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.