Lecture #135: DPR: History and Physical Exam of the Ankle and Foot

What are the principal joints of the ankle?

The principal joints are the tibiotalar joint and the subtalar, or talocalcaneal, joint.

What are the principal landmarks of the ankle?

The main landmarks are the medial malleolus, lateral malleolus, and calcaneus.

What is the longitudinal arch of the foot?

The longitudinal arch spans from the calcaneus along the tarsal bones to the metatarsals and toes and helps support weight bearing.

What bones make up the hindfoot?

The hindfoot consists of the calcaneus and talus and contains the subtalar joint.

What bones make up the midfoot?

The midfoot consists of the navicular, cuboid, and three cuneiform bones.

What joints allow inversion and eversion in the midfoot?

The calcaneocuboid and talocalcaneonavicular joints allow inversion and eversion of the foot.

What structures make up the forefoot?

The forefoot includes the five metatarsals and all the phalanges.

What joints are in toes 2 through 5?

Toes 2 through 5 have metatarsophalangeal joints, proximal interphalangeal joints, and distal interphalangeal joints.

What joints are in the first toe?

The first toe has a metatarsophalangeal joint and an interphalangeal joint.

What muscles dorsiflex the ankle?

The main dorsiflexor is tibialis anterior, with extensor digitorum longus and extensor hallucis longus assisting as toe extensors and dorsiflexors.

What muscles plantarflex the ankle?

The main plantarflexors are the gastrocnemius, soleus, plantaris, and tibialis posterior.

What muscles flex the toes?

The deep posterior compartment contains flexor hallucis longus for the first toe and flexor digitorum longus for toes 2 through 5.

What muscles evert the foot?

The peroneus longus and peroneus brevis evert the foot and also contribute some plantarflexion.

Where does peroneus longus insert?

Peroneus longus inserts at the medial cuneiform and first metatarsal.

Where does peroneus brevis insert?

Peroneus brevis inserts on the base of the fifth metatarsal.

What is the function of the intrinsic foot muscles?

Intrinsic foot muscles lie distal to the ankle on the plantar surface, help move the toes, and help maintain the arch of the foot.

What history questions are emphasized for ankle and foot pain?

Ask whether the problem is acute or chronic, the nature and circumstances of injury, foot and ankle position at injury, whether there was a snap or pop, whether pain and swelling were immediate, have the patient point to the pain, and use OPQRST.

What chronic-use history points are important for foot and ankle complaints?

Ask whether a chronic injury started as an acute injury that never healed, how much activity the patient performs daily or weekly, what footwear is used and for how long, and how the pain has progressed.

What should be inspected on the ankle and foot exam?

Observe ambulation with shoes and socks removed, note swelling, erythema, ecchymosis, visibility of bony landmarks, skin lesions, blisters, ingrown toenails, distal toe discoloration, and shoe wear patterns.

Why are shoe wear patterns important on ankle and foot exam?

Shoe wear patterns can reveal underpronation, normal mechanics, or overpronation and may help explain pain or abnormal biomechanics.

What is the general palpation approach for the ankle and foot?

Begin just below the knee, palpate the full length of the lower leg, palpate the proximal fibula and tibia down to the malleoli, then palpate bones and ligaments for tenderness or instability.

What landmarks should be palpated on the ankle and foot?

Key landmarks are the lateral and medial malleoli, calcaneus, talar head, navicular, cuboid, first metatarsal, first metatarsophalangeal joint, styloid process of the fifth metatarsal, deltoid ligament, anterior talofibular ligament, calcaneofibular ligament, and Achilles tendon.

How should ankle and foot range of motion be assessed?

ROM should be tested actively and passively, compared bilaterally, and recorded in degrees.

What movements are included in ankle and foot ROM testing?

ROM includes plantarflexion, dorsiflexion, inversion, and eversion.

What muscles produce plantarflexion?

Plantarflexion is produced mainly by gastrocnemius, soleus, plantaris, and tibialis posterior.

What muscles produce dorsiflexion?

Dorsiflexion is produced mainly by tibialis anterior, extensor digitorum longus, and extensor hallucis longus.

What muscles produce inversion?

Inversion is produced mainly by tibialis posterior and tibialis anterior.

What muscles produce eversion?

Eversion is produced mainly by peroneus longus and peroneus brevis.

How is ankle and foot strength tested?

Strength is tested bilaterally on skin exam with active movement against examiner resistance, especially plantarflexion and dorsiflexion.

How is the anterior drawer test of the ankle performed?

With the affected foot off the table, the examiner cups the heel, places the other hand on the anterior tibia, and applies a posterior-to-anterior force to assess anterior talofibular ligament integrity.

What is a positive anterior drawer test at the ankle?

Anterior translation of the ankle without a firm endpoint indicates ATFL tear or disruption with laxity, while pain alone may indicate a mild sprain.

How is the talar tilt test performed?

In the same position as the anterior drawer, the examiner stabilizes the lower leg and inverts the talus to assess range of motion and lateral ligament integrity.

What does a positive talar tilt test indicate?

Increased laxity, excessive tilt, or pain compared with the unaffected side suggests ATFL and calcaneofibular ligament tear or disruption, while pain alone may indicate a mild sprain.

How is the eversion test performed at the ankle?

With the ankle stabilized as in the anterior drawer position, the examiner everts the foot to assess medial ankle motion and deltoid ligament integrity.

What does a positive eversion test indicate?

Laxity, increased range of motion, or pain at end range compared with the other side suggests deltoid ligament tear or disruption, while pain alone may indicate a mild sprain.

How is Kleiger’s external rotation test performed?

With the patient seated, the examiner stabilizes the anterior tibia and externally rotates the foot, including the talus, against the lower leg.

What does a positive external rotation, Kleiger’s, test indicate?

Pain along the syndesmosis suggests syndesmosis tear or disruption, while pain along the medial ankle suggests medial deltoid ligament tear or disruption.

How is the syndesmosis squeeze test performed?

The examiner places the thenar eminence of one hand on the tibial shaft and the other on the fibular shaft, squeezes for 2 to 3 seconds, then releases briskly.

What does a positive squeeze test indicate?

Pain at the level of the syndesmosis indicates syndesmosis tear or disruption.

How is the Thompson test performed?

With the patient prone and the distal lower leg hanging off the table, the examiner squeezes the gastrocnemius and watches for plantarflexion.

What does a positive Thompson test indicate?

Absence of plantarflexion with calf squeeze indicates Achilles tendon rupture.

How is the tibiotalar shuck, Cotton’s, test performed?

One hand stabilizes the lower leg while the other grasps the talus from underneath and moves it medially and laterally.

What does a positive tibiotalar shuck, Cotton’s, test indicate?

Pain and or laxity compared with the nonaffected side suggests syndesmosis injury or disruption, also called a high ankle sprain.

How is leg length measured in the ankle and foot exam?

With the patient relaxed and symmetrically aligned supine with legs extended, measure from the ASIS to the medial malleolus with the tape crossing the medial side of the knee.

What are the key components of the ankle and foot neurovascular exam?

The neurovascular exam includes deep tendon reflexes, sensory testing, and vascular assessment.

What reflexes are tested in the ankle and foot neuro exam?

L4 is tested with the patellar reflex, there is no standard L5 reflex, and S1 is tested with the Achilles reflex.

What dermatomes are tested in ankle and foot sensory exam?

L4 corresponds to the medial foot, L5 to the dorsal foot, and S1 to the lateral foot.

What pulses are checked in the ankle and foot vascular exam?

The dorsalis pedis and posterior tibial pulses should be assessed.

What common ankle and foot conditions are highlighted in the lecture?

Common conditions include lateral and medial ankle sprains, tendinitis, gastrocnemius or soleus strain, plantar fasciitis, chronic exertional compartment syndrome, and medial tibial stress syndrome.

What are the key features of Achilles tendinitis?

Achilles tendinitis occurs at or above the Achilles insertion, is due to microtrauma, causes heel pain worse with push-off, and is tender to palpation.

How is Achilles tendinitis treated according to the lecture?

Treatment includes rest, ice, NSAIDs, exercises, and a heel lift, and cortisone shots should be avoided.

What is the greatest risk factor for ankle sprain?

The greatest risk factor for ankle sprain is a previous ankle sprain.

What is the usual mechanism of most ankle sprains?

Most ankle sprains injure the lateral ligaments and occur with inversion of the ankle plus some degree of plantarflexion.

What are common findings in ankle sprain?

Tenderness, swelling, and ecchymosis are common.

What do the Ottawa ankle rules say for ankle radiographs?

Ankle radiographs are indicated if there is pain in the malleolar zone plus either bony tenderness over a potential fracture site or inability to bear weight for four steps immediately after injury and in the office or emergency department.

What do the Ottawa foot rules say for foot radiographs?

Foot radiographs are indicated if there is pain in the midfoot zone plus either bony tenderness at the base of the fifth metatarsal or navicular, or inability to bear weight for four steps immediately after injury and in the office or emergency department.

What structures make up the tibiofibular syndesmosis?

The syndesmosis includes the anterior tibiofibular ligament, posterior superficial and deep tibiofibular ligaments, and the interosseous membrane.

What mechanism is common in high, syndesmotic, ankle sprain?

The mechanism is often similar to a lateral sprain but usually includes an added rotational component.

What tests were specifically discussed for diagnosing high ankle sprain?

The lecture specifically names the tibiotalar shuck test and external rotation test, with additional squeeze testing and the crossed-leg test.

What is the treatment of acute ankle sprain in this lecture?

Treatment includes RICE, ice, an air stirrup brace or lace-up support, early range-of-motion exercises, functional mobilization with weight bearing as tolerated, pain medications as tolerated, and OMM.

What measures help prevent recurrent ankle sprains?

Prevention includes follow-up at 4 to 6 weeks to assess instability, rehabilitation exercises, proprioceptive training, strengthening, and supports or taping.

What OMM approaches are mentioned for lymphatic congestion of the ankle or foot?

The lecture recommends improving restrictions, treating thoracic inlet dysfunction, rib raising, normalizing sympathetic activity, improving restrictions at the diaphragms, improving lymphatic flow, and using the pedal pump.

What sympathetic levels are emphasized in ankle and foot OMM?

L1 and L2 sympathetic ganglia are emphasized, and soft tissue paraspinal inhibition is noted to have autonomic effects similar to rib raising.