Ankle and Foot OSCE Examination

1. Introduction
2. General Inspection
3. Look (Inspection)
4. Gait Assessment
5. Feel (Palpation)
6. Move (Range of Movement)
7. Special Tests
8. Neurovascular Assessment
9. Completing the Examination
10. Quiz

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient's details, taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail. A useful way to explain it is "I would like to look at your ankles and feet, feel for any tender areas, and then ask you to move them and walk a few steps. Is that alright?".

Adequately expose both lower limbs from the knees down, so that the knees, ankles and feet can be compared side to side. The patient should also have their footwear and socks removed, as the shoes themselves give valuable clues (see General Inspection).

Position the patient sitting on the edge of the couch initially, but remember that a complete examination requires the patient to stand and walk, so ensure they are able and well enough to do so.

Ask the patient if they have any pain anywhere before you begin, and watch their face for discomfort throughout. This is both good practice and avoids you losing marks for causing the patient pain.

Begin with a general inspection of the patient from the end of the bed. Assess whether the patient looks comfortable or is in pain, and note their general wellbeing and body habitus (a raised body weight loads the foot and is relevant to conditions such as gout and tibialis posterior dysfunction). A patient who is systemically unwell with a hot, swollen joint may have septic arthritis or gout, both of which are important not to miss.

Look around the bedside for objects and clues:

• Mobility aids such as walking sticks, crutches, a frame or a wheelchair, which indicate the degree of functional impairment.
• Orthotic devices such as ankle-foot orthoses (AFOs), insoles or a moon boot, which suggest an existing diagnosis such as foot drop or a healing fracture.
• Footwear — examine the patient's shoes for asymmetrical wear of the sole, which reflects an abnormal gait or weight-bearing pattern, and for any custom adaptations.
• Prescriptions or medications at the bedside, such as analgesia or disease-modifying anti-rheumatic drugs (DMARDs), hinting at conditions like rheumatoid arthritis.

Inspection should be performed both with the patient standing (weight-bearing) and sitting/lying (non-weight-bearing), as some abnormalities only become apparent when the foot is loaded. Ask the patient to stand and inspect the feet and ankles from the front, sides and behind, then re-inspect with the patient seated.

From the front, look at the skin and toes for:

• Scars, suggesting previous surgery or trauma.
• Swelling, which may be generalised (suggesting effusion or oedema) or localised to a single joint (suggesting arthritis, gout or infection).
• Skin changes such as erythema (infection or active inflammation), psoriatic plaques on extensor surfaces (associated with psoriatic arthritis), and ulceration or calluses, which form over areas of abnormal pressure and are particularly important in diabetic and neuropathic feet.
• Toe deformities such as hallux valgus (lateral deviation of the great toe with a prominent medial bunion) and, less commonly, hallux varus (medial deviation), along with claw toes, hammer toes and mallet toes (fixed flexion deformities differing in which toe joint is buckled). These are commonly seen in rheumatoid arthritis and in feet subjected to poorly fitting footwear.
• Nail changes such as pitting and onycholysis (psoriasis) or fungal involvement.

Image - Hallux valgus, showing lateral deviation of the great toe and a prominent medial bony bump (bunion). This deformity is common in rheumatoid arthritis and is exacerbated by narrow footwear

Creative commons source by Lamiot [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

From the sides, assess the medial longitudinal arch:

• A flattened arch (pes planus, or flat foot) occurs when the arch collapses towards the floor. It may be flexible and asymptomatic, or rigid. New, painful, unilateral flat foot in an adult should raise suspicion of tibialis posterior tendon dysfunction, as this tendon is the key dynamic support of the medial arch.
• An abnormally high arch (pes cavus) is associated with neuromuscular conditions such as Charcot-Marie-Tooth disease and other causes of muscle imbalance in the foot.

From behind, inspect the heel and Achilles tendon for:

• Hindfoot alignment — the heel should lie in slight valgus (a few degrees pointing outward). Excessive valgus is seen with a collapsing flat foot, while varus (heel pointing inward) is seen with pes cavus.
• The "too many toes" sign — when standing behind the patient, more toes than usual are visible lateral to the heel. This reflects forefoot abduction and hindfoot valgus and is a sign of tibialis posterior dysfunction.
• Calf muscle wasting, suggesting disuse, a chronic tendon problem or a lower motor neuron lesion.
• Swelling or a gap in the line of the Achilles tendon, which may indicate a rupture.

Finally, inspect between the toes and the soles for maceration, ulceration, calluses and signs of infection — areas that are easy to forget but clinically vital, especially in diabetic patients.

Image - A neuropathic ulcer on the sole, sitting over a high-pressure area. Ulcers like this are painless because of the underlying sensory neuropathy, which is exactly why inspecting the soles and between the toes must never be skipped in a diabetic foot

SimpleMed original image, credit 'SimpleMed original'

Ask the patient to walk to the end of the room, turn, and walk back while you observe. A normal gait cycle is divided into a stance phase (the foot is on the ground) and a swing phase (the foot is moving forward), and abnormalities at any point give clues to the underlying problem.

Look specifically at:

• The stance phase — is it shortened on one side because weight-bearing is painful? This produces an antalgic (painful) gait, in which the patient spends as little time as possible on the affected limb.
• The swing phase and heel strike — a patient with foot drop (weak ankle dorsiflexion, classically from a common peroneal nerve palsy or an L5 radiculopathy) cannot lift the foot clear of the floor, so they lift the knee high (a high-stepping gait) and the foot may slap down.
• Push-off — weakness of plantarflexion, for example after an Achilles tendon rupture, reduces the power of toe-off.
• Width of gait and stability — a broad-based gait may indicate poor proprioception or a neurological cause.

You can also ask the patient to walk on their heels (tests ankle dorsiflexion, and therefore the deep peroneal nerve and L4/L5) and walk on their tiptoes (tests plantarflexion and calf power, and therefore the tibial nerve and S1, as well as the integrity of the Achilles tendon). An inability to tiptoe walk is a useful screening sign for both Achilles pathology and S1 weakness.

Before palpating, ask again about pain and watch the patient's face. Begin by assessing temperature, running the back of your hand along the leg, ankle and foot and comparing sides. Increased warmth over a joint suggests active inflammation or infection, whereas a cold foot raises concern about arterial insufficiency.

Systematically palpate the bony and soft tissue structures, feeling for tenderness, swelling and irregularity:

• The malleoli (medial and lateral) and the ankle joint line.
• The Achilles tendon — tenderness and thickening suggest Achilles tendinopathy, while a palpable gap suggests rupture.
• The medial structures, including the course of the tibialis posterior tendon behind the medial malleolus.
• The lateral ligament complex (anterior talofibular ligament in particular), which is the most commonly injured ligament in an inversion ankle sprain.
• The midfoot and tarsal bones, the base of the fifth metatarsal (a common avulsion fracture site) and the metatarsals.
• The metatarsophalangeal (MTP) joints — squeeze across the MTP joints; pain here (a positive "squeeze test") is an early sign of rheumatoid arthritis. The first MTP joint is the classic site of gout (podagra).

Where there is swelling around the ankle, you can attempt to detect an effusion. Palpation should be reasoned: localising tenderness to a specific structure allows you to differentiate, for example, a ligament sprain from a bony fracture or a tendon problem.

Preview the Ankle and Foot OSCE Examination quiz