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Wheeless' Textbook of Orthopaedics

Examination of the Foot and Ankle



- Inspection:
    - look at shoes for signs of abnormal wear;
    - inspect standing foot and ankle alignment from behind;
    - note arch height;

- Assessment of Gait:
    - always examine the soles of the patient's shoes for signs of asymmetrical wear;
    - look for side to side asymmetry or abnormal contact w/ the ground;
    - note whether gait is heel to toe (normal), flat foot, or toe to heel (c/w equinus contracture);
    - distinguish between Trendelenburg vs antalgic gait;
    - note whether hammer or claw toe deformities are present during gait cycle;

- Ankle Joint:
    - note presence of ankle effusion by noting the fullness on either side of the Achilles tendon;
    - ankle dorsiflexion; (see: equinus contracture:)
          - in pts with pes planus, the examiner frequently finds that a shortened triceps surae will prevent sufficient dorsiflexion of foot to allow the heel, if held in inversionn, to contact floor;
          - to check the degree of shortening, initiate forceful dorsiflexion of foot with the heel in full inversion;
          - dorsiflexion injures:
                 - anterior impingement syndorme
                 - anterior tibiofibular sprain:
                 - typically results from pure dorsiflexion injury, whereas common lateral ligament complex sprain usually has inversion mechanism;
    - ankle plantar flexion:
          - diff dx of posterior ankle pain;
          - pain may occur when the pt points the toe, and may lack 10 deg of plantar flexion as compared to the opposite ankle;
    - ankle stability:
          - anterior drawer test
                 - evaluates the anterior talofibular ligament (look for diff. of 8 mm)
          - inversion (supination) test
                 - w/ ankle in plantarflexion: evaluates ATFL;
                 - in neutral / slight dorisflexion: evaluates calcaneofibular ligament;
          - eversion test:
                 - in neutral evaluates superficial Deltoid Ligament complex
          - external rotation stress test evaluates syndesmotic ligaments and additionally - the deep deltoid ligament -
    - syndesmostic sprain:

- ROM of Hindfoot and Forefoot:
    - functional hindfoot valgus is measured by noting the relationship of the leg to the hindfoot while the the patient is viewed from behind (w/ patient standing);
          - functional hindfoot varus is measured by having the patient raise up on the forefoot;
    - exam of the subtalar joint:
          - note position of the hindfoot relative to the forefoot;
                  - patient is examined sitting with the knee flexed;
                  - dorsiflex the ankle to a neutral position, and then evert and invert the subtalar joint until the navicular is centralized under the talar head;
                  - observe the position of the forefoot relative to the hindfoot;
          - if exam reveals a fixed or limited inversion and erversion, it is important to see how this is manifested in the wt bearing foot;
          - 2 common patterns:
                  - a rigid forefoot eversion (valgus) with associated flexible hindfoot inversion (varus) pattern, presenting as a pes cavus foot;
                  - a rigid hindfoot eversionn (valgus) wiht compensatory forefoot inversion (varus), presenting as a pes planus foot;
    - windlass Action:
          - normally dorsiflexion of the toes increases the tension of the plantar aponeurosis, which causes the longitudinal arch to rise;
          - failure of the longitudinal arch to do so suggests the presences of prolonged pes planus with attendant abnormal stretching and elongation of the plantar aponeurosis



Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes.

- no varus or valgus of the hindfoot;
- w/ pt standing on tiptoe, no calcaneal inversion;
- no plantar tenderness
- no plantar callus
- no hallux valgus or rigidus
- no hammer toe or claw toes



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, September 21, 2012 12:40 pm