Fellow Level Foot and Ankle Exam Techniques
By: Gregory Rubin, DO
Like many other physical exam techniques in orthopedics, learning how to properly examine takes years to cultivate and master. However, we all must start with the basics as we start our training. The following six physical exam techniques will help get you off on the right foot.
1) Sub-talar rocking
The sub-talar joint is frequently neglected in medical education. The sub-talar joint is also known as the talocalcaneal joint. The sub-talar joint can develop degenerative changes that can lead to ankle pain. The talocalcaneal joint translates with the hindfoot during inversion and eversion (1). In order to assess the motion of the talocalcaneal joint, you should first grasp the calcaneus with one hand and the forefoot with the other. Then, the ankle is placed in neutral dorsiflexion (1). Subtalar motion should then be assessed by rocking it laterally and medially. A positive test would be a restriction in the range of motion. We typically expect more inversion than eversion (1).
2) Too many toes sign
An acquired flat foot deformity occurs due to posterior tibialis tendon degeneration (2). When evaluating a foot for hindfoot deformity, the too many toes sign can be used. While standing behind a patient, the physician needs to see how many toes are visible on the lateral portion of the foot. A positive test occurs when there is excessive forefoot abduction, giving the examiner the ability to see the third, fourth, and fifth phalanx. In a foot without an acquired flat foot deformity, or pes planus, only one or two of the lateral toes should be seen (6). The too many toes sign can also be seen in a patient with pes planus, so it is important to check both feet to see if there is asymmetry between them to suggest an acquired deformity in one foot (6).
3) External rotation stress test
There are many tests that aid in diagnosing a high ankle sprain. The role of physical exam tests for a high ankle sprain is to assess if there has been an injury to the syndesmotic ligaments. A positive external rotation stress test has been associated with longer recovery times in patients compared to lateral ankle sprains (11). The external rotation stress test is done with the patient seated and their legs hanging off the tables with their knee bent to 90 degrees (3). The tibia should be secured, but not the fibula. The ankle is then externally rotated and a positive test is pain and separation at the distal tibiofibular joint (3, 7).
4) Squeeze test
Another special test looking for a high ankle sprain is the squeeze test. To perform a squeeze test, the patient is seated with his knees hanging off of the table at 90 degrees (3). Then, the provider should externally squeeze the mid calf at the area above the midpoint of the calf (3). A positive test is pain at the level of the ankle. Pain would suggest a syndesmotic injury (7). Compared to the external rotation stress test, the squeeze test has a lower specificity (7).
5) Talar tilt
The talar tilt test is used when evaluating for injury to the calcaneofibular and anterior talofibular ligament (6). One hand is used to stabilize the distal tibia and the other hand grasps the patient’s heel. The patient’s ankle is then stressed with a varus force in order to assess for ligament laxity (6). Both ankles should be assessed and a difference greater than 10 degrees would be a positive test (6).
6) Anterior drawer
The anterior drawer test helps to determine ligament laxity in lateral ankle sprains. The patient should be seated with their legs hanging off the table at 90 degrees (9). One hand will grasp the patient’s heel and plantar flex the ankle to 10 degrees (9). The other hand will be holding the distal portion of the tibia (9). Gentle translation forward is applied to the heel. The physician is evaluating for a dimple to appear just anterior to the lateral malleolus, which would suggest a rupture of the anterior talofibular ligament (9).
1) Schumer, Ross, and Mederic Hall. “Physical Examination of the Foot and Ankle .” Musculoskeletal Physical Examination: An Evidence-Based Approach, vol. 10, pp. 199–217.
2) Richie, Douglas. “Biomechanics and Orthotic Treatment of the Adult Acquired Flatfoot.” Clinics in Podiatric Medicine and Surgery, vol. 37, no. 1, Jan. 2020, pp. 71–89. PubMed, doi:10.1016/j.cpm.2019.08.007.
3) Hunt, Kenneth J., et al. “High Ankle Sprains and Syndesmotic Injuries in Athletes.” The Journal of the American Academy of Orthopaedic Surgeons, vol. 23, no. 11, Nov. 2015, pp. 661–73. PubMed, doi:10.5435/JAAOS-D-13-00135.
4) Seligson, David, et al. “Ankle Instability: Evaluation of the Lateral Ligaments:” The American Journal of Sports Medicine, Apr. 2016. world, journals.sagepub.com, doi:10.1177/036354658000800107.
5) Papaliodis, Dean N., et al. “The Foot and Ankle Examination.” The Medical Clinics of North America, vol. 98, no. 2, Mar. 2014, pp. 181–204. PubMed, doi:10.1016/j.mcna.2013.10.001.
6) Young, Craig C., et al. “Clinical Examination of the Foot and Ankle.” Primary Care, vol. 32, no. 1, Mar. 2005, pp. 105–32. PubMed, doi:10.1016/j.pop.2004.11.002.
7) Miller, Timothy L., and Timothy Skalak. “Evaluation and Treatment Recommendations for Acute Injuries to the Ankle Syndesmosis without Associated Fracture.” Sports Medicine (Auckland, N.Z.), vol. 44, no. 2, Feb. 2014, pp. 179–88. PubMed, doi:10.1007/s40279-013-0106-1.
8) Vuurberg, Gwendolyn, et al. “Diagnosis, Treatment and Prevention of Ankle Sprains: Update of an Evidence-Based Clinical Guideline.” British Journal of Sports Medicine, vol. 52, no. 15, Aug. 2018, p. 956. PubMed, doi:10.1136/bjsports-2017-098106.
9) van Dijk, C. N., et al. “Physical Examination Is Sufficient for the Diagnosis of Sprained Ankles.” The Journal of Bone and Joint Surgery. British Volume, vol. 78-B, no. 6, Nov. 1996, pp. 958–62. online.boneandjoint.org.uk (Atypon), doi:10.1302/0301-620X.78B6.0780958.
11) Alonso, A. , Khoury, L. , Adams, R. Clinical tests for ankle syndesmosis injury: reliability and prediction of return to function. J Orthop Sports Phys Ther.1998;27:276–284.