Introduction
Ankle and foot problems are common in primary care, emergency medicine, and orthopaedic OSCEs. The examination follows the familiar Look-Feel-Move-Special Tests framework and should always include Ottawa ankle rules when trauma is the presenting complaint.
💎 Clinical Pearl
Compare both ankles and feet throughout. Examine the patient standing first for alignment and arch assessment, then seated with feet hanging free.
Preparation
- Introduce yourself, confirm patient identity
- Explain the examination and gain verbal consent
- Expose both lower legs, ankles, and feet
- Ask about pain before touching
1. Look
Standing
| Finding | Significance |
|---|---|
| Pes planus (flat foot) | Tibialis posterior dysfunction, hypermobility |
| Pes cavus (high arch) | Charcot-Marie-Tooth disease, Friedreich's ataxia |
| Hindfoot valgus or varus | Tibialis posterior dysfunction, OA |
| Hallux valgus | Bunion, RA, gout |
Seated
- Skin: erythema, swelling, bruising, ulcers, calluses
- Nails: thickening (fungal), psoriatic pitting
- Deformities: claw toes, hammer toes
- Muscle wasting: intrinsic foot muscles
2. Feel
| Structure | Pathology |
|---|---|
| Medial malleolus | Fracture, deltoid ligament injury |
| Lateral malleolus | Fracture (Ottawa), ATFL or CFL injury |
| Base of 5th metatarsal | Avulsion fracture (common after ankle inversion) |
| Achilles tendon | Tendinopathy, partial or complete rupture |
| Plantar fascia | Plantar fasciitis (tender at calcaneal insertion) |
| 1st MTP joint | Gout (hot, red, exquisitely tender), OA, hallux rigidus |
💎 Clinical Pearl
Gout at the 1st MTP joint (podagra) is classically the most painful joint condition known. Patients often cannot tolerate even a bedsheet touching the foot.
3. Move
| Movement | Normal range | Joint |
|---|---|---|
| Dorsiflexion | 20 degrees | Talocrural |
| Plantarflexion | 50 degrees | Talocrural |
| Inversion | 35 degrees | Subtalar |
| Eversion | 15 degrees | Subtalar |
| Great toe dorsiflexion | 70 degrees | 1st MTP |
4. Special Tests
Ottawa Ankle Rules
🧠 Mnemonic
Ottawa = Bone Tenderness + Can't Bear Weight
X-ray is required if: bony tenderness at the posterior tip or tip of either malleolus, OR at the navicular or base of the 5th metatarsal, AND the patient cannot bear weight for 4 steps immediately after injury and in the emergency department.
Anterior Drawer Test
Stabilise the tibia with one hand, grasp the heel with the other. Apply anterior force with the ankle in 20 degrees of plantarflexion. Excessive anterior translation compared to the contralateral side = ATFL laxity or rupture.
Talar Tilt Test
Invert the hindfoot while stabilising the tibia. Excessive tilt = calcaneofibular ligament (CFL) injury.
Simmonds' (Thompson's) Test
With the patient prone, squeeze the calf. Absence of plantarflexion = complete Achilles tendon rupture.
Common OSCE Diagnoses
| Diagnosis | Key features |
|---|---|
| Lateral ankle sprain (ATFL) | Inversion injury, anterior drawer positive, lateral tenderness |
| Achilles tendinopathy | Insertional or mid-portion tenderness, crepitus |
| Achilles rupture | Thompson's test positive, palpable gap, sudden pop |
| Plantar fasciitis | Morning pain, tender calcaneal insertion |
| Gout | 1st MTP hot and swollen, elevated urate, responds to NSAIDs |
| RA | Bilateral MTP involvement, synovitis, morning stiffness |
How to Present
"On examination the right ankle was swollen with bruising over the lateral malleolus. There was point tenderness at the anterior talofibular ligament. The anterior drawer test was positive with increased laxity compared to the left. Ottawa ankle rules were met due to lateral malleolus bony tenderness and inability to weight-bear. My findings are consistent with a grade II lateral ankle sprain with possible ATFL rupture."
"What are the Ottawa ankle rules?"
An ankle X-ray is required if the patient has bony tenderness at the posterior tip or distal 6 cm of either malleolus, and cannot bear weight for 4 steps. A foot X-ray is needed if there is tenderness at the navicular or base of the 5th metatarsal with inability to weight-bear. These rules have near 100% sensitivity for fractures and help avoid unnecessary X-rays.
"How do you test for Achilles tendon rupture?"
Use Simmonds' (Thompson's) test: ask the patient to lie prone and squeeze the calf. Normally this produces plantarflexion. Absence of plantarflexion indicates complete rupture of the Achilles tendon. A palpable gap in the tendon and a history of a sudden audible pop during activity support the diagnosis.
"What are the main ligaments injured in a lateral ankle sprain?"
The most commonly injured ligament is the anterior talofibular ligament (ATFL), followed by the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). These form the lateral ligament complex. ATFL injury is tested by the anterior drawer test; CFL injury is tested by the talar tilt test.
"What condition should you consider in a hot swollen 1st MTP joint?"
Gout is the classic diagnosis: monosodium urate crystal deposition at the 1st metatarsophalangeal joint (podagra). It presents as an acutely hot, erythematous, exquisitely tender joint, often with a preceding dietary or alcohol trigger. Diagnosis is confirmed by joint aspiration showing negatively birefringent needle-shaped crystals under polarised light.
Related guides: [Knee Examination OSCE](/blog/knee-examination-osce) | [Hip Examination OSCE](/blog/hip-examination-osce) | [Musculoskeletal History OSCE](/blog/musculoskeletal-history-osce)