Assessment of the Foot and Ankle



Assessment of Foot and Ankle

A detailed clinical examination of the foot/ankle complex assists the examiner in making a clear diagnosis of any problem in this area, in addition to supplying information about any irregularities in the function of this complex.

While conducting such an examination, it is essential to start off by taking clear notes on the patient’s chief complaint, most specifically the dominant region of pain and the progression of symptoms associated with it.

The patient’s surgical and medical history also need to be taken into consideration to gain a better understanding of any previous injuries, medications or allergies that could be contributing to the progress of the condition.

Attention must be paid to the patient’s work and home situation as well, in case, the patient is frequently involved in any laborious type of activity.

After having gathered the required information on the background of the patient, the physical examination should commence, involving a thorough assessment of the patient’s gait pattern, standing posture, and shoe wear pattern.

Any prominent deformities or malalignments in this complex need to be observed and noted.

The patient should first be observed standing, in order to check for any asymmetries especially in the position of the trunk and hips. This is critical to rule out any anatomical variations that could potentially increase the risk of a particular injury or that could lead to compensatory abnormalities in gait.

An evaluation of hip and knee alignment is essential because of the interconnection of the lower extremity joint complexes.

Variations in knee alignment such as genu varus or genu valgus need to be observed, as these are most commonly considered to be risk factors for many overuse injuries.

The medial arch needs to be inspected in both weightbearing and nonweightbearing positions, to check for high or low arches that decrease the optimal dispersion of the forces of impact loading of the foot. These also increase the risk for overuse injuries such as plantar fasciitis.

The shape of the foot must be examined thoroughly to determine which proximal metatarsal and metatarsal phalangeal joint take on the maximum load, and to spot any deformities of the toe such claw toe or hammertoe.

Gait tests such as having the patient walk on the toes or single-heel raises, are a good way of testing any subtle deficits in plantar flexor strength.

Thompson’s Test is recommended to evaluate the integrity of the Achilles Tendon by squeezing the calf muscle slightly distal to the place of widest girth. This is done to look for a ruptured Achilles Tendon, which is signified by no plantar movement in the foot.

Dermatological conditions such as plantar warts, calluses, tinea pedis and dyshidrotic eczema may signal problems with the immune system, abnormal loading of the foot, infectious diseases or circulatory problems. These need to be inspected along with any kind of discolouration, swelling, cuts or ulcers in the feet.

Palpation of the ankle helps to localise an area suspicious for bony injury. The structures to focus on would include the shaft of tibia and fibula, as well as the borders of both the medial and lateral malleoli. This can also be performed on the muscles tendons that cross the ankle joint.

Soft tissue palpation should include all ligamentous structures such as the posterior talofibular ligament, the calcanerofibular ligament, the deltoid ligament complex and the anterior tibiofibular syndemosis.

For a clear assessment of the ankle range of motion, the active, passive and resistive range of motion need to be tested. This should be performed keeping in mind the four main motions that occur at the ankle joint namely, dorsiflexion, plantar flexion, inversion and eversion.

A neurovascular assessment of the foot/ankle complex is also required to detect any discrepancies in the nerve function, particularly in terms of sensation, reflexes and motor strength. In the case of a diabetic patient, lack of skin sensitivity increases the risk of developing foot ulcers.

In order to develop more effective neuro-rehabilitation programs which improve the overall well-being of the patient, it becomes essential to use an integrated approach to design combinational therapies, focusing on both, the multiple impairments in the upper body and the lower limbs.

An assessment of lower limbs biomechanics can help identify problematic areas. This can help in formulating treatment plans to repair the overall efficiency of the system and to bring balance to the entire musculoskeletal system.

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References:

  1. Craig C. Young, Mark W. Niedfeldt, George A. Morris, Kevin J. Eerkes (2005) Clinical Examination of the Foot and Ankle. Primary Care: Clinics In Office Practice: 2005, Vol. 32, pp. 105-132. doi:10.1016/j.pop.2004.11.002
  2. Luke, A. (2011) Physical Examination Info. Ankle Physical Examination. Retrieved from http://orthosurg.ucsf.edu

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