With the patient sitting on the couch, their feet overhanging the end of it:
- Observe the feet, comparing one with the other for symmetry.
- Look specifically at the forefoot for nail changes or skin rashes such as psoriasis.
- Look for alignment of the toes and evidence of hallux valgus of the big toe. Look for clawing of the toes, joint swelling and callus formation. If there is clawing of the toes, calluses above and below the MTP joints, pain and restriction of movement, then there is likely to be subluxation (partial dislocation) of the MTP joints.
- Look at the underside or plantar surface for callus formation.
- Look at the patient’s footwear. Check for abnormal or asymmetrical wearing of the sole or upper, for evidence of poor fit or the presence of special insoles.
With the patient weight-bearing:
- Look again at the forefoot for toe alignment.
- Look at the midfoot for foot arch position (a dropped arch in a normal subject should resolve when standing on tip toes).
- From behind, look at the hindfoot for Achilles tendon thickening or swelling.
- Look for normal alignment of the hindfoot (see fig. 18). Disease of the ankle or subtalar joint may lead to a varus or valgus deformity.
- Assess the temperature over the forefoot, midfoot and ankle.
- Check for the presence of a peripheral pulse.
- Gently squeeze across the MTP joints, watching the patient’s face for signs of discomfort.
- Palpate the midfoot, the ankle and subtalar joints for tenderness.
- Assess, both actively and passively, movements of inversion and eversion at the subtalar joint, plus dorsi- and plantar flexion at the big toe and ankle joint.
- Movement of the mid-tarsal joints can also be performed by fixing the heel with one hand and, with the other hand, passively inverting and everting the forefoot.
- If not already done, assess the patient’s gait, watching for the normal cycle of heel strike, stance, and toe-off.
Examination of the foot and ankle: checklist
- Introduce yourself/gain consent to examine
With the patient lying on couch:
- Look at dorsal and plantar surfaces of the foot
- Assess skin temperature
- Palpate for peripheral pulses
- Squeeze the MTPJs
- Palpate the midfoot, ankle joint line and subtalar joint
- Assess movement (actively and passively) at the subtalar joint (inversion and eversion), the big toe (dorsi- and plantar flexion), the ankle joint (dorsi- and plantar flexion) and mid-tarsal joints (passive rotation)
With the patient standing:
- Look at the forefoot, midfoot (foot arch) and the hindfoot
- Assess the gait cycle (heel strike, stance, toe-off)
CMC(J) carpometacarpal (joint); CT computerized tomography; DEXA dual-energy x-ray absorptiometry; DIP(J) distal interphalangeal (joint); ESR erythrocyte sedimentation rate; GALS gait, arms, legs and spine; MCP(J) metacarpophalangeal (joint); MRI magnetic resonance imaging; MTP(J) metatarsophalangeal (joint); NSAID non-steroidal anti-inflammatory drug; OA osteoarthritis; PIP(J) proximal interphalangeal (joint); RA rheumatoid arthritis; REMS regional examination of the musculoskeletal system.