Ankle Examination

Ankle examination is an important diagnostic tool used to assess the health and function of the ankle joint. Foot and ankle examination typically involves a history taking and the Look, Feel & Move, in addition to special tests of the ankle joint.

History Taking

The most frequent symptom of a foot or ankle is pain, and it is important to determine the exact location, nature, and timing of the pain. Other symptoms include stiffness, swelling, deformity, instability, weakness, numbness, burning, and limping.

Inquire about any underlying conditions or symptoms related to the lower back, hips, or knees as an abnormality in the lower limb can cause compensatory changes in the foot and ankle biomechanics. Additionally, it is important to determine whether the patient had any foot disorders during childhood.

Understanding how the symptoms affect the patient’s daily life, work, and sports activities is also important, as well as determining whether the patient uses any orthotics or walking aids. If the patient presents following trauma, obtain a detailed description of the injury mechanism. It is important to note that foot and ankle pathology can be a part of a systemic condition, and a clear history and directed examination are crucial.

Foot deformities can result from a congenital or acquired spinal condition. Peripheral neuropathy, including diabetic neuropathy, can cause an insensate foot and degenerative (Charcot) joints. Rheumatoid arthritis can affect the forefoot, midtarsal joint, and hindfoot, leading to metatarsalgia, claw toes, hammer toes, talonavicular arthritis, tibialis posterior tenosynovitis, pes planus, and a progressive hindfoot valgus deformity. Cardiac failure, peripheral vascular disease, and venous insufficiency can all cause foot and ankle symptoms.

Ankle Examination

Range of movement should be assessed individually in the ankle joint, subtalar (talocalcaneal) joint and midtarsal (talonavicular and calcaneocuboid) joint. The relative alignment of the hindfoot, midfoot and forefoot, and the arches of the foot (medial longtitudinal, lateral longtitudinal, transverse and anterior) should be assessed in weight-bearing and non-weight-bearing positions. Ankle stability is assessed by examining the lateral ligament complex (anterior and posterior talofibular and calcaneofibular ligaments) and medial deltoid ligament complex.

Complete foot and ankle examination should include neurovascular assessment of the lower limbs and clinical gait analysis.

See Also: Ankle Anatomy

Inspection (Look)

Before starting the ankle examination, it is important to ensure that the patient is adequately exposed.

Begin by inspecting the anterior, posterior, medial and lateral aspects of the feet and ankles, as well as the soles. Look for any abnormal or asymmetrical wear patterns in the footwear, orthoses or insoles, and any walking aids. Request that the patient removes any orthotic insoles from their footwear, places them on the floor, and stands on them; assess if the deformity is corrected.

Perform a general inspection of the foot and ankle, observing for skin changes such as those of peripheral arterial disease or venous insufficiency, old surgical or traumatic scars, erythema and fungal infection. Check for ankle oedema – is it localized or diffuse, unilateral or bilateral, pitting or non-pitting?

From in front, examine for any asymmetry, splay foot, hallux valgus, abnormal swellings or exostoses, lesser toe deformities, bunions, bunionettes, nail changes, or ingrowing toenails, and inspect between the toes.

Look at the sole, searching for distribution of callus, discrete keratoses, plantar warts, or thickening of Dupuytren’s disease.

From behind, check for swellings associated with the Achilles tendon, including a prominent posterosuperior calcaneal tuberosity. Observe the movement of any swelling relative to the tendon to distinguish inflammation of the tendon from inflammation of the tendon sheath. If the posture of the hindfeet is asymmetrical, examine the spine, knees and hips with particular attention to leg length measurement.

Evaluate the general posture of the ankle and foot, including the medial arch, and any asymmetry or abnormalities in the hallux and the lesser toes. It is worth noting that there are three common foot types in the general population, which are the Egyptian foot, the Greek foot, and the squared foot.

In the normal foot, there is a narrow lateral weight-bearing area and moderate callus under the heel and first metatarsal head. Determine whether a pes planus or planovalgus deformity is fixed (rigid) or flexible (correctable), and look for abnormalities such as pes planus, pes cavus, splaying of the forefoot, hallux valgus, metatarsus primus varus, and lesser toe deformities (e.g., under-riding/overriding toes, claw toe, hammer toe, mallet toe).

See Also: Foot Anatomy

Palpation (Feel)

During foot and ankle examination, it is important to palpate bony landmarks and soft-tissue structures systematically, from the hindfoot to the midfoot and forefoot. Peripheral pulses should also be assessed. Tenderness or swelling along the course of a tendon may indicate tendinitis or tenosynovitis. Other conditions, such as stress fractures, tarsal tunnel syndrome, rheumatoid arthritis, and Morton’s neuroma, may also be identified through palpation and other special tests.

Movements (Move)

Active and Passive Movements

To assess ankle joint movements, ask the patient to perform active plantarflexion, dorsiflexion, inversion, eversion, as well as flexion, extension, abduction, and adduction of the toes. Passive movements are easily assessed with the patient seated on an examination couch with legs hanging freely. Reduced range of movement, pain, and crepitus may indicate osteoarthritis.

Combined Movements

The ankle, subtalar, and midtarsal joints are involved in complex combined movements. Supination of the foot (35°) is achieved by a combination of inversion at the subtalar joint, adduction at the midtarsal joint, and plantarflexion, while pronation (20°) is achieved by a combination of eversion at the subtalar joint, abduction at the midtarsal joint, and dorsiflexion.

Ankle Movement

Ankle plantarflexion (40-55°) and dorsiflexion (10-20°) can be best assessed by grasping the calcaneum firmly in one hand, resting the foot on the examiner’s forearm, and holding the distal lower leg above the ankle. The Silfverskiold test can be used to distinguish a tight gastrocnemius from other causes of reduced dorsiflexion. Ankle dorsiflexion should be reassessed in maximal inversion.

See Also: Ankle Range of Motion

Subtalar Movement

By applying varus and valgus stress to the calcaneus with the ankle in neutral and the talar neck stabilized, the contribution of inversion and eversion of the subtalar joint to supination and pronation can be assessed.

Midtarsal Movement

By grasping the midfoot in one hand and stabilizing the hindfoot, movement at the midtarsal joint can be assessed. Movement at this composite joint contributes to overall inversion, eversion, abduction, adduction, dorsiflexion, and plantarflexion.

Tarsometatarsal Movement

With the midfoot stabilized, the forefoot can be moved superiorly and inferiorly in the sagittal plane. The first, second, and third tarsometatarsal (TMT) joints are much less mobile than the fourth and fifth TMT joints, which articulate with the cuboid, and the first ray should be assessed for hypermobility.

Metatarsophalangeal Movement

To assess the great toe (hallux) movement, it can be plantarflexed (70-90°) and dorsiflexed (60-90°) with the forefoot stabilized. Pain, stiffness, impingement, or crepitus should be noted. The test should also be repeated in the lesser toes, noting any stiffness, deformity (e.g. hammer toe), and whether it is fixed or flexible.

Resisted Movements

Resisted movements can be used to assess muscle strength according to the Medical Research Council grading system, identify individual tendons, and palpate for tenderness and localized swelling seen in tendinitis or tenosynovitis. Peroneus brevis and adjacent peroneus longus can be easily identified during resisted eversion and plantarflexion, respectively. Peroneal subluxation can be demonstrated during resisted eversion with dorsiflexion. Tibialis anterior and posterior can be palpated during resisted inversion in dorsiflexion and plantarflexion, respectively.

Foot & Anke Special Tests

1. Homans Sign
2. Thompson Test
3. Squeeze Test
4. External Rotation Test
5. Anterior Drawer Test of The Ankle
6. Posterior Drawer Test of The Ankle
7. Navicular Drop Test
8. Ankle Girth Measurement
9. Silfverskiold Test
10. Jack Test Foot Flexibility
11. Coleman Block Test
12. Talar Tilt Test
13. Windlass Test
14. Triple Compression Stress Test
15. Ankle Impingement Test
16. Achilles Tendon Rupture Tests
17. Staheli Test
18. Mortons Neuroma Test
19. Heel Thump Test
20. Ottawa Ankle Rules

References & More

1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
2. Alazzawi S, Sukeik M, King D, Vemulapalli K. Foot and ankle history and clinical examination: A guide to everyday practice. World J Orthop. 2017 Jan 18;8(1):21-29. doi: 10.5312/wjo.v8.i1.21. PMID: 28144575; PMCID: PMC5241541.
3. Papaliodis DN, Vanushkina MA, Richardson NG, DiPreta JA. The foot and ankle examination. Med Clin North Am. 2014 Mar;98(2):181-204. doi: 10.1016/j.mcna.2013.10.001. Epub 2013 Dec 18. PMID: 24559868.
4. Larkins LW, Baker RT, Baker JG. Physical Examination of the Ankle: A Review of the Original Orthopedic Special Test Description and Scientific Validity of Common Tests for Ankle Examination. Arch Rehabil Res Clin Transl. 2020 Jul 8;2(3):100072. doi: 10.1016/j.arrct.2020.100072. PMID: 33543095; PMCID: PMC7853358.