Mastering the Foot and Ankle Exam: A Step-by-Step Guide for Chiropractors
Foot and ankle pain is a common complaint across all age groups, with a significant impact on quality of life. Chronic foot pain impacts 14% to 40% of adults, hindering mobility and daily activities and increasing the risk of falls. (1-3) And ankle sprains alone account for 16-42% of all sports-related trauma. (4)
As chiropractors, mastering the ankle and foot exam is crucial for accurately diagnosing and managing these patients. This blog features a comprehensive ankle and foot physical exam tutorial to help you elevate your diagnostic skills to the next level! In the next few minutes, you’ll review:
The top tests for differentiating foot and ankle pain, including the best tests for plantar fasciitis
A complete foot and ankle exam tutorial video
When to image a painful ankle
Watch this tutorial on performing a quick foot and ankle physical exam.
Top 3 Foot and Ankle Diagnoses for Chiropractors
According to the latest ChiroUp Network Dataset Analysis of 631,970 clinical diagnoses collected from more than 2,200 evidence-based chiropractic providers, the top three most common foot and ankle diagnoses in chiropractic offices were:
Plantar fasciitis
Foot hyperpronation
Lateral ankle sprain
Providers must consider many other potential diagnoses affecting the region's bones, joints, cartilage, ligaments, tendons, muscles, and nerves.
Essential Questions To Ask During An Ankle and Foot Exam
Like most other musculoskeletal complaints, a comprehensive patient history is the primary source of diagnostic information for foot-related issues. Key history questions during a foot and ankle physical exam include:
Onset - Traumatic onsets can indicate sprains, strains, or fractures. Conversely, non-traumatic foot or ankle pain emerges slowly and often signals myofascial, degenerative, or systemic conditions. Overuse conditions, notably plantar fasciitis, tendinopathies, and neuropathies, frequently stem from a consistent pattern of repetitive microtrauma.
Symptom location and character - Pain location can provide diagnostic clues; however, several etiologies generate a similar overlapping pattern of discomfort. The following illustrations depict common symptomatic presentations.
In addition to the standard OPPQRST inquiry, other essential questions include:
Significant stiffness - Foot and ankle osteoarthritis patients commonly report morning stiffness. However, if this stiffness exceeds 30 minutes, it may raise suspicion of inflammatory arthropathy. Download the ChiroUp Inflammatory Arthropathy Quick Reference Card for a handy refresher.
Health history - Conditions such as diabetes, thyroid disorders, vitamin D deficiency, psoriasis, and osteoporosis can increase the risk or serve as potential catalysts for various foot and ankle-related issues.
Age - Clinicians must be aware of conditions such as Sever's disease or Kohler disease in children and early adolescents. Conditions like plantar fasciitis, Morton's neuroma, and Achilles tendinopathy frequently occur in middle-aged individuals, whereas osteoarthritis and posterior tibial tendon dysfunction are more prevalent among seniors.
How To Perform A Foot and Ankle Exam
The essential components of a physical exam for foot and ankle pain include:
Inspection - swelling, deformity, atrophy
Range of motion - active, passive, and resisted movements
General palpation - tenderness, swelling, and warmth
Joint palpation - stability testing, motion palpation
Orthopedic assessment - various foot and ankle orthopedic exam tests specific to the differential diagnoses
Gait & Functional assessments - foot hyperpronation, halux rigidus, lower crossed syndrome, etc.
Want more? Watch this webinar on assessing foot hyperpronation and gait imbalances.
Neuro eval - dermatomes, myotomes, reflexes
Vascular eval - capillary refill, distal pulses
Lumbosacral evaluation - radiculopathies often refer to the foot, and up to nearly one-third of foot and ankle problems may arise from an asymptomatic spine. (5)
Plantar Fasciitis Exam: Top Tests for Plantar Fasciitis
Plantar fasciitis is the leading cause of heel pain. The following plantar fasciitis physical exam tests can aid in diagnosing this condition:
Weightbearing
The most common presenting complaint of plantar fasciitis is a sharp pain with the first couple of steps in the morning or after prolonged inactivity. (6,7) Symptoms are often noted during the push-off phase when the band is at peak tension. (8) Prolonged weight bearing amplifies symptoms, especially when compounded by inadequate foot support or walking barefoot. (25) Patients report relief when unloading the foot by sitting or lying down.
Palpatory Tenderness
Palpation will likely reveal tenderness at the medial calcaneal tubercle. (9) Some patients note tenderness to palpation in the mid portion of the plantar arch. (9) Palpation may demonstrate palpable bands of tenderness or adhesion.
Great Toe Dorsiflexion Sign
During a plantar fasciitis exam, tenderness to palpation is often exacerbated by simultaneously dorsiflexing the great toe to 65 degrees. (10)
Windlass Test
The Windlass test for plantar fasciitis is the reproduction of heel pain during passive dorsiflexion of all toes. Performing this test while the patient is standing/weight bearing more than doubles sensitivity to almost 33%. (11)
Want More Clinical Pearls for Plantar Fasciitis?
Check out the top-rated chiropractic blog and video 🤩on 5 Potent Plantar Fasciitis Treatment Tools.
Review current plantar fasciitis exam and treatment best practices in the new ChiroUp webinar, Plantar Fasciitis Management: Skills for Clinical Excellence.
Watch this quick ChiroUp Instagram Reel on Differentiating Plantar Fasciitis From The Imposters, and while you’re there, be sure to follow us so you never miss these clinical pearls.
Pro Tip: ChiorUp subscribers can download exam templates for a foot and ankle exam (or any other region) by visiting the Practice Resources forms library and then selecting Clinical/ Regional exam forms.
When To Image The Foot and Ankle
Imaging Acute Ankle Pain- The Ottawa Ankle Rules
The Ottawa ankle rules are a well-established standard for determining the need for ankle radiographs following trauma. (12) The Ottawa ankle rules suggest that radiographs are appropriate when any of the following are present:
Tenderness along the posterior half of the lower 6 cm of the fibula or tibia, the medial malleolus, the base of the fifth metatarsal, or navicular bone.
Inability to bear weight for at least four steps.
Did you know?
If none of these findings are present during screening, the likelihood of a fracture is less than 1%. (13)
The Ottawa ankle rules boast nearly 100% sensitivity and have reduced unnecessary X-rays by 30-40%. (13,14)
The Ottowa ankle rules were intended for adults but have since been shown to be accurate for children as young as two. (15,16)
Pro Tip: Check out this popular ChiroUp blog for more about the Ottowa Ankle Rules.
Imaging Acute Foot Pain- Beyond the Ottowa Ankle Rules
The Ottowa ankle rules help guide foot imaging decisions for acute presentations involving the navicular and base of the fifth metatarsal; however, radiographs may also be appropriate in specific clinical scenarios when the Ottawa ankle exam rules cannot be applied. (17) Plain film radiography is generally appropriate when there is suspected pathology in an anatomic area not addressed by Ottawa rules. (17)
Imaging Chronic Foot And Ankle Pain
Plain film radiographs are the typical first-line imaging study for chronic foot or ankle pain. (1,18)
Routine ankle radiographs usually consist of anteroposterior, lateral, and mortise views (obtained by internally rotating the foot 15 to 20 degrees). (18)
Routine foot views may include anteroposterior, lateral, and oblique. Depending on the suspected diagnosis, additional views such as sesamoid views (for sesamoid injuries), calcaneal views (for heel pain), or views focusing on the midfoot or forefoot may be necessary.
Advanced Imaging For Foot And Ankle Pain
Follow-up advanced imaging of chronic ankle pain may be appropriate to rule out various ankle conditions, including osteochondral lesions, tendon abnormalities, ankle instability, and ankle impingement, or when the etiology remains uncertain. (18)
Likewise, follow-up advanced imaging of chronic foot pain may be appropriate to rule out various foot conditions, including chronic regional pain syndrome, sesamoiditis, Morton’s neuroma, intermetatarsal bursitis, chronic plantar plate injury, Freiberg’s infraction, plantar fascia tear, occult fracture, and painful accessory ossicles, or when the etiology remains uncertain. (18)
Ready to Up Your Game One More Notch?
Now that you’ve got the lowdown on the essential tests for diagnosing foot and ankle pain, it’s time to take that knowledge and run with it. ChiroUp subscribers can dive into the Clinical Skills tab for step-by-step tutorials on all the related best-practice treatments, exercises, and ADL advice your patients need.
Not a subscriber yet? Here’s your chance to see just how straightforward accessing and sharing resources can be. We’re talking lay-friendly condition descriptions and exercise demos that you can pull up in a snap—actually, four clicks, to be precise. Check out this video on how to whip up fully customized condition reports for your patients in seconds. It’s a game-changer!
Take a test drive today and join us on our journey to make our shared profession the undeniable best choice for patients and payors.
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2. Ahn JM, El-Khoury GY. Radiologic evaluation of chronic foot pain. American family physician. 2007 Oct 1;76(7):975-83. Link
3. Hawke F, Burns J. Understanding the nature and mechanism of foot pain. Journal of Foot and Ankle Research. 2009 Dec;2:1-1. Link
4. Halabchi F, Hassabi M. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics. 2020 Dec 12;11(12):534. Link
5. Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). J Man Manip Ther. 2020 Sep;28(4):222-230. Link
6. Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review: plantar fasciitis. Bmj. 1997 Jul 19;315(7101):172-5. Link
7. Young CC, Rutherford DS, Niedfeldt MW. Treatment of plantar fasciitis. Am Fam Physician. 2001 Feb 1;63(3):467-74. Link
8. Michaud T, New Techniques For Treating Plantar Fasciitis Competitor Group Published Mar. 6, 2014
9. Banks AS. McGlamry's comprehensive textbook of foot and ankle surgery. Lippincott Williams & Wilkins; 2001.
10. Thordarson DB. Re: The association between diagnosis of plantar fasciitis and windlass test results, De Garcea D, Dean D, Requejo SM, Thordarson DB, Foot Ankle Int. 24 (3): 251-255, 2003. Author's reply. Foot Ankle International. 2004 Sep 1;25(9):687-8.
11. De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot & ankle international. 2003 Mar;24(3):251-5. Link
12. Stiell IG, Greenberg GH, McKnight RD, Wells GA. Ottawa ankle rules for radiography of acute injuries. The New Zealand Medical Journal. 1995 Mar 22;108(996):111. Link
13. Kerkhoffs, G.M., van den Bekerom, M., Elders, L.A., van Beek, P.A., Hullegie, W.A., Bloemers, G.M., de Heus, E.M., Loogman, M.C., Rosenbrand, K.C., Kuipers, T. and Hoogstraten, J.W.A.P., 2012. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British journal of sports medicine, 46(12), pp.854-860.
14. Gomes YE, Chau M, Banwell HA, Causby RS. Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC musculoskeletal disorders. 2022 Sep 23;23(1):885. Link
15. Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP, Wright RB. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Academic Emergency Medicine. 2009 Apr;16(4):277-87. Link
16. Plint AC, Bulloch B, Osmond MH, Stiell I, Dunlap H, Reed M, Tenenbein M, Klassen TP. Validation of the Ottawa Ankle Rules in children with ankle injuries. Academic Emergency Medicine. 1999 Oct;6(10):1005-9. Link
17. Gorbachova T, Chang EY, Ha AS, Amini B, Dorfman SR, Fox MG, Khurana B, Klitzke A, Lee KS, Mooar PA, Shah KH. ACR appropriateness criteria® acute trauma to the foot. Journal of the American College of Radiology. 2020 May 1;17(5):S2-11. Link
18. Chang EY, Tadros AS, Amini B, Bell AM, Bernard SA, Fox MG, Gorbachova T, Ha AS, Lee KS, Metter DF, Mooar PA. ACR Appropriateness Criteria® chronic ankle pain. Journal of the American College of Radiology. 2018 May 1;15(5):S26-38. Link
