Foot Examination

Commonly Tested

The foot examination requires systematic assessment of the hindfoot, midfoot, and forefoot. Key concepts include differentiating flexible from rigid flatfoot, recognizing PTTD (posterior tibial tendon dysfunction), and understanding the windlass mechanism. The Coleman block test is critical for cavovarus foot.

Exam day cheat sheet

Foot Examination Summary

Look

Hindfoot alignment (varus/valgus)
Medial arch (high/low/normal)
Too-many-toes sign
Forefoot deformities (hallux valgus, claw toes)
Skin (calluses, ulcers)

Feel

Posterior tibial tendon
Spring ligament
Navicular
Metatarsal heads
Plantar fascia

Move

Subtalar (inversion/eversion)
Midtarsal (forefoot abduction/adduction)
First ray mobility
MTP joints
IP joints

Special Tests

Single heel raise (PTTD)
Jack test (windlass)
Coleman block (cavovarus)
Silfverskiold (equinus)
First ray hypermobility

Introduction and Setup

Before You Start

Patient Positioning:

Standing for alignment and functional tests
Seated for detailed examination
Walking for gait assessment

Exposure: Both feet and ankles exposed, observe with and without shoes

Consent Script: "I'm going to examine your feet. I'll start by watching you walk, then look at both feet standing and sitting. Please tell me if anything is painful."

Key Anatomy:

Hindfoot: Talus, calcaneus (subtalar joint)
Midfoot: Navicular, cuboid, cuneiforms (Chopart's and Lisfranc's joints)
Forefoot: Metatarsals and phalanges
Medial longitudinal arch: Maintained by plantar fascia, spring ligament, posterior tibial tendon

Look (Inspection)

Standing Assessment

Hindfoot alignment: Valgus (flatfoot), varus (cavus)
"Too-many-toes" sign: More than 1.5 toes visible laterally = forefoot abduction (flatfoot)
Heel position: Neutral, valgus, varus
Calf bulk: Compare sides
Achilles tendon: Alignment, thickening

Seated/Supine Assessment

Toe alignment: Hallux valgus angle, lesser toe deformities
MTP joint swelling: RA, gout, OA
Skin: Dorsal corns, bunionette
Extensor tendons: Visible, intact

Key Concept

Too-Many-Toes Sign: Stand behind patient. If you can see more than 1.5 lateral toes on the affected side, there is forefoot abduction relative to the hindfoot. This is characteristic of adult acquired flatfoot (PTTD Stage II+).

Feel (Palpation)

Systematic Palpation Sequence

Hindfoot:

Posterior tibial tendon: Behind medial malleolus to navicular insertion
Flexor hallucis longus: Behind PTT, more posterior
Spring ligament: Plantar to talar head (soft tissue support of arch)
Sustentaculum tali: Medial calcaneal shelf

Midfoot:

Navicular tuberosity: PTT insertion, accessory navicular
Talonavicular joint: Dorsomedial
Calcaneocuboid joint: Dorsolateral
Cuneiform bones: 3 bones, first is largest

Forefoot:

Metatarsal heads: Plantar tenderness (metatarsalgia)
1st MTP joint: Medial (bunion), dorsal (OA)
Lesser MTP joints: Swelling, instability
Web spaces: Morton's neuroma (3rd web space)
Sesamoids: Under 1st metatarsal head

Plantar Surface:

Plantar fascia: Origin at calcaneus (plantar fasciitis)
Metatarsal fat pad: Atrophy in elderly
Calluses: Indicate abnormal pressure

Move (Range of Motion)

Subtalar Inversion

normalRange: 0-30°
technique: Cup heel, invert
keyPoints: Hindfoot motion

Subtalar Eversion

normalRange: 0-15°
technique: Cup heel, evert
keyPoints: Limited in coalition

Transverse Tarsal

normalRange: Variable
technique: Lock subtalar, rotate forefoot
keyPoints: Supple vs rigid midfoot

First MTP Dorsiflexion

normalRange: 0-70°
technique: Extend big toe
keyPoints: Hallux rigidus if limited

First MTP Plantarflexion

normalRange: 0-45°
technique: Flex big toe
keyPoints: Usually preserved

Lesser MTP/IP

normalRange: Variable
technique: Test each joint
keyPoints: Fixed vs flexible deformities

movement	normalRange	technique	keyPoints
Subtalar Inversion	0-30°	Cup heel, invert	Hindfoot motion
Subtalar Eversion	0-15°	Cup heel, evert	Limited in coalition
Transverse Tarsal	Variable	Lock subtalar, rotate forefoot	Supple vs rigid midfoot
First MTP Dorsiflexion	0-70°	Extend big toe	Hallux rigidus if limited
First MTP Plantarflexion	0-45°	Flex big toe	Usually preserved
Lesser MTP/IP	Variable	Test each joint	Fixed vs flexible deformities

Key Concept

Subtalar Motion: The calcaneus moves in inversion/eversion under the talus. This is the key joint for hindfoot flexibility. Reduced subtalar motion suggests tarsal coalition, previous fracture, or arthritis.

Special Tests

Flatfoot Assessment

Special test

Single Heel Raise Test

Posterior tibial tendon function and hindfoot flexibility

Technique

1Patient stands facing wall with hands for balance
2Ask patient to raise affected heel off ground (unilateral heel raise)
3Observe from behind

Positive Sign

Inability to perform single heel raise, OR heel does not invert during rise

Indicates

Posterior tibial tendon dysfunction (Stage II+), weak calf, neurological deficit

Diagnostic Accuracy

Sensitivity88%

Ability to detect true positives

Specificity94%

Ability to exclude false positives

Special test

Double Heel Raise with Observation

Assess hindfoot flexibility

Technique

1Patient performs bilateral heel raise
2Observe hindfoot alignment from behind

Positive Sign

Hindfoot corrects from valgus to varus = flexible; remains in valgus = rigid

Indicates

Flexible flatfoot if corrects, rigid/fixed deformity if does not correct

Diagnostic Accuracy

Sensitivity92%

Ability to detect true positives

Specificity85%

Ability to exclude false positives

Special test

Jack Test (Windlass Mechanism)

Test integrity of plantar fascia and arch mechanics

Technique

1Patient standing or sitting
2Dorsiflex the hallux (great toe) passively

Positive Sign

Arch reconstitutes (medial longitudinal arch rises)

Indicates

Flexible flatfoot (arch restored by windlass mechanism). No reconstitution = rigid flatfoot or plantar fascia insufficiency

Diagnostic Accuracy

Sensitivity90%

Ability to detect true positives

Specificity90%

Ability to exclude false positives

Special test

Hubscher Maneuver

Non-weight-bearing equivalent of Jack test

Technique

1Patient seated
2Passively dorsiflex hallux
3Observe arch formation

Positive Sign

Arch reconstitutes with hallux dorsiflexion

Indicates

Intact windlass mechanism

Diagnostic Accuracy

Sensitivity85%

Ability to detect true positives

Specificity88%

Ability to exclude false positives

Cavovarus Foot Assessment

Special test

Coleman Block Test

Determine if hindfoot varus is forefoot-driven or fixed

Technique

1Patient stands with lateral border of foot on 1-inch (2.5cm) wooden block
2First ray (1st metatarsal and great toe) hangs off medial edge of block
3Observe hindfoot alignment from behind

Positive Sign

Hindfoot corrects from varus to neutral = forefoot-driven (flexible); remains in varus = fixed hindfoot

Indicates

Forefoot-driven cavovarus (corrects) vs fixed hindfoot varus (does not correct). Determines surgical planning.

Diagnostic Accuracy

Sensitivity95%

Ability to detect true positives

Specificity90%

Ability to exclude false positives

Special test

Peek-a-Boo Heel Sign

Identify hindfoot varus

Technique

1Observe patient's feet from directly in front while standing

Positive Sign

Medial heel visible (peeking) on either side of ankle

Indicates

Hindfoot varus (cavus foot)

Diagnostic Accuracy

Sensitivity78%

Ability to detect true positives

Specificity85%

Ability to exclude false positives

First Ray Assessment

Special test

First Ray Mobility Test

Assess hypermobility or rigidity of first ray

Technique

1Stabilize the lesser metatarsals (2nd-5th) with one hand
2Grasp first metatarsal with other hand
3Move first ray dorsally and plantarly

Positive Sign

Excessive dorsiflexion indicates hypermobility; restricted motion indicates rigidity

Indicates

First ray hypermobility (can cause metatarsalgia, hallux valgus recurrence) or rigidity (hallux rigidus precursor)

Diagnostic Accuracy

Sensitivity70%

Ability to detect true positives

Specificity75%

Ability to exclude false positives

Neuroma and Metatarsalgia

Special test

Mulder's Click (Morton's Neuroma)

Detect interdigital neuroma

Technique

1Squeeze metatarsal heads together with one hand
2Apply dorsoplantar pressure to web space (usually 3rd) with other hand

Positive Sign

Palpable and sometimes audible click as neuroma subluxes between metatarsal heads

Indicates

Morton's neuroma (interdigital neuroma)

Diagnostic Accuracy

Sensitivity61%

Ability to detect true positives

Specificity62%

Ability to exclude false positives

Special test

Web Space Tenderness

Localize interdigital pathology

Technique

1Palpate each web space from dorsal approach
2Apply pressure between metatarsal heads

Positive Sign

Tenderness, reproduction of shooting pain to toes

Indicates

Morton's neuroma, interdigital bursitis

Diagnostic Accuracy

Sensitivity85%

Ability to detect true positives

Specificity50%

Ability to exclude false positives

Equinus Assessment

Special test

Silfverskiold Test

Differentiate gastrocnemius from soleus equinus

Technique

1Test ankle dorsiflexion with knee extended
2Test ankle dorsiflexion with knee flexed to 90°
3Compare the two measurements

Positive Sign

Improved dorsiflexion with knee flexion = isolated gastrocnemius tightness

Indicates

Gastrocnemius equinus if dorsiflexion improves; Achilles/soleus equinus if no improvement. Important for surgical decision (gastrocnemius recession vs TAL)

Diagnostic Accuracy

Sensitivity90%

Ability to detect true positives

Specificity92%

Ability to exclude false positives

Gait Assessment

Observe Patient Walking

Key Observations:

Heel strike: Present (normal) or absent (equinus, forefoot strike)
Midstance: Arch collapse timing, PTT function
Push-off: Single-limb heel raise function
Forefoot loading: Abnormal pattern suggests pathology

Specific Gait Patterns:

Antalgic

Observation: Short stance on affected side
Indicates: Pain

Equinus

Observation: Toe-walking
Indicates: Achilles/gastrocnemius tightness

Flatfoot

Observation: Arch collapse, late heel rise
Indicates: PTTD

High-stepping

Observation: Excessive hip/knee flexion
Indicates: Foot drop

Pattern	Observation	Indicates
Antalgic	Short stance on affected side	Pain
Equinus	Toe-walking	Achilles/gastrocnemius tightness
Flatfoot	Arch collapse, late heel rise	PTTD
High-stepping	Excessive hip/knee flexion	Foot drop

Neurovascular Assessment

Neurological Examination

Sensory Testing (Critical in Diabetic Foot):

Monofilament (10g Semmes-Weinstein): Tests protective sensation
Light touch: All dermatomes
Vibration: 128Hz tuning fork on bony prominences

Motor Testing:

Tibialis anterior

Nerve: Deep peroneal
Root: L4,5
Test: Ankle dorsiflexion

EHL

Nerve: Deep peroneal
Root: L5
Test: Great toe extension

Peronei

Nerve: Superficial peroneal
Root: L5,S1
Test: Foot eversion

Gastrocnemius/Soleus

Nerve: Tibial
Root: S1,2
Test: Plantarflexion

Tibialis posterior

Nerve: Tibial
Root: L4,5
Test: Inversion

FHL

Nerve: Tibial
Root: S1,2
Test: Great toe flexion

Muscle	Nerve	Root	Test
Tibialis anterior	Deep peroneal	L4,5	Ankle dorsiflexion
EHL	Deep peroneal	L5	Great toe extension
Peronei	Superficial peroneal	L5,S1	Foot eversion
Gastrocnemius/Soleus	Tibial	S1,2	Plantarflexion
Tibialis posterior	Tibial	L4,5	Inversion
FHL	Tibial	S1,2	Great toe flexion

Vascular Assessment

Pulses:

Dorsalis pedis: Lateral to EHL tendon
Posterior tibial: Behind medial malleolus

Signs of Vascular Compromise:

Hair loss on dorsum of foot
Trophic skin changes
Poor capillary refill (greater than 2 seconds)
Cool temperature
Dependent rubor

Ankle-Brachial Index (ABI):

Normal: 0.9-1.3
Mild disease: 0.7-0.9
Moderate: 0.4-0.7
Severe: less than 0.4

Complete the Examination

Must Know

Always state to the examiner:

"To complete my examination, I would like to:

Examine the ankle in more detail
Assess footwear (wear pattern, orthotic use)
Examine the spine and hips (especially in cavus foot - CMT)
Perform neurological assessment (especially if cavus)
Obtain weight-bearing X-rays (AP, lateral, oblique)"

Summary Presentation

Viva scenarioStandard

Presenting Your Findings

Clinical prompt

“55-year-old woman with progressive medial foot and ankle pain, difficulty walking long distances.”

Common Conditions Table

Adult Flatfoot (PTTD)

look: Hindfoot valgus, arch collapse
feel: PTT tenderness
move: No single heel raise
specialTests: Too-many-toes +, Jack test corrects

Cavovarus Foot

look: High arch, hindfoot varus
feel: Lateral overload calluses
move: May be rigid
specialTests: Coleman block determines flexibility

Hallux Rigidus

look: Dorsal osteophyte 1st MTP
feel: 1st MTP tender dorsally
move: Limited dorsiflexion
specialTests: Grind test +

Morton's Neuroma

look: Normal
feel: Web space tenderness (3rd)
move: Normal
specialTests: Mulder's click +

Plantar Fasciitis

look: Normal
feel: Medial calcaneal tenderness
move: Tight gastrocnemius
specialTests: Windlass increases pain

condition	look	feel	move	specialTests
Adult Flatfoot (PTTD)	Hindfoot valgus, arch collapse	PTT tenderness	No single heel raise	Too-many-toes +, Jack test corrects
Cavovarus Foot	High arch, hindfoot varus	Lateral overload calluses	May be rigid	Coleman block determines flexibility
Hallux Rigidus	Dorsal osteophyte 1st MTP	1st MTP tender dorsally	Limited dorsiflexion	Grind test +
Morton's Neuroma	Normal	Web space tenderness (3rd)	Normal	Mulder's click +
Plantar Fasciitis	Normal	Medial calcaneal tenderness	Tight gastrocnemius	Windlass increases pain

PTTD Staging

Stage I

deformity: None
flexibility: Normal alignment
findings: PTT tendinopathy, swelling, pain
treatment: Non-operative (orthosis, PT)

Stage II

deformity: Flexible flatfoot
flexibility: Correctable hindfoot valgus
findings: Too-many-toes, failed single heel raise
treatment: Reconstruction (calcaneal osteotomy + FDL transfer)

Stage III

deformity: Rigid flatfoot
flexibility: Fixed hindfoot valgus
findings: Subtalar arthritis, rigid deformity
treatment: Triple arthrodesis

Stage IV

deformity: Valgus tilt of talus
flexibility: Fixed + ankle involvement
findings: Deltoid insufficiency, ankle tilt
treatment: Tibiotalocalcaneal fusion

stage	deformity	flexibility	findings	treatment
Stage I	None	Normal alignment	PTT tendinopathy, swelling, pain	Non-operative (orthosis, PT)
Stage II	Flexible flatfoot	Correctable hindfoot valgus	Too-many-toes, failed single heel raise	Reconstruction (calcaneal osteotomy + FDL transfer)
Stage III	Rigid flatfoot	Fixed hindfoot valgus	Subtalar arthritis, rigid deformity	Triple arthrodesis
Stage IV	Valgus tilt of talus	Fixed + ankle involvement	Deltoid insufficiency, ankle tilt	Tibiotalocalcaneal fusion

Examiner Tips

Exam day cheat sheet

Scoring High in the Foot Examination

Do

Start with standing alignment
Perform single heel raise test
Use Coleman block for cavus foot
Check for equinus (Silfverskiold)
Assess footwear for wear pattern

Don't

Forget to look from behind
Miss the too-many-toes sign
Confuse Jack test with Coleman block
Ignore associated conditions (CMT in cavus)
Forget vascular assessment in older patients