Video Summary - Comprehensive Foot and Ankle Examination

Main ideas and lessons (comprehensive foot/ankle exam workflow)

The presenter emphasizes that the foot and ankle exam is complex (roughly 26 bones and ~33 joints), and can feel daunting—especially in settings where foot/ankle subspecialty training is limited.

They propose a practical, repeatable structure:

Good exposure (see the knees and feet/ankles; ideally topless to also examine the back)
Footwear assessment first (to infer biomechanical problems and deformities)
Gait assessment (pattern recognition of common gait abnormalities)
Inspection from multiple views (front, side, back): alignment, muscle wasting, scars, and toe/forefoot deformities
Inspect the plantar surface (“sole mirror”) for callosities and abnormal pressure distribution
Palpation in a systematic order
- Pulses
- Sensation
- Then structured tenderness by anatomic region
Range of motion (ROM)
- Active first, then passive using joint-locking positions to isolate joints
Muscle/tendon function testing (using positions to isolate specific tendons)
Special tests to confirm or differentiate key diagnoses

Methodology / step-by-step instruction

1) Exposure / setup

Have the patient wear shorts so that knees and feet/ankles are visible.
Prefer the patient is topless so you can examine the back (back pathology can contribute to foot/ankle deformity/disease).
Ensure you can see both knees and both feet, and examine the back as well.

2) First step: footwear examination (before physical foot exam)

Assess whether footwear is:

Custom-made vs ready-made

Then evaluate:

Shoe type
Inside sole/insole and any modifications
Shoe bottom wear pattern

Use wear patterns as biomechanical clues:

Cavus foot → increased wear on the outside
Planus/overpronation → inside wear; external border may be relatively spared
Conus / contracture-type heel not landing → more wear at the front
Calcaneus → more wear at the heel region
Hallux valgus with specific shoe wear → indirect evidence for why the deformity happened (deformity + wear pattern context)

Key lesson: footwear provides diagnostic biomechanical hints—inspect it carefully first.

3) Gait assessment

Ask the patient to walk.
Assess:
- Is gait normal?
- Foot progression angle (foot path relative to midline)
  - Typical: slight external rotation (near “neutral” progression)
  - Negative foot progression angle suggests rotational abnormality (e.g., posterior/femoral contributors)
- Heel strike
- Flat feet
- Toe-off adequacy
Recognize gait patterns:
- Antalgic gait: decreased stance time/stride length; avoids weight-bearing on the painful side
- Foot drop gait: “slap” as the foot hits ground due to poor dorsiflexion
- Reduced toe-off: e.g., hallux rigidus/big toe arthritis → decreased toe-off and altered gait

4) Inspection (front → side → back)

A) From the front

Check coronal malalignment (patient stands straight; observe heel/knee alignment).
Evaluate knees:
- excessive valgus or varus can alter foot biomechanics
Assess rotational profile of both limbs.
Look for:
- muscle wasting
- deformities
- scars from previous surgery
Forefoot/hindfoot visual cues:
- Too much heel visibility suggests varus deformity (“positive peek-a-boo sign”).
Estimate arch visually:
- Rough criterion described: index finger should pass under the arch without touching
Assess both sides.

B) From the side

Look for muscle wasting:
- thigh, calf, and anterior compartment
Check:
- lateral fullness
- scars/incisions
Arch assessment:
- If arch appears flat, do a Jack test
  - Dorsiflex the big toe → observe whether the arch reconstitutes
- Flexible flatfoot: arch forms on toe dorsiflexion

C) From the back

First ensure there’s no abnormality in the back, since foot/ankle deformity may originate there.
Inspect for:
- calf wasting
- rotational deformity
- hindfoot alignment
  - Normal described as slight valgus (~5° referenced)
  - “Coming together” / too much inversion suggests slight varus
Toe visibility from back:
- Normally about one and a half toes
- If more: sign of planus/valgus and possible posterior dysfunction implication
Tiptoe assessment:
- Alignment can change on tiptoe (presenter notes varus correcting on tiptoe)

5) Forefoot toe inspection

Inspect for:

Bunion / hallux valgus
Hallux varus / helix varus (as described)
Callosities on pressure points
Lesser toe deformities:
- Hammer toe: PIP flexed, MCP slightly extended, DIP slightly extended (only PIP flexed)
- Claw toe: MCP hyperextension + proximal and distal IP flexion patterns
- Mallet toe: MCP and PIP near normal, DIP slightly flexed
Inspect between toes:
- fungal infection
- skin abnormalities (speaker mentions melanoma/“Nevis”)

6) Sole/palm inspection (pressure distribution)

Use the principle:

“Sole is the mirror of your foot.”

Normal weightbearing described as a tripod:

calcaneus (heel)
1st metatarsal
5th metatarsal

Abnormal pattern:

Shifting toward lesser metatarsals → callosities

Example:

Callosity under the 2nd–3rd toe area (classically around the 2nd metatarsal) suggests transverse metatarsalgia.

7) Palpation (feel part) + vascular + sensation before deep palpation

A) Pulses

Dorsalis pedis:
- lateral to extensor hallucis tendon
- between the 1st and 2nd metatarsal areas
Posterior tibial:
- behind the medial malleolus

B) Sensation check (rough)

Superficial peroneal nerve (between first webspace)
Deep peroneal nerve
Tibial (medial plantar), plantar branches, and lateral plantar
Sural nerve (outer aspect)

C) Systematic palpation by region

General approach: start posterior, then move systematically.

Posterior and heel-related targets:

Achilles tendon
- Feel for gap in injury (gap about an inch above insertion)
- Insertional vs non-insertional tendinitis clues:
  - bump above insertion → non-insertional
  - lateral bump/tenderness → insertional
Retrocalcaneal bursa
Haglund’s deformity
- lateral calcaneal tuberosity tenderness
“Impingement” area
- tenderness in certain athletes (e.g., footballers/ballet dancers)
- pain reduced with dorsiflexion performed to unload the impingement

Key medial side palpation:

Medial malleolus tenderness
Deltoid ligament tenderness
Plantar fascia insertion tenderness → plantar fasciitis
Posterior tibial tendon:
- pain/fullness/tenderness → tibialis posterior dysfunction
Flexor hallucis longus synovitis clue:
- toe plantarflexion OK, but dorsiflexion reproduces pain/restriction
Tarsal tunnel syndrome suspicion area:
- tingling or symptom reproduction when pressing behind medial malleolus (special tests follow later)

Anterior ankle palpation:

Anterior ankle and medial/lateral gutters
- suggests arthritis or osteochondral injury (talar dome)
Fullness
- may suggest synovitis/inflammatory pathology

Lateral ankle palpation:

Lateral malleolus tenderness
Lateral ligament complex:
- ATFL
- CFL
- PTFL
Peroneal tendons
- tenderness → tendinitis
Sinus tarsi tenderness
- can indicate joint pain
Calcaneus squeeze test
- pain may suggest calcaneal insufficiency/fracture

Midfoot palpation:

Talonavicular joint / accessory navicular
- bump and pain
Tarsal joints and individual tenderness by joint/metatarsal region
Principle: pinpoint tenderness helps localize pathology.

8) Range of motion (active then passive)

A) Active movement (approximate degrees given)

Ankle:
- dorsiflexion ~20°
- plantarflexion ~40°
Inversion ~20°
Eversion ~10°

B) Passive movement (positioning to isolate joints)

Dorsiflexion purely at ankle:
- position to “lock” other joints
- assess ankle dorsiflexion/plantarflexion without subtalar/shockpart motion confounding results
Subtalar joint movement:
- immobilize talus (thumb in front of talar neck)
- gentle inversion/eversion about ~5° each direction
Inversion/eversion as complex:
- inversion involves subtalar + Chopart-region contributions
Forefoot movement:
- immobilize midfoot to isolate transverse tarsal contribution
Hallux movement:
- cited generally: dorsiflexion ~80–90°; plantarflexion ~20–30°

(ROM assessment of the full foot/ankle is completed after these components.)

9) Muscle/tendon function testing (isolate tendons via specific foot positions)

Extensor hallucis / tibialis anterior
- foot neutral (~90°) with slight inversion to isolate tibialis anterior
- ask patient to lift/dorsiflex against resistance; palpate tendon
Tibialis posterior tendon
- plantarflexion + slight inversion
- ask patient to resist; palpate posterior tibialis tendon
Peroneus longus
- slight plantarflexion + slight inversion; palpate
Peroneus brevis
- neutral position (~90° described); palpate behind lateral malleolus region

Emphasis: maintain the described foot positions so tendons are truly isolated.

Special tests (diagnostic differentiation)

1) Tarsal tunnel syndrome

Tinel’s/tap test
- tapping reproduces burning pain/paresthesia → positive
Compression test
- compressing reduces symptoms → positive
Nerve stretch + compression
- evert foot slightly (stretch nerve), then compress; symptom reduction → positive

2) Morton’s neuroma

Suspected space: 3rd–4th webspace (sometimes 2nd–3rd)
Compression test
- compress between metatarsal heads (dorsal-to-plantar) → burning pain reproduced → positive
Click/reproduction maneuvers
- press medial-lateral to provoke a click → positive
- described technique for 3rd/4th space involves pushing “sides” and listening/feeling for a click

3) Silverskiold test (gastroc vs soleus tightness)

If both gastroc and soleus tight:
- dorsiflexion restricted at knee flexion (90°) and knee extension
If isolated gastroc tightness:
- dorsiflexion limited in knee extension
- dorsiflexion improves with knee flexed

4) Thompson test (Achilles rupture/disruption)

Compare both sides visually.
Then:
- squeeze the calf (“squeeze the car”)
- observe dorsiflexion response
- compare to the other side
Positive:
- less dorsiflexion or no movement compared to the other side → suggests Achilles discontinuity

5) Peroneal tendon subluxation/disruption (ankle sprain context)

After ankle sprain, consider possible disruption of superior peroneal retinaculum/tendon control.
Test:
- ask patient to evert/invert while feeling for tendon “popping”
Positive:
- tendon subluxates/pops as it moves

6) First MTP joint disorders (hallux valgus/rigidus)

Hallux valgus: bunion on medial aspect
Hallux rigidus:
- bony swelling dorsally
- dorsal bump on side view
- pressing reproduces tenderness
Grind test
- “grind s”: grind 1st MTP joint surfaces together
- crepitus or pain reproduction → positive
ROM clue:
- hallux rigidus shows loss of dorsiflexion and painful motion
Flexible vs rigid evaluation (hallux varus/valgus concept):
- if deformity corrects passively → suggests less need for certain surgical release steps (presenter’s implication)

7) “Squeeze test” for syndesmotic injury / ankle fracture

Squeeze tibia and fibula together (proximal leg compression).
Positive:
- pain felt down at ankle region → “definite F sign” → suggests ankle fracture or syndesmotic injury

8) Anterior drawer test (ATFL insufficiency/instability)

Stabilize the leg; hold heel/calcaneus.
Translate talus anteriorly relative to tibia.
Compare with the normal side.
Positive:
- soft/loose endpoint or excessive translation compared with other side → ATFL deficiency/insufficiency

9) Tibialis posterior dysfunction assessment

Screening signs:
- “too many toes” sign (> ~1.5 toes visible from behind)
- excessive heel valgus
Single heel raise vs double heel raise
- indicates whether the deformity is correctable
- if heels come together/correct → suggests posterior tibialis function is preserved
Strength specificity:
- do unilateral heel raise assessment on affected side
- if deformity corrects there → flexible/potentially less advanced dysfunction
Coleman block test (for cavus-related deformity flexibility)
- patient stands on block at edge:
  - lateral forefoot on block
  - medial side off block
- observe hindfoot alignment from behind toward neutral
- if alignment improves → deformity is flexible; helps assess fixed vs flexible contributions
- used to inform surgical planning

Conclusion / stated purpose

The presenter frames the video as a comprehensive demonstration covering:

inspection
palpation
ROM
tendon function testing
special tests

Goal: help viewers become more comfortable performing foot/ankle exams and recognizing pathology patterns.

Speakers / sources featured

Primary speaker/presenter: unnamed clinician demonstrating the foot and ankle examination (mentions asking a resident named Akash for clinical demonstrations).
Other person(s) featured:
- Akash (resident/volunteer used for walking and clinical demonstrations).
Sources cited: no external studies or named guidelines are cited in the subtitles.

Comprehensive Foot and Ankle Examination

Key takeaways