Foot & Ankle Physical Exam: A Fast, Structured Walkthrough

Dr. Wang lays out a practical, clinician-friendly foot and ankle exam using the classic flow: inspection → palpation → range of motion → special tests. Here’s the distilled playbook.

1) Inspection (standing and supine)

Standing (360° look):

• Alignment & deformity: toe rotation, valgus/varus, hallux valgus, claw/hammer/mallet toes.
• Arch/biomechanics: compare arches side to side. Use a quick “finger under the arch” screen; relative pes planus is often obvious visually.
• “Too many toes” sign: from behind, seeing more lateral toes on one side suggests posterior tibialis dysfunction and medial arch collapse.
• Heel rise test: during plantarflexion, a subtle lateral shift of the ankle/medial heel at end-range is normal; loss of this excursion suggests hindfoot/ subtalar instability.
• Tendons/bursae: look for fusiform thickening of the Achilles and swelling in the retrocalcaneal bursa.

Supine:

• Survey for edema (check pitting), erythema, ecchymosis (often migrates distally over days), and focal swelling over joints/tendons.

2) Palpation (think quadrants)

Patients often localize pain precisely—use that advantage.

Anterior:

• Joint line (tibiotalar) vs extensor tendons (TA, EDL, EHL).
• Tarsometatarsal (TMT/Lisfranc) region: anatomy is dense; identify the tender point, then correlate with imaging or ultrasound to map talus → navicular → cuneiforms → metatarsals.

Medial:

• Deltoid ligament (proximal to malleolus) and sustentaculum tali (just inferior)—common tender spots.
• Behind the medial malleolus (Tom, Dick, AN, Tom): TP (most commonly symptomatic), FDL, artery/veins/nerve, FHL. Trap TP against bone to provoke focal tenderness.
• Spring ligament and navicular plantar-medial tenderness; plantar fascia origin just anteromedial to the calcaneal tuberosity.

Lateral:

• ATFL (from lateral malleolus toward big toe)—hallmark tenderness after inversion sprain.
• Sinus tarsi (anterior–inferior “divot”): deep ligament pain in repetitive inversion injuries (sinus tarsi syndrome).
• Peroneals behind the malleolus; look for retinacular pain, popping/subluxation, and fibularis brevis insertion pain at the base of the 5th metatarsal (differentiate stress/“marcher’s” fracture vs Jones avulsion).

Posterior/Plantar:

• Achilles: watershed zone 2–6 cm proximal to insertion is classic for tendinopathy; fusiform swelling is typical.
• Plantar fascia (medial > lateral band), plantar plate tenderness (apply distal-to-proximal directed pressure), sesamoids (medial/lateral).

3) Range of Motion (ROM)

• Dorsiflexion/Plantarflexion: posterior chain tightness vs anterior impingement; dancers may report posterior impingement in PF.
• Inversion/Eversion: inversion stresses ATFL/CFL; eversion is less common but can be painful with deltoid injury.
• Midfoot/forefoot torsion: assess pronation–supination mechanics.
• Hallux MTP: screen for hallux rigidus/limitus (loss of extension most common).

4) Special Tests

• Thompson test: prone calf squeeze → absent PF = Achilles rupture.
• Anterior drawer: calcaneus forward on stabilized tibia → ATFL laxity.
• Talar tilt (inversion stress): targets CFL.
• External rotation stress test: stabilizes tibia, externally rotates foot → distal pain (and sometimes proximal fibular symptoms) suggests syndesmotic (“high ankle”) sprain.
• Metatarsal torsion test: invert/evert forefoot while stabilizing midfoot—reproduces pain/laxity at TMT joints.
• Intermetatarsal shear: isolate motion between adjacent metatarsals to detect intermetatarsal ligament sprain.
• Metatarsal squeeze (Morton’s neuroma): ML compression of distal metatarsals with head stabilization → neuropathic pain/paresthesia.
• Grind tests (axial load + circumduction): sensitive for MTP/IP arthropathy—start gently.

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Pearls

• Let patient-pointed tenderness guide you; the foot’s localization is often exact.
• Map pain by quadrant, then confirm with ultrasound or plain films for joint/tendon differentiation.
• Don’t miss posterior tibialis dysfunction, sinus tarsi syndrome, Achilles watershed tendinopathy, 5th metatarsal base fractures, and syndesmotic injury—they change management.