be observed.

Lumbar spine assessment

Symptoms in the foot and ankle are occasionally referred from the lumbar spine.
Examination should include:

1- Posture on standing: assessing for any abnormal curves (especially scoliosis).

2- Range of movement and associated pain and its distribution.

3- Slump testing. This test can be performed with the foot dorsiflexed and
everted in order to test the tibial nerve, and plantarflexed and inverted to test the
common peroneal nerve. (Video 1, Video 2) (Kopell and Thompson, 1960) There is
also a simpler version of this test, where it can be carried out with only one examiner.
(Video)

Tests focusing on specific diagnoses

Musculoskeletal tests:

1- Calf squeeze test (Simmond's/Thompson’s test).

2-. Posterior impingement test: this can be tested passively with the patient lying
in a prone position with the ankle passively plantarflexed. (Video) Posterior
impingement can also be tested actively (a more sensitive test): the athlete performs
five consecutive heel raises on the affected side, in a standing position. (Video) With
posterior impingement, the athlete will complain of posterior pain on both of these
tests.

3-. Anterior impingement test: this can be tested passively, with the patient
supine and the ankle passively dorsiflexed. The athlete can also be tested actively in
the standing position, where the athlete is asked to repeat 5 consecutive plies
(dorsiflexions). (Video) The athlete with anterior impingement will complain of
anterior pain with either of these tests. The active test is more sensitive.

4-. Anterior drawer test for ankle laxity: there are two ways of assessing this.
One method is to assess the patient supine and the knee extended and the ankle is
drawn directly forwards by pressure on the heel. (Video) However, this technique is
limited by the pull of gastrocnemius and also by resistance of the anterior fibers of
deltoid. Another method, testing only the anterior talofibular ligament is to have the
patient sitting with the knee flexed and drawing the ankle forwards whilst rotating it
around the pivot of the medial malleolus. (Video) This technique isolates the anterior
talofibular ligament and a suction sign (in-drawing of the capsule due to a vaccum
effect) may be seen anterior to the lateral malleolus when the anterior talofibular
ligament is incompetent.

5- Heel raises to assess tibialis posterior function: in normal circumstances, the

heel will invert during this test. Athletes with tibialis posterior tendon dysfunction
will be unable to initiate a single heel raise and will also demonstrate lack of heel
inversion during the double heel raise. In normal people, the heel should invert and
the arch should become more prominent on heel rise.

6- Mulder’s click test (for neuroma): the web spaces between the MTP joints
should be palpated for tenderness to assess for neuromas (especially the third/fourth
web space). Mulder's click is a 'click' that can be felt due to the swollen nerve
impinging against the intermetatarsal ligament. The thumb and index finger are used
to palpate for the 'click' in the relevant intermetatarsal space, whilst the metatarsal
heads are squeezed together.

7- Lachman’s toe translation test. The metatarsal is stabilized with the fingers of
one hand, whilst the thumb and index finger of the opposite hand of the examiner
translate the proximal phalanx superiorly and inferiorly. In capsulitis, the patient will
experience pain on upward translation. Abnormal movement or even a subluxation of
the joint can be felt when the plantar plate is completely ruptured.

8- Calcaneal squeeze test: the calcaneal squeeze test should be used to assess for
a calcaneal stress fracture.

9- Peroneal subluxation. The peroneal tendons can be seen to slide out of the
retro-malleolar space onto the lateral aspect of the lateral malleolus when the ankle is
placed in maximum plantarflexion and the patient is asked to dorsiflex the ankle
whilst the clinician holds the ankle plantarflexed and the subtalar joint everted.

10-. Syndesmosis sprain tests. (Video 1, Video 2)

11-. Assessment of hallux rigidus.

Neurological examination

Motor and sensory examination of the foot and ankle should be performed if an
entrapment or peripheral neuropathy is considered. A Tinel's sign is positive when, on
direct percussion over the nerve at the site of entrapment or damage, pain and
paresthesia are experienced in the distribution of that nerve. This may be a useful test
in tarsal tunnel syndrome.

Vascular examination

The presence of the peripheral pulses in the foot (dorsalis pedis and posterior tibial
artery) should confirm if a vascular disorder is a possibility or if surgery should be
considered. (Video)
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