Approach to the Exam of the Ankle and Foot

Important anatomical structures that one must be familiar with while examining the painful ankle and foot, are the following:

1. Lateral ligaments of the ankle:
   1. Anterior Talo-Fibular Ligament (ATFL): running anteriorly from the lateral malleolus to the talusPosterior Talo
   2. Fibular Ligament (PTFL): running posteriorly from the lateral malleolus to the posterior aspect of the talus
   3. Calcaneo-Fibular ligament (CFL): running from the lateral malleolus to the lateral aspect of the calcaneous, in the middle between the ATFL and the PTFL
2. Achilles tendon
3. The talar dome: upper portion of the talus, where the articular cartilage for the tibiotalar joint is located
4. Metatarsal bones
5. Interdigital nerves
   
   

First, have the patient lying down supine with the knee bent on the affected side.

Then, observe the lateral aspect of the foot and ankle for hematomas or bruises.

Then, locate the three lateral ligaments and palpate along their course for crepitus and tenderness.

This is a provocative test done to check for the integrity of the ATFL. One hand holds the leg down, while the other hand pulls the foot upwards and anteriorly. It is important to compare one side with the other. The presence of tenderness or laxity on one side only indicates an ATFL rupture.

This is a provocative test done to check for the integrity of the CFL. Forcefully invert the foot while keeping the leg still with the other hand. Make sure to compare side to side. Again, tenderness or laxity on one side indicate a CFL lesion.

To assess for an osteochondral defect we must first locate the talar dome and then palpate to elicit tenderness.

To locate the talar dome we must identify the lateral malleolus and then move anteriorly from it, up to the anterior recess. From here we can move medially and anteriorly along the joint line. The talar dome will be right beneath this point.

Any tenderness elicited by palpating at the level of the anterior joint line is indicative of an osteochondral defect.

To asses for a fracture at the level of the 5^th metatarsal base, palpate along the lateral margin of the foot to elicit pain and to feel for any bone defects or irregularities.

If there is a high grade ankle sprain with associated damage of the talar dome and/or a 5^th metatarsal fracture, we must rule out an injury of the syndesmosis. To assess for a syndesmosis damage, we can use two provocative tests: the external rotation test and the squeeze test.

Achilles tendinopathy is one of the most common foot pathologies. It can affect both athletes and recreational exercisers, being reported in inactive people as well. Clinically it manifests with foot pain on exertion associated with swellings, nodules and tenderness on palpation of the tendon.

To assess for Achilles tendinopathy, palpate the entire length of the tendon moving downwards. Identify any fusiform swellings, defects or tenderness.

Also, palpate the sides of the tendon at the level of the heel to check for the presence of a bursa, or for any bony spurs.

Once an abnormality is identified, if it moves upon flexion and extension of the foot, then we can conclude that it is part of the Achilles tendon.

Commonly presenting with acute onset pain at the heel during physical activities that determine a sudden stretching of the tendon, followed by loss of function of the affected lower extremity.

Sometimes it is possible to hear a popping sound when the rupture occurs.

Perineural fibrosis that develops around one of the interdigital nerves, as a consequence of chronic trauma. More common in middle-aged women, it classically presents as a paroxysmal stabbing pain originating from a web space, usually the 2^nd or 3^rd web space.

The most common site for a stress fracture in the forefoot is the 2^nd metatarsal, given that most of the body’s weight is transferred on this particular bone during every given gait cycle.

To uncover a stress fracture on physical exam, carefully palpate the 2^nd metatarsal in all its length. Tenderness upon palpation would be a sign that a fracture is present. 

This represents the most common cause of heel pain.

The pain is usually described as sharp and tends to be more intense with the first steps after long periods without weigh bearing, such as after a night sleep.

There are two ways of confirming the suspicion of plantar fasciitis on physical exam.

First, we can elicit pain upon palpation of the origin of the plantar fascia on the plantar-medial calcaneal tubercle.

Also, we can notice tenderness on forced dorsiflexion of the first toe, a maneuver called “the windlass mechanism.”

A common cause of both pain and deformity of the forefoot is the hallux valgus or bunion. It consists of a valgus deformity of the first MTP joint. The etiology is not completely understood even though it seems to be related to wearing tight shoes. Also, it is more commonly diagnosed in women.

Physical exam findings

It is usually possible to elicit a characteristic crepitus of the first MTP joint upon palpation.

Also, there is usually evidence of restricted ROM of the first MTP joint.