Clinical examination of the lower leg, ankle and foot


Clinical examination of the lower leg, ankle and foot



Although the main question is the current problem – where the pain is now – it is best to try to obtain a chronological account, as summarized in Box 55.1. In order to work out the problem systematically, the questions asked should follow the order given below.

If there was an injury:

If there was no injury:

Sometimes there will be some evolution in degree and localization of pain, swelling and functional disability during the weeks or months after the onset.

The examiner should also find out what sort of treatment the patient has already had, and what the results were.

The present complaints should be investigated further:

Because foot disorders cause pain while the foot is performing its function, walking or running will always be the provoking activities:

Further questioning should establish whether there are ‘twinges’ or instability:

• Do you have twinges, and when? A twinge in the foot is a very important symptom. It is a sudden, sharp pain, mostly occurring during walking. It should always be differentiated from ‘giving way’. In a twinge, there is only momentary pain and not a feeling of instability. By the time the patient realizes it, the pain has disappeared. A twinge is very often an indication of a momentary impaction of a loose body in the ankle or subtalar joint. If localized in the forefoot, it can be a symptom of Morton’s metatarsalgia or sesamoiditis.

• Do you have a feeling of instability? If so, describe it. Real instability of the ankle or foot is only important in sports. Normal walking or even running on a flat surface hardly ever causes a feeling of giving way. In the occasional case where this does happen, it is the result of neurological weakness of the peronei muscles, rather than of a ligamentous lesion.


Inspection is first made in a standing position. The shape of the legs is evaluated: valgus or varus deformity is checked. The normal intermalleolar distance should not exceed 5 cm. A slight outward rotation of the tibiae is normal, with an outward pointing of the toes of about 15°. Exaggeration of this outward rotation can be caused by short calf muscles and results in a restricted step during walking and running.

The shape of the feet in a standing position is studied next. At the calcaneus there can be a valgus or varus deformity.

The longitudinal arch of the foot is then estimated: a cavus deformity or a flat foot may be identified. At the mid-tarsal region the shape and regularity of the bones is inspected and, at the forefoot, special attention is paid to the existence of an insufficient anterior arch, hallux valgus, claw toes, hammer toes or metatarsus inversus.

After inspection in the standing position, it is sometimes advisable to check the patient’s gait and how the shoes have worn down.

Inspection in the supine-lying position gives information about contours, shape, atrophy, colour of the skin, swelling, oedema, haematoma, the condition of the skin and nails, and the existence of callosities.

Sometimes a second inspection in a standing position may follow the routine functional examination, when special attention should be paid to:

Jun 5, 2016 | Posted by in ORTHOPEDIC | Comments Off on Clinical examination of the lower leg, ankle and foot

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