Ankle examination

1.Look
General inspection
1. Body habitus: obesity is a significant risk factor for joint pathology
due to increased mechanical load (e.g. osteoarthritis).
2. Scars: may provide clues regarding previous lower limb surgery.
3. Wasting of muscles: suggestive of disuse atrophy secondary to joint
pathology or a lower motor neuron injury.
Gait
1. Gait cycle: note any abnormalities of the gait cycle (e.g.
abnormalities in toe-off or heel strike).
2. Range of movement: often reduced in the context of chronic joint
pathology (e.g. osteoarthritis, inflammatory arthritis).
3. Limping: may suggest joint pain (i.e. antalgic gait), weakness or joint
instability (e.g. ligamentous injury).
4. Leg length: note any discrepancy which may be the cause or the
result of joint pathology.
5. Turning: patients with joint disease may turn slowly due to
restrictions in joint range of movement or instability.
6. Height of steps: high-stepping gait is associated with foot drop,
which can be caused by peroneal nerve palsy (e.g. trauma, surgery).
Ask the patient to walk on their tip-toes and then on their heels to
further screen for pathology. Patient’s with arthritis or lower limb muscle
weakness will struggle to perform these tasks.
Closer inspection of the ankles and feet
Anterior inspection
1. Scars: note the location of scars as they may provide clues as to the
patient’s previous surgical history or indicate previous joint trauma.
2. Bruising: suggestive of recent trauma or spontaneous
haemarthrosis (e.g. patients on anticoagulants or with clotting
disorders such as haemophilia).
3. Swelling: note any evidence of asymmetry in the size of the ankle
joints that may suggest unilateral swelling (e.g. effusion,
inflammatory arthropathy, septic arthritis, haemarthrosis, Charcot
joint).
4. Psoriasis plaques: typically present over extensor surfaces and
important to note due to the association with psoriatic arthritis.
5. Fixed flexion deformity of the toes: subtypes include hammer-toe
and mallet-toe.
6. Big toe misalignment: note any evidence of lateral (hallux
valgus/bunion) or medial (hallux varus) big toe angulation.
7. Calluses: thickened, hardened skin that develops as a result of
repetitive friction which may be caused by poorly fitting footwear or
a gait abnormality.
Lateral inspection
Foot arch: inspect for evidence of flat feet (pes planus) or an abnormally
raised foot arch (pes cavus).
Posterior inspection
Scars: again look for scars indicative of previous trauma or surgery.
Muscle wasting: inspect for any asymmetry in the muscle bulk of the
posterior compartment of the lower leg suggestive of disuse atrophy or a
lower motor neuron lesion.
Heel misalignment: may be caused by a valgus or varus deformity of the
ankle joint.
Achilles tendon: discontinuity and swelling may indicate tendonitis
and/or rupture.

Feel
1.Temperature
Assess and compare ankle joint and foot temperature using the back of
your hands.
Increased temperature of a joint, particularly if also associated with
swelling and tenderness may indicate septic arthritis or inflammatory
arthritis.

2.Pulses
Posterior tibial pulse
Dorsalis pedis pulse
3.Metatarsophalangeal joint squeeze
Gently squeeze across the metatarsophalangeal (MTP) joints and observe
for verbal and non-verbal signs of discomfort. Tenderness is suggestive
of active inflammatory arthropathy.

4.Ankle and foot palpation

Palpate the ankle joints and the various joints/bones of each foot, noting
any swelling, irregularity or tenderness:
Metatarsal and tarsal bones
Tarsal joint
Ankle joint
Subtalar joint
Calcaneum
Medial/lateral malleoli
Distal fibula

5.Achilles tendon palpation

Palpate the gastrocnemius muscle and the Achilles tendon:
Note any focal tenderness or swelling suggestive of tendonitis.
Note any discontinuity in the tendon suggestive of rupture.
Move
Active and passive movement
1. Foot plantarflexion.
2. Foot dorsiflexion.
3. Toe flexion.
4. Toe extension.
5. Ankle/foot inversion.
6. Ankle/foot eversion.

Passive movement only

Special tests
Thompson test
is used to assess for clinical evidence of Achilles tendon rupture:
1. Ask the patient to kneel on a chair with their feet hanging over the
edge.
2. Squeeze each of the patient’s calves in turn.
No movement suggest tendon rupture.
Anterior Drawer Test
This test is used to assess the anterior talofibular ligament of the lateral
ligament complex To detect ligament laxity.

Morton test (metatarsal squeeze test)

Peroneal tendon
Post. Tibial tendon.