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Foot and Ankle examination

Foot and Ankle examination


Obtaining a patient history and completing an objective assessment is the gold standard for foot and ankle evaluation. The purpose of using special examinations and tests is to confirm the clinical diagnosis.

We cannot treat patients on the basis of X-rays or MRIs alone. These things have to come together (with objective assessment). helen Simpson Foot and Ankle examination



Lisfranc joint complex

Sesamoid distal to first metatarsal

X-rays are helpful to check for bone and soft tissue damage:

  • Achilles tendon rupture is aided in the diagnosis by the presence of five radiographic signs. [1] Lateral ankle radiographs reliably support the diagnosis of Achilles tendon rupture. [1]
  • May not be sufficient to identify ankle fractures. [2]
  • Syndesmosis injuries are often overlooked on radiographs. [2]
  • Aids in the diagnosis of ankle fractures. AP side view and mortise view are recommended. The mortise view is the AP view with 15° internal rotation. If possible, x-rays should be taken while the patient is standing. Advise patients to stand, even if they are light weight (even 99% on the uninjured foot). Exceptions are made when there are significant dislocations/open fractures. When ankle fractures are ruled out but the patient’s recovery is not progressing and the patient continues to complain of pain, repeat x-rays should be done within 6 weeks to rule out Osteochondral injury or hairline fracture.
  • Misalignment of the second tarsal metatarsal joint is a common feature of Lisfranc fracture-dislocations. AP view of x-ray shows lateral displacement of the base of the second metatarsal and more than 2 mm of separation between the base of the first and second metatarsal. X-rays are recommended Each foot is in a weight-bearing position so that the injured side can be compared to the opposite side. [3]
  • Hindfoot deformity results in disability of the foot and ankle. It is important to evaluate X-ray findings of hindfoot alignment. The recommendation for clinical and research purposes is to use the long axis hindfoot view while standing bilaterally. [4]
  • Sesamoid fractures show up on x-rays as rough spaces between the bone fragments. A smooth separation of two bones seen on x-rays is normal in about 10% of people.
  • Ligament injuries are confirmed on the first diagnostic x-ray in only 50% of patients. This number increased to 66% of patients during the second x-ray when the diagnosis was confirmed. [5]

Diagnostic Ultrasound

Morton’s neuroma between 3rd and 4th MT heads in the US

Diagnostic ultrasound allows dynamic examination of foot and ankle pathology. It is a non-invasive, economical and readily available tool recommended as a first-line diagnostic modality to rule out ligament tears, tendinitis, tenosynovitis, plantar fascial soft tissue masses, or Morton’s disease Neuroma. [6] [7]

Diagnostic ultrasound has been found to be an effective diagnostic tool for the following foot and ankle injuries:

  • Fractures of the lateral and medial malleolus of the fifth metatarsal in patients with foot and/or ankle sprains. Note: Sensitivity is low for scaphoid fractures. [8]
  • Tears and sprains of the anterior talofibular and calcaneofibular ligaments were ruled out. [9][10][11]
  • Ankle pain associated with lateral ligamentopathy, tendinopathy, and joint effusion. Note: Use is limited in suspected posterior talofibular ligament injuries. [12]
  • Achilles tendon injuries.[13]
  • It is statistically significant for diagnosing syndesmosis injuries with widening of the tibiofibular space ≥ 6.0mm. [14]
  • It should be considered the primary treatment modality for foot and ankle fractures. [15]


MRI Ankle Sprain

MRI is the investigation of choice for chronic foot pain. According to available research, MRI is a modality used for various soft tissue diseases of the foot and ankle due to its high resolution and contrast, but interpretation of the results is key to correct diagnosis. MRI modality is expensive and Always readily available in many countries and this particular investigation should be made by a plastic surgeon.

It’s amazing to look at your soft tissue. If we’re looking for cartilage damage, it’s sensitive, but it probably overestimates the extent of the damage. helen simpson

MRI is:

  • The gold standard for diagnosing Achilles tendon rupture. [1]
  • Recommended for patients with persistent pain at rest after an ankle sprain, as clinical examination is insufficient when syndesmotic injury is suspected. [16]
  • A preoperative decision tool for repairing the anterior talofibular ligament in the setting of chronic lateral ankle instability. [17] [18]
  • Routine examination methods of ankle ligaments in the case of ankle ligament injury. Weight-bearing MRI is recommended because the full length of the ligament can be visualized in both lateral and coronal positions. [5]
  • A valuable tool for diagnosing post-traumatic ankle pain as it is 96% accurate in detecting tendon injuries. [19]
  • Useful for assessing tendons, ligaments, nerves, and fascia, and for identifying occult bone injuries. [19]
  • The study of metatarsalgia was chosen because of its high-resolution presentation of the sesamoid anatomy, plantar glenoid apparatus, and adjacent flexor abductor and adductor tendons. [20]

CT Scan

Triplane fracture CT

In ankle injuries, CT scans are recommended as a modality to assess passive subsystems. It is a quick tool that can be used during surgery. Weight-bearing computed tomography (WBCT) allows measurement and analysis of foot and ankle bone position and its The recommendations for deformity [21] using CT scan and WBCT are:

  • Assess for fractures in the ankle region. [2]
  • Assess for syndesmosis reduction. Weight-bearing CT (WBCT) scans have been shown to be more reliable. [twenty two]
  • Syndesmotic injury predicting ankle fractures. [twenty three]
  • Characterize hindfoot alignment to determine the amount of translation required for neutral alignment during calcaneal osteotomy. [twenty four]
  • Diagnosis of subtle Lisfranc instability. [25]

Special Tests

Ottawa Foot and Ankle Rules

The Ottawa Ankle Rules determine the need for x-rays for acute ankle sprains. It is an accurate instrument for ruling out ankle and midfoot fractures, but the test has some limitations:

  • High accuracy in the first 10 days after injury
  • High sensitivity detected in patients under 55 years old

Details can be found on the Ottawa Ankle Rules page.

Knee To Wall Test

  • Knee-To-Wall Test

    Should always be performed when assessing ankle and foot injuries

  • Provides a method for assessing the length of the gastrocnemius muscle
  • Dorsiflexion range of motion assessment is recommended when examining conditions such as foot pronation or plantar fasciitis
  • Starting position for the test: Toes are on the wall and gradually removed. Use a ruler to measure the distance between your toes and the wall and record it for comparison and later re-evaluation.


Details can be found on the knee-to-wall test page.

Anterior Drawer Test

  • Always perform when assessing ankle and foot injuries
  • Always compare with the “normal” side
  • Remember to hug the calcaneus during the test as it moves the talus.
  • See more ankle front drawers here
Squeeze Test
  • Performed to detect syndesmotic injury
  • Attempting to reproduce pain symptoms

Details can be found on the squeeze test page.

External Rotation Test

  • Performed to detect a syndesmotic injury
  • Attempts to reproduce the damage mechanism


Details can be found on the External Spin Test page.

Cotton Test

  • For the detection of syndesmotic instability
  • It is a manual stress test
  • It determines the amount of lateral translation of the talus in the ankle hole


Coleman Block Test

  • Used to assess rearfoot mobility and forefoot pronation
  • Finished by supporting the lateral forefoot on a plank 2.5-4 cm thick
  • Determine if the turned heel is due to a forefoot problem


Other Tests

Other special tests include:

  • Ankle ligament stress tests
  • Talar tilt test
  • Eversion stress test
  • Silfverskiöld test
  • Windlass test
  • Impingement sign ankle
  • Navicular drop test

For more information on these tests, see the relevant pages for which links are provided.

Balance Tests


  • Assessment tool for postural stability
  • Requires two test surfaces stopwatch and scorer

Details can be found on the Balance Error Scoring System page.

Star Excursion Balance Test (SEBT)

  • Assesses anterior movements
  • Record the movements and compare results
  • Used to show progress
  • The Y Balance Test is a shorter version of the Star Test
  • See more here Star Excursion Balance Test


Return to Sports Tests

The purpose of a return-to-sport test is to determine an individual’s readiness to participate in high-level activity.


  • Help determine when to resume unrestricted activity.
  • Aim to decrease the risk of re-injury.
  • They test the athlete’s ability to return to the field. They should imitate the movement of athletes. Example: Single-leg or double-leg hop testing in a long jumper with a history of ankle sprains. Other examples include jumping to stability tests or shuttle runs.
  • They are not standardized. There are no data to support the use of one test or series of tests.
  • It is important to utilize a wide range of assessments: eg patient self-report questionnaires and assessments of psychological factors. [31]
  • See also Return to Play in Sports

Outcome Measures

Foot and ankle injuries are fairly common, and patient progress and satisfaction with results is a focus for all physical therapy providers. Outcome measures used at different stages of rehabilitation help monitor functional improvements and identify further limitations Prevent patients from returning to exercise or activities of daily living. The most commonly used self-reported outcome measures for ankle injuries are as follows:[32]

  • Ankle Ability Measure (FAAM)
  • Oxford Ankle Foot Questionnaire
  • Ankle Disability Index (FADI)
  • Lower‐Limb Tasks Questionnaire (LLTQ)
  • Foot Function Index (FFI)
  • American Academy of Orthopedic Surgeons (AAOS) Lower Extremity Core Score/Foot and Ankle Module
  • Ankle Functional Assessment Tool (AJFAT)
  • VISA-A Scale


Watch the video below that demonstrates the application and interpretation of special tests for foot and ankle evaluation:

Foot and Ankle examination

Knee To Wall Test

External Rotation Test

Cotton Test

External Rotation Test

Coleman Block Test

Star Excursion Balance Test (SEBT)



1-to: 1.0 1.1 1.2 Bowen L Evans R Bodger O Howard J Anne-Marie H. Investigation of the usefulness of emergency department soft-tissue signs on lateral ankle radiographs to aid in the diagnosis of Achilles tendon rupture. Int J ankle.

2-: 2.0 2.1 2.2 Szymański T Zdanowicz U. Conventional computed tomography versus plain X-ray imaging for ankle fractures—how much are we missing? . Foot and ankle surgery. April 1, 2021. ↑ Stavlas P Roberts CS Xypnitos FN Giannoudis PV. The role of Lisfranc fracture and dislocation reduction and internal fixation: A systematic review of the literature. International integrity. 2010 Dec;34(8):1083-91. ↑ ML Reilingh L Beimers GJM Tuijthof SAS Stufkens M Maas et al. Radiographic measurement of hindfoot alignment: the long-axial view is more reliable than the hindfoot alignment view. Bone Radiology 2010;39(11): 1103-1108. 

3-Qi Huafeng. Analysis of the clinical value of weight-bearing magnetic resonance in the diagnosis of ankle ligament sports injuries. IEEE access. March 30,

4-Khoury V Guillin R Dhanju J Cardinal É. Ankle and Foot Ultrasound: Overuse and Sports Injuried. Musculoskeletal Radiology Symposium 2007 Jun; 11(02)

5-Rawool NM Nazarian LN. Ultrasound of the ankle and foot. In: Ultrasound CT and MRI Symposium Jun 2000; 21(3)

6-Atilla OD Yesilaras M Kilic TY Tur FC Reisoglu A Sever M Aksay E. Accuracy at the bedside Ultrasonography as a diagnostic tool for ankle and foot fractures. Academic Emergency Medicine. 2014 Sep;21(9):

7-Hosseinian SH Aminzadeh B Rezaeian A Jarahi L Naeini AK Jangjui P. Diagnostic value of ultrasound in ankle sprains. Journal of Foot and Ankle Surgery. August 2021 20. ↑ Esmailian M Ataie M Ahmadi O Rastegar S Adibi A. Sensitivity and specificity of ultrasonography in the diagnosis of traumatic ankle injuries. Journal of Medical Science Research: Official Journal of Isfahan Medical University.

8-Gribble PA. assessment and Identify ankle instability. Journal of Athletic Training. 2019 Jun;54(6

9-Singh K Thukral CL Gupta K Singh A. High-resolution ultrasonography compared with clinical presentation in patients with ankle pain. J Otterson.

10- https://www.youtube.com/watch?v=l6gkHR02rIM

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