Foot and Ankle Examination OSCE — Complete Guide with Special Tests

Why Foot and Ankle Examination Is Tested

Foot and ankle presentations are among the most common in emergency, primary care, and orthopaedic settings. Examiners test this station because it integrates gait observation, systematic joint examination, applied anatomy, special tests, and clinical decision-making (Ottawa rules). Candidates frequently lose marks by omitting distal neurovascular assessment or failing to examine the patient walking.

Preparation and Consent

Introduce yourself, confirm the patient's identity, explain you will examine their foot and ankle, and obtain consent. Ask the patient to remove shoes, socks, and expose both lower limbs to the knee. Adequate exposure is a common mark-scheme point. Ask about pain before palpating.

Gait Observation — Start Here

Always begin by watching the patient walk before they lie down. Note:

• Antalgic gait — shortened stance phase on painful side
• Steppage gait — foot drop, suggests common peroneal nerve injury
• Trendelenburg — indicates hip or proximal pathology affecting gait mechanics
• Flat foot (pes planus) — look for loss of medial arch in static standing

Ask the patient to walk on tiptoes (tests gastrocnemius/soleus and S1) and on their heels (tests tibialis anterior and L4/L5).

Look

Inspect both feet simultaneously with the patient standing, then seated, then lying:

Feel

Systematically palpate with warm hands, watching the patient's face:

• Medial malleolus and lateral malleolus
• Sinus tarsi (anterior to lateral malleolus — tender in sinus tarsi syndrome)
• Plantar fascia — origin at calcaneal tuberosity (plantar fasciitis)
• Achilles tendon — palpate full length, note gap (rupture), thickening (tendinopathy)
• Metatarsal heads — squeeze test (metatarsalgia, Morton's neuroma)
• First MTP joint — gout, hallux rigidus
• Posterior tibial pulse (behind medial malleolus) and dorsalis pedis pulse

Move

Passive Range of Motion

Test active, then passive. Note crepitus, pain, and end-feel.

Special Tests

Ottawa Ankle Rules

Indicated when there is ankle or mid-foot pain after injury and any of:

• Bone tenderness at posterior edge/tip of lateral malleolus
• Bone tenderness at posterior edge/tip of medial malleolus
• Bone tenderness at base of 5th metatarsal (mid-foot rule)
• Bone tenderness at navicular (mid-foot rule)
• Inability to weight-bear (4 steps) immediately and in ED

Simmonds-Thompson (Calf Squeeze) Test

Patient prone, kneel on couch. Squeeze calf — foot should plantarflex. Absent plantarflexion = positive = Achilles tendon rupture.

Windlass Test

Extend the big toe passively. Normally this tightens the plantar fascia (windlass mechanism) and raises the medial arch. Pain at the plantar fascia origin = positive = plantar fasciitis.

Anterior Drawer Test (Ankle)

Stabilise the tibia, pull the calcaneum anteriorly with the foot in 20° plantarflexion. Excessive translation = anterior talofibular ligament (ATFL) laxity.

Talar Tilt Test

Invert the hindfoot in neutral position. Excess inversion = calcaneofibular ligament (CFL) laxity.

Common Pathologies Summary

Mark-Scheme Checklist

Common Mistakes

Frequently Asked Questions

"How do I apply the Ottawa ankle rules in an OSCE?"

The Ottawa ankle rules are a clinical decision rule to determine whether an ankle X-ray is needed after acute injury. You should cite the rule clearly: X-ray is indicated if there is pain in the malleolar zone AND bony tenderness at the posterior tip of the lateral or medial malleolus, OR inability to weight-bear for four steps both immediately and at assessment. The mid-foot rules apply if there is pain in the mid-foot zone with bony tenderness at the navicular or base of the fifth metatarsal. The rules have near 100% sensitivity for clinically significant fractures and are used to safely exclude fracture without imaging. Importantly, they apply only to adults after acute injury — not to chronic pain, children under 5, or patients with altered consciousness. In the OSCE, state the indication, apply the rule systematically, and explain what a positive result means for management.

"What is the Simmonds-Thompson test and when is it positive?"

The Simmonds-Thompson (calf squeeze) test assesses integrity of the Achilles tendon. The patient lies prone with their feet hanging off the end of the couch. You firmly squeeze the mid-calf muscle bulk — in a normal intact Achilles, this produces passive plantarflexion of the foot. If squeezing the calf produces no foot movement, this is a positive test, strongly indicating complete Achilles tendon rupture. Sensitivity is approximately 96% and specificity around 93% for complete rupture. Note that a gap may be palpable in the tendon, and the patient will report a sudden pop during the injury. Management of confirmed rupture involves orthopaedic referral and a shared decision between surgical repair and conservative management with functional bracing. Always perform this test in the OSCE when the history includes a sudden sharp pain in the heel during activity.

"What causes pes cavus and why does it matter clinically?"

Pes cavus (high-arched foot) has a neurological cause in the majority of cases, and this is an important teaching point for OSCEs. Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy) is the most common neurological cause and presents with bilateral pes cavus, clawing of toes, and distal muscle wasting — it should prompt family history taking and neurological examination. Other neurological causes include Friedreich's ataxia, spina bifida, and polio. Idiopathic pes cavus also occurs. Clinically, pes cavus causes abnormal weight distribution across the metatarsal heads, leading to callosity formation, stress fractures, and ankle instability. Finding pes cavus in the OSCE should prompt you to state "I would like to perform a full neurological examination of the lower limbs and take a family history."

"How do I differentiate plantar fasciitis from other causes of heel pain?"

Plantar fasciitis is the most common cause of heel pain in adults and has a characteristic history and examination. The hallmark is first-step pain — severe pain on taking the first few steps in the morning or after prolonged rest, which eases with walking but worsens again after prolonged activity. Examination reveals point tenderness at the calcaneal insertion of the plantar fascia (medial plantar heel), and the Windlass test may be positive. Differential diagnoses include: heel fat pad atrophy (diffuse plantar heel pain, no first-step phenomenon, affects older patients), Achilles tendinopathy (posterior heel, not plantar), calcaneal stress fracture (bilateral squeeze pain, history of increased activity), seronegative spondyloarthropathy (enthesitis at insertion — check for other SpA features), and tarsal tunnel syndrome (burning/tingling medial heel and arch, Tinel's sign behind medial malleolus).

"What are the causes of a flat foot (pes planus) in adults?"

Adult-acquired flat foot (loss of medial longitudinal arch) is most commonly caused by tibialis posterior tendon dysfunction (TPTD), which is the key diagnosis to consider in middle-aged women presenting with medial ankle pain, swelling, and progressive arch collapse. Examination findings include inability to perform a single-leg heel rise (classic test), medial hindfoot swelling, and the "too many toes" sign when viewed from behind (lateral forefoot visible due to hindfoot valgus). Other causes include ligamentous laxity (Ehlers-Danlos syndrome, Marfan syndrome), Charcot neuroarthropathy (diabetes, syringomyelia), inflammatory arthritis destroying tarsal joints, and post-traumatic (calcaneal fracture malunion). In children, flat foot is usually physiological until age 6-8 and rarely requires treatment. Always assess whether the flat foot is flexible (arch reforms on tiptoe) or rigid (fixed deformity suggesting tarsal coalition or arthritis).

"What neurological examination should I include in a foot and ankle OSCE?"

The foot and ankle station should include a brief but systematic neurological assessment of the lower limb periphery. Test light touch sensation in the dermatomes: L4 (medial lower leg and foot), L5 (dorsum of foot and big toe), and S1 (lateral foot and sole). Check the Achilles tendon reflex (S1) — use reinforcement if absent. Test motor function: toe extension (L5/EHL), ankle dorsiflexion (L4/tibialis anterior), and plantarflexion (S1/gastrocnemius). Assess proprioception at the big toe. Common neurological findings include peripheral neuropathy (diabetes, alcohol — glove-and-stocking loss), common peroneal nerve palsy (foot drop, weak dorsiflexion and eversion, loss of sensation dorsum of foot), and tarsal tunnel syndrome (tibial nerve compression causing medial heel and sole symptoms). State findings systematically and link them to anatomy in your presentation.

Related guides: Ankle Examination OSCE · Gait Assessment OSCE · Diabetic Foot Examination OSCE · Musculoskeletal History OSCE · GALS Screening Examination OSCE