Foot & Ankle General Examination

Published July 2, 2026 Read time 4 min read Readers 3
Foot Ankle General Examination

History Taking

Age

  • Congenital talipes equinovarus (CTEV) is present since birth.
  • Talipes equinovarus (TEV) secondary to polio, neural tube defects, and other neurological conditions develops later.
  • Congenital vertical talus (CVT) is usually recognized when the child begins walking (around 1 year of age).

Sex

  • CTEV is more common in boys.

Pain

Assess the following characteristics:

  • Duration
  • Site
  • Radiation
  • Type
  • Character
  • Aggravating factors
  • Relieving factors
  • Diurnal variation
  • Postural variation

Swelling

Evaluate:

  • Duration
  • Onset (following trauma, fever, involvement of other joints, morning stiffness)
  • Progression
    • Progressive enlargement (suggests tumors)
    • Regressive swelling (common after trauma)
    • Intermittent swelling (may indicate infection)
  • Aggravating factors (e.g., walking in subtalar arthritis)
  • Relieving factors (e.g., antibiotics for infection, chemotherapy for tumors)
  • Response to previous treatment
  • Diurnal and postural variation
  • Presence of deformity in the opposite foot

Limp

Determine:

  • Onset
  • Duration
  • Painful or painless
  • Progressive or non-progressive

Instability

Assess:

  • Duration
  • Onset (especially after trauma)
  • Unilateral or bilateral involvement (may indicate generalized ligamentous laxity)
  • Whether instability occurs on even or uneven surfaces (common in a stiff subtalar joint)

Deformity

Evaluate:

  • Time of onset
    • Present at birth (CTEV)
    • Appeared later (acquired clubfoot)
    • Around walking age (CVT)
    • Following febrile illness with muscle weakness (polio)
  • Progression
    • Congenital deformities are generally less progressive than acquired deformities.
  • Previous treatment
    • Casting
    • Surgery
  • Response to treatment

Associated Diseases

  • Previous history of fever, myalgia, and limb weakness suggestive of poliomyelitis.

Inspection

Gait

Observe for:

  • Antalgic gait
  • Short-limb gait
  • Foot drop
  • Equinus gait
  • Stiff first metatarsophalangeal (MTP) joint

Anterior Aspect

  1. Alignment
    • Hallux valgus or hallux varus
    • Claw, hammer, or mallet toes
    • Relationship of the forefoot, midfoot, and hindfoot
    • Tibia vara
    • Tibial rotation
  2. Skin
    • Discoloration
    • Ulcers
    • Dilated veins
    • Edema (pitting or non-pitting)
  3. Toes
    • Loss of transverse skin creases (may occur in polio)
    • Corns (heloma durum)
    • Nail deformities from fungal infection
    • Paronychia
    • Ingrown toenail
  4. Bony Prominences
    • Medial osteophyte over the first MTP joint (bunion)
    • Lateral osteophyte over the fifth MTP joint (bunionette)
  5. Extensor Tendons
    • Observe extensor hallucis longus (EHL) and extensor digitorum longus (EDL) during active contraction.

Mnemonic: The Himalayas Are Not Dry Places

  • Tibialis Anterior
  • Extensor Hallucis Longus
  • Anterior Tibial Artery
  • Deep Peroneal Nerve
  • Extensor Digitorum Longus
  • Peroneus Tertius
  1. Malleoli Relationship
  • Normally the lateral malleolus lies lower and more posterior than the medial malleolus.
  1. Malleolar Swelling
  • Trauma
  • Tendinitis
  1. Anterior Tibia
  • Swelling
  • Deformity

Lateral Aspect

Inspect:

  • Lateral malleolus
  • Base of the fifth metatarsal
  • Achilles tendon
  • Peroneus brevis tendon
  • Any swelling or deformity

Posterior Aspect

  1. Hindfoot varus or valgus
  2. Too Many Toes Sign
  • More than two toes visible from behind indicates forefoot abduction, commonly associated with pes planus.
  1. Heel
  • Width
  • Shape
  • Position
  1. Ask the patient to stand on tiptoes.
  • Assess the windlass mechanism (arch elevation and hindfoot inversion).
  1. Examine:
  • Plantar fat pad
  • Calcaneal tuberosity
  • Haglund deformity (pump bump)
  1. Retrocalcaneal bursa
  • Look for bursitis.
  1. Achilles tendon
  • Tendinitis
  • Rupture (typically 2–6 cm proximal to insertion)
  • Swelling
  1. Calf Muscle
  • Compare for muscle wasting, which may occur in:
    • Residual CTEV
    • Achilles tendon rupture
    • Prolonged immobilization

Medial Aspect

  1. Medial longitudinal arch
  • Pes cavus
  • Pes planus
  • Rocker-bottom deformity
  1. Bony landmarks
  • Medial malleolus
  • First metatarsal head
  • Calcaneal tuberosity
  • Navicular tuberosity
  1. Tibialis posterior tendon

Mnemonic: The Doctors Are Never Happy

  • Tibialis Posterior
  • Flexor Digitorum Longus
  • Posterior Tibial Artery
  • Posterior Tibial Nerve
  • Flexor Hallucis Longus

Plantar Aspect

  • Callosities indicating abnormal weight-bearing
  • Painful metatarsal calluses
  • Corns (hard or soft)
  • Ulcers (especially diabetic ulcers)
  • Plantar warts
  • Tinea pedis

Palpation

Anterior

  • Local temperature
  • Tenderness over:
    • Tibial crest (stress fracture)
    • Talar dome (osteochondral lesion)
    • Navicular (Köhler disease)
    • Talonavicular joint
    • Cuneiforms
    • Metatarsals
    • First MTP joint
    • Second MTP joint (Freiberg disease)
  • Morton neuroma tenderness between the third and fourth metatarsal heads
  • Swelling
  • Joint effusion
  • Extensor tendons
  • Corns and ingrown toenails
  • Tinel sign over the deep peroneal nerve (anterior tarsal tunnel syndrome)

Lateral

Palpate:

  • Lateral malleolus
  • Anterior talofibular ligament
  • Calcaneofibular ligament
  • Peroneal tendons
  • Calcaneus
  • Calcaneocuboid joint
  • Sinus tarsi
  • Fibular shaft

Posterior

  • Gastrocnemius-soleus complex
  • Achilles tendon
  • Retrocalcaneal bursa

Medial

Palpate:

  • Medial malleolus
  • Subcutaneous tibial border
  • Talar head
  • Navicular tuberosity
  • Flexor hallucis longus
  • Flexor digitorum longus
  • Tibialis posterior tendon
  • Tinel sign over the posterior tibial nerve and plantar nerves

Plantar

Assess:

  • Tender callosities
  • Sesamoid tenderness
  • Plantar fascia tenderness
  • Plantar fibromatosis nodules
  • Plantar fat pad tenderness

Range of Motion

Ankle

Evaluate:

  • Dorsiflexion: 20°
  • Plantar flexion: 50°

Assess passive dorsiflexion with the knee both extended and flexed when equinus deformity is present.

Interpretation:

  • Increased dorsiflexion with knee flexion → isolated gastrocnemius tightness.
  • No change → isolated soleus contracture.
  • Partial improvement but persistent limitation → combined gastrocnemius and soleus tightness.

Subtalar Joint

Assess:

  • Inversion: 40°
  • Eversion: 20°

The examination is best performed with the patient prone while stabilizing the talus.

Forefoot

Evaluate:

  • Abduction
  • Adduction

The calcaneus should be maintained in a neutral position.

Great Toe

Metatarsophalangeal (MTP) Joint:

  • Extension: 70°
  • Flexion: 45°

Interphalangeal (IP) Joint:

  • Flexion: 90°
  • Extension: 0°

Lesser Toes

Assess:

  • Flexion and extension at the interphalangeal joints (40°)
  • Flexion (40°) and extension (0°) at the MTP joints
  • Toe abduction
  • Toe adduction toward the second toe