Alazzawi S, Sukeik M, King D, Vemulapalli K. Foot and ankle history and clinical examination: A guide to everyday practice. World J Orthop 2017; 8(1): 21-29 [PMID: 28144575 DOI: 10.5312/wjo.v8.i1.21]
Corresponding Author of This Article
Sulaiman Alazzawi, Specialty Registrar, Trauma and Orthopaedic Department, Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB, United Kingdom. salazzawi2@gmail.com
Research Domain of This Article
Orthopedics
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Minireviews
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No heel strike The foot lands on the floor with a sound like a slap
Foot drop Polio Tibialis anterior dysfunction
Trendelenburg (lurching) gait
Trunk deviation towards the normal side When the foot of the affected side leaves the floor, the pelvis on this side drops
Weak gluteus medius
Waddling gait
Lateral deviation of the trunk with an exaggerated elevation of the hip
Muscular dystrophy
Table 5 Movements of the ankle joint and possible causes of restrictions[3,9]
Movement
Normal range of motion
Possible causes of restriction
Dorsiflexion
0-20 degrees
Tight Achilles tendon Tightness of the posterior ligaments Loss of flexibility in the ankle syndesmosis Impingement of anterior soft tissue or osteophytes
Tension in the joint capsules and the lateral ligaments1
Eversion
0-15 degrees
Tension in the joint capsules and the medial ligaments1
Table 6 Examination techniques of muscles functions[3]
Muscle
Ankle position
Manoeuvre of the test
Tibialis Anterior
Maximum Dorsiflexion and inversion
Try to plantar flex the ankle with your hand and ask the patient to resist, use your second hand on the tendon to feel the contraction (Figure 1)
Tibialis posterior
Plantar flexion and inversion
Patient inverts the foot in full plantar flexion whilst the examiner pushes laterally against the medial border of the patient’s foot (in an attempt to evert the foot). The examiner needs to use second hand on the tendon to feel the contraction (Figure 2)
Peroneal longus and peroneal brevis
Plantar flexion and eversion
Patient everts the foot in full plantar flexion and the examiner pushes medially against the lateral border of the patient’s foot (in an attempt to invert the foot) (Figure 3)
Extensor hallucis longus
Neutral
Patient extends the great toe and the examiner try to planter flex it (Figure 4)
Extensor digitorum longus
Neutral
Patient extends the lesser toes toe and the examiner try to planter flex it1 (Figure 5)
Flexor hallucis longus and flexor digitorum longus
Neutral
Patient curls the toes downward and the examiner tries to dorsiflex them1
Table 7 Examination techniques of performing the foot and ankle special tests[2,3,9,10]
Name of the test
Purpose of the test
Maneuver
Anterior drawer test
Lateral ligament complex
The leg hangs loosely off the table The examiner hold the patient’s leg just above the ankle joint with one hand The examiner uses the other hand to hold the ankle in plantar flexion and try to gently to pull the ankle forward - anterior translation (Figure 6) Look at the skin over the anterolateral dome of the talus to watch for anterior motion of the talus with this maneuver - sulcus sign
Inversion stress test
Stability of the lateral ankle ligaments (ATFL)
The knee is flexed 90 degree With one hand perform inversion stress by pushing the calcaneus and talus into inversion while holding the leg form the medial side with the other hand (Figure 7) The test is positive when there is excessive inversion and/or pain
Calf compression or “squeeze” test
Syndesmotic injury
The leg hangs loosely off the table - knee flexed The examiner uses both hand to squeeze at midpoint of the tibia and fibula Pain caused by this maneuver indicates Syndesmotic injury
External rotation stress
Syndesmotic injury
The leg hangs loosely off the table - knee flexed and foot fully dorsiflexed The examiner uses one hand to stabilize the lower leg With the other hand they externally rotate the foot Pain caused by this maneuver indicates Syndesmotic injury
Coleman block test
To assess the flexibility of the hindfoot, i.e., whether the cavus foot is caused by the forefoot or the hindfoot
A block is placed under the lateral border of the patients foot The medial forefoot is allowed to hang over the side The first metatarsal will be able to drop below the level of the block, i.e., eliminate the contribution by the first ray (Figure 8) With a flexible hindfoot, the heel will fall into valgus or neutral termed forefoot-driven hindfoot varus In case of rigid hindfoot or hindfoot-driven hindfoot varus the heel will remain in varus, and no correction will be happen
Semmes-weinstein monofilament test
To assess the degree of sensory deficit
Pressure testing using a 10 g Semmes-Weinstein mono- filament. Especially useful in diabetic charcot feet (Figure 9)
Table 8 Examination techniques of performing the foot and ankle special tests[2,3,9,10]
Name of the test
Purpose of the test
Manoeuvre
Silfverskiold test
Differentiate between a tight gastrocnemius and a tight soleus muscle
The leg hangs loosely off the table - knee flexed Dorsiflex the ankle to the maximum Patient should then extend their knee Repeat the ankle dorsiflexion (Figure 10) If there was more ankle dorsiflexion with the knee flexed then there is gastrocnemius tightness
Thompson’s test
Achilles’ tendon rupture
Patient lies is prone on the bed or kneel on a chair The examiner gently squeeze the gastrocsoleus muscle (calf) If the tendon is intact, then the foot passively plantar flexes when the calf is squeezed
Test for tarsal tunnel syndrome
Compressions of the posterior tibial nerve underneath the flexor retinaculum at the tarsal tunnel
Tap inferior to the inferior to the medial malleolus to produce Tinel’s sign
Test for flat foot
Differentiate between flexible vs rigid
Ask patient to stand on tiptoes If the medial arch forms and heel going into varus then it is flexible flat foot Beware of rupture tibialis posterior tendon or tarsal coalition
Test for stress fractures
Stress fractures
Place a tuning fork onto the painful area If it increases the pain, then it is positive Other test: One spot tenderness on palpation with finger
Babinski’s response
Upper motor neuron disease
Scratch the lateral border of the sole of the foot A positive response is dorsiflexion of the great toe
Oppenheim’s test
Upper motor neuron disease
Run a knuckle or fingernail up the anterior tibial surface A positive response is dorsiflexion of the great toe
Mulder's test
Morton’s neuroma
A mass felt or audible Click is elicited by palpating (grasping) the forefoot (web space) with the index finger and thumb of the examiner
Table 9 Three common pathologies and the related necessary clinical tests[7]
Special pathology
Required tests
Pes cavus
Claw toes Examine peroneal tendons Tibialis anterior and posterior Coleman block test Examine the Achilles tendon Full lower and upper limb neurological examination Hand - inspect for muscle wasting Spine
Pes planus
Single leg sustained tip toe test Testing tibialis posterior power Too many toes sign Examine the Achilles tendon
Hallux valgus/ rigidus
Dorsal osteophyte Passive ROM Grind tests Correct the deformity Examine the Achilles tendon
Table 10 Medical Research Council scale to assess the strength of muscle[8]
Grade
Description
Grade 0
No contraction
Grade 1
Flicker or trace of contraction
Grade 2
Active movement with gravity eliminated
Grade 3
Active movement against gravity
Grade 4
Active movement against gravity and resistance
Grade 5
Normal power
Citation: Alazzawi S, Sukeik M, King D, Vemulapalli K. Foot and ankle history and clinical examination: A guide to everyday practice. World J Orthop 2017; 8(1): 21-29