Ankle and Foot Examination:

Evidence Based Review

Ankle injuries

Inversion injuries are far more common than eversion injuries, due to the relative instability
of the lateral joint and weakness of the lateral ligaments compared with the medial ligament
(Brukner and Khan, 2007 [pdf]). The aim of the initial assessment is to rule out an ankle
fracture and if possible diagnose the site of abnormality as accurately as possible. The
differential diagnoses that must be considered after an ankle injury include:

Common causes:
• lateral ligament sprain: anterior talofibular ligament (ATFL)
• calcaneofibular ligament (CFL)
• posterior talofibular ligament (PTFL)

Less common causes:

• medial ligament injury (deltoid ligament complex)
• fractures: lateral/medial/posterior malleoli, calcaneum, and talus
• osteochondral lesion of the talus
• dislocation (fracture/dislocation)
• tendon rupture/dislocation: tibialis posterior and peroneal tendons

Not to be missed:
• greenstick fractures in children
• disruption of distal tibiofibular joint

Foot injuries

As previously stated, it is easier to divide the foot into three areas when considering the
differential diagnosis.

Rear foot pain

Common causes:
• plantar fasciitis
• fat pad contusion

Less common causes:

• calcaneal fractures (traumatic or stress)
• nerve entrapment
• tarsal tunnel syndrome
• talar stress fractures
• retrocalcaneal bursitis

Not to be missed:
• osteoid osteoma
• spondyloarthropathies

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Midfoot pain
Common causes:
• navicular stress fractures
• midtarsal joint sprain
• tendinopathy (extensor and tibialis posterior)

Less common causes:

• cuneiform, cuboid and 2nd metatarsal stress fractures
• tendinopathy (peroneal)
• abductor hallucis strain
• accessory navicular bone

Not to be missed:
• Lisfranc’s joint injury
• osteoid osteoma

Forefoot pain
Common causes:
• fracture of the metatarsals
• first metatarsophalangeal (MTP) joint sprain
• synovitis of the MTP joints
• subungual haematoma
• phalangeal fractures

Less common causes:

• sesamoid pathology
• stress fractures of the metatarsals
• synovitis of the metatarsocuneiform joint

It is essential that a thorough history and examination is undertaken to identify the cause of
the patient’s pain and disability on presentation. It is important to consider the common
causes first and to rule them out if possible before considering the less common causes.
Understanding the anatomy of the injured or painful area is essential to allow a careful
examination of both bony and soft tissue structures. Investigations should be employed with
due diligence to confirm the suspected diagnosis and to allow the employment of the correct
treatment regimes.

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Anatomy

It is essential to have a basic knowledge of the anatomy of the ankle and foot, not only to
ensure that you know which structures you are assessing when you examine, but to ensure
investigations and provisional diagnoses are rational.

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Ankle
1. This is a mortice joint.

2. The dome of the talus articulates with the medial malleolus of the distal tibia and the lateral malleolus of
the distal fibula.

3. The bones of the ankle joint are held together by ligaments laterally (see below) and medially by the
deltoid ligament and the strong interosseous ligament between tibia and fibula.

4. Inversion of the ankle may cause injury to the lateral ligaments and eversion to the medial (deltoid)
ligament.

Foot
There are several regions, including:
• hindfoot: calcaneus and talus
• midfoot: navicular, cuboid and three cuneiform bones
• forefoot: metatarsals and phalanges

There are three regions of the joint:

• subtarsal joint: anterior talocalcaneal joint and talonavicular joint
• midtarsal joint: talonavicular joint and calcaneocuboid joint
• Lisfranc joint: tarsometarsal joint
• the bones can only be identified if they can be recognised

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Clinical features
History
The history should include
• mechanism of injury
• detailed history of symptoms, e.g. pain, swelling, stiffness, range of movement, ability to weight
bear or walk
• previous injury to the joint
• occupation and sporting activity
• past medical history, medications and allergies

Examination
Look Observe the patient walking (if able)
Inspect for: deformity, asymmetry, swelling, erythema, bruising and
colour of the skin
Check for chronic changes – scars, wasting, callosities, soft tissue,
and swelling

Feel Palpate the bones of the ankle and foot systemically, then palpate the
important soft tissues
Ensure that the entire lower leg is examined when assessing an acute
ankle injury and pay special attention to the Achilles tendon
Ensure that both the foot and the ankle are examined when assessing
the patient with foot pain
Check for symmetry with respect to the contralateral side

Move Check all movements

Other tests Check vascular status (dorsalis pedis and posterior tibial arteries)
Check sensation in the foot
Check for ligament stability – anterior draw test and talar tilt test
Check the Achilles with Simmonds squeeze test

Anterior draw test talar tilt test

Check if the patient can walk or weight bear on the affected side (although if suspicious of
fracture wait for radiographs first)

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Diagnostic strategies
Ankle and foot
Clinical examination

Radiographs, if the injury adheres to the Ottawa ankle rules (Stiell et al, 1992; see below)

Tenderness in either malleolar “red” zone suggests that an ankle radiograph is required. Tenderness in
the midfoot “orange” zone suggests that a foot radiograph is required.

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Common pathologies and management of ankle sprains

Common pathologies include: sprains and fractures as well as medical conditions such as
gout, infection, etc.

It is important to grade sprains and to arrange appropriate treatment, advice and follow-up.
Ankle sprains:

Grade 1 – tender no laxity

Grade 2 – tender some laxity
Grade 3 – gross laxity

Severity Analgesia Early Physiotherapy Crutches Ankle brace Review

mobilisation 10 days

1 9 9 8 8 8 8

2 9 Consider Consider Consider Consider 9

3 9 8 9 9 9 9

Common pitfalls

• Assuming that all partially weight bearing patients do not have a fracture.
• Missing potential damage to other associated structures (e.g. lateral ligament sprain and an avulsion
fracture of peroneus brevis off the base of the 5th metatarsal).
• Failing to refer those foot and ankle injuries with significant soft tissue damage for early physiotherapy.
• Inappropriate use of immobilisation casts.
• Sending a patient home (without checking that they can cope), resulting in at least re-attendance or
further injury to the patient.
• Inadequate or misleading advice to patient with ankle sprains.