Pocket Notes for an Efficient and Accurate Assessment of the Ankle/Foot – Ryan G., Physical Therapist 

Below are listed several tips to look for when performing an evaluation of someone’s ankle and foot.  It is important to note that often times, a patient can be complaining of hip or low back pain when the cause of this pain lies in the feet.  The lower trunk is a kinetic chain and all joints must be considered when evaluating a patient.

1. Callus formation on the 2^nd and 3^rd metatarsal heads: this can often times be the result of a collapsed metatarsal arch which in turn can be the result of a pes cavus, rheumatoid arthritis, shortened heel cord, or hammertoes.

2. An observed outward curve of the Achilles tendon: potentially indicative of a collapsed medial longitudinal arch and/or pes planus. 

3.Observed or palpated swelling posterior to the lateral malleolus: this is often times an indication of posterior peroneal retinaculum injury.

4.Signs and/or symptoms of vasomotor involvement:

a. Loss of hair on the feet.

b. Toenail color changes.

c.  Temperature changes between feet.

d. Pain and/or rubor upon dependency in the feet.

5. Observed or palpated swelling superior to the lateral malleolus: this can be an indication of a fibular fracture or high ankle sprain (tibia-fibula syndesmosis sprain).

6.Pes Planus/Flatfoot: often times an overly pronated foot or referred to as a hypermobile foot.  Also look for muscle weakness to the intrinsics and extrinsics of the feet, ligamentous laxity, previous trauma, muscle paralysis, and a dropped talar head.  A medial rotation of the hip or medial tibial torsion can also result in flat feet.

7.Pes Cavus/Rigid foot: easily referred to as an over supinated foot and a high, rigid arch.  Often the result of congenital deformity or neurological impairment (e.g. spina bifid, Charcot-Marie-Tooth). Can also be the result of muscle imbalances and/or a genetic predisposition for “high arches”.

The ankle/foot is an enigmatic and often confusing joint to assess and successfully evaluate. Given the many stresses we put on our feet and the numerous motions capable in the foot, knowing the subtle clues to point you in the right direction can be all the difference in a patient’s outcome

One last note to consider is a patient’s shoe.  If the patient comes to you with brand new shoes ask for a used well-worn pair to examine.  The locations of wear and tear on the footwear can also point you in the direction of success.  In a “normal” foot the greatest wear is usually beneath the balls of the feet and slightly to the lateral and posterolateral side of the shoe.  Deviations such as excessive bulging of the shoes medially are indicative of excessive pronation while the reverse is indicative of excessive supination.  All facets of the feet with shoes on and off should be considered to deliver successful and efficient care for our patients.

Reference: Orthopedic Physical Assessment. Chapter 13. David J. Magee, 2008.