Lower Limb

Foot & Ankle Exam




Shoes - raises / wear patterns

Stigmata generalised disease

Hands - RA, CMT




Knee alignment

Forefoot - Hallux & Lesser toes 


Circulatory changes


Medial Side


Turn affected side away & ask to step foot forward

Flexed attitude of knee

Medial arch - planus / cavus




Spine - scoliosis / spinal dysraphism

Hindfoot varus / valgus

Forefoot (Too many toes)



Calf wasting


Double heel raise 

- Heel swings into varus or remains in valgus

- ? mobile subtalar joint

- ? Medial arch restoration


Single heel raise

- Must put patient close to blank wall half a foot length from the wall

- otherwise will cheat by pushing up or leaning forward against wall 


Lateral side



Peroneal tendons





- Stiff / Fixed equinus 

- Weak / Foot drop

- Painful / Antalgic


Foot Progression angle

Tip toe - strong S1

Heel walk - strong L4




On edge of bed with legs hanging

- examiner sits on chair


Screen active ROM AKJ and STJ bilaterally


Look at sole

- normal distribution weight pattern

- callosities

- lumps / plantar fibromatosis



" Where is it painful?"


Lateral aspect

- lateral malleolus

- lateral ligament complex

- Peroneal tendons

- sinus tarsi

- base of 5th 


Posterior aspect

- tendo-achilles

- insertional / non insertional



- deltoid ligament

- tibialis posterior

- MT joints

- sustenaculum tali



- ankle joint tenderness / effusion




- fat pad

- insertion of plantar fascia





- hallux rigidus

- sesamoids

- metatarsalgia

- Mulder test / interdigital tenderness




DF - active and passive range 20o


PF - active and passive range 50o


Subtalar joint motion 

- ankle in 90° DF

- thumb on talar neck to detect talar movement 

- opposite hand cups heel and inverts & everts 

- Inversion 10-15o

- Eversion 0-5o


Midtarsal joint

- Foot at 90 to lock ankle mortise

- Adduct foot 20o

- abduct foot 10o

- dorsiflex

- plantarflex


T Ach

- Tenderness along tendon /Insertion, ? lump

- test power / pain


Foot Exam Tibialis AnteriorFoot Exam Tibialis PosteriorFoot Exam Peroneals


Tibialis posterior

- Prominent with plantarflexion and inversion

- Thickening

- Tenderness

- Check power if abnormal


Peroneus brevis & longus

- thickening

- Tenderness

- Dislocation (resisted eversion)

- active eversion


Tibialis anterior

- Prominent with dorsiflexion and inversion

- Insertion


EHL & EDL - Dorsiflex toes


Special tests




Anterior drawer

- Due to complete tear of ATFL

- Grasp lower tibia and cup calcaneum

- "clunk" or draw

- compare with other side > 3 mm


Lateral instability

- Inversion stress

- Gaping of soft tissues

- Talar tilt (may occur in normal & must compare with other side)

- Needs to be confirmed on stress views

- > 20o


Medial instability

- Eversion stress

- Gaping / widening

- Needs to be confirmed on stress views


Gastrocnemius /soleus contracture


Test if limited dorsiflexion


Silverskiold Test

- Extend knee - dorsiflexion limited by both soleus & gastrocnemius contracture

- Flex knee - gastrocnemius relaxed (crosses knee joint)

- If dorsiflexion still limited it is due to soleus contracture

- If limited in extension & not in flexion then due to gastrocnemius contraction


Pes cavus


Claw toes - flexible / fixed


Individual power compared with other side

- Tibialis anterior (inversion in DF)

- Tibialis posterior (inversion in PF)

- Peronei


Coleman block test

- Dynamic visualisation of hindfoot correction

- Stand on 2cm block


Passive correction of plantar-flexed 1st MT


Spine / Neuro Exam


Hallux valgus


MTPJ Painful / limited range

- flexion 45o

- extension 70-90o

- redo range with correction



- hallux interphalangeus

- extension / flexion


Lesser toes

- fixed / mobile

- dislocated





Neuro exam

Vascular exam

Ligamentous laxity



Gait Exam



Limp - asymmetrical gait pattern

Note:  Children assume adult walking patterns by the age of eight


Normal Gait


1.  Rate

- increased, decreased or normal


2.  Rhythm

- normal or limp

- limp is a disturbance in normal rhythm

- numerous causes - see below


3. Gait cycle

- individual cycle

- from one foot strike to the same foot strike

- stance 60% swing 40%




Initial contact - knee extended


Loading response - knee flexed, ankle DF


Mid stance


Terminal stance - hip extends, heel rise


Pre swing - ankle PF


Initial swing 

- need foot clearance 

- knee flexed, ankle DF


Mid swing


Terminal swing


Elements of gait asymmetry





Trendelenburg (gait or lurch)

Rigid -  hip / knee / ankle

Antalgic - painful, shortened stance phase

Weak - hip (trendelenberg), knee (back knee gait), ankle (high stepping)

Supratentorial (CNS - spastic / ataxic / toe walking / crouch / jump)


Gait Examination


Examine in coronal plane (from front) and in sagittal plane (from side)





- foot progression angle

- bilateral in / out toeing

- old SUFE (walk with ER)


Sagittal (F/E)

- should have 3 rocker phases (might have just one or two)

- Heel Strike / Plant / Toe off

- nil heel strike in toe walker / cp - equinus may be fixed or not

- high stepping gait if weak

- equinus if LLD (shouldn't be fixed)





- varus / valgus malalignment & thrust

- squinting / medially facing patella secondary increase PFA


Sagittal (F/E)

- achieving full extension in stance (not in a cp)

- back leg gait (weak knee extensors eg polio)

- may hold flexed in LLD





- abductor lurch

- scissoring (adductor tightness in cp, increased PFA)


Sagittal (F/E)

- hyperflexion / FFD (hyperlordosis)

- weak hip flexors - back extension





- pelvic asymmetry secondary to LLD / scoliosis



- hyperlordosis (hip FFD)




Coronal - swaying side to side


Head - up and down with LLD



- a hemiplegic will swing only one arm


Specific Gait patterns



- head and shoulders drop as patient steps onto short limb (bobbing up & down of head and shoulders in sagittal plane)

- Pelvis drops on affected side with heel strike and exaggerated head motion in sagittal plane

- vaulting gait

- flexion knee, equinus ankle 





- head & torso sways front to back in sagittal plane as walks

- Decreased hip flexion on swing phase and lumbar motion increases (AP sway)



- hip circumducts

- little flexion / extension through stance



- may turn foot out to use STJ

- limitation F/E in sagittal plane

- DDX unilateral fixed equinus

- Tight TA / Hemiplegic CP / Short leg / Foot drop



- shortened stance phase





- Trendelenberg / abductor lurch

- head and shoulders sway side to side



- weak quads

- back knee gait



- Foot drop gait

- High stepping gait




Spastic gait 



1.  Equinus gait - nil heel strike in rocker phases

2.  Jump gait - ankle equinus, knee flexion

3.  Crouch gait - ankle / knee + hip flexion

4.  Scissoring gait



- unilateral loss heel strike, knee held flexed

- nil movement of arm in swing



- broad based gait




Hip Exam



Walking aid


Footwear - shoe raises



- Overall alignment of Lower Limb



- lumbar lordosis

- flexed attitude of hip / knee

- scars



- lumbar spine

- buttock wasting

- popliteal creases

- examine ROM

- try to differentiate spine and hip


Functional Leg Length


Attain symmetrical stance

- knees extended

- feet flat on ground

- check levels of ASIS

- comment on


A.  Pelvis is level / not level

B.  Stance is symmetrical

C.  Coronal plane deformity - Knee is flexed, ankle is in equinus 




A.  Pelvis is level with symmetrical stance

- no LLD


B.  Pelvis is not level with symmetrical stance

- uncompensated LLD


C.  Pelvis is level with asymmetrical stance

- compensated LLD


D.  Pelvis is not level with asymmetrical stance

- partially compensated LLD

- contractures



- if pelvis not level

- to assess functional leg length discrepancy





- assess if patient's abductors can elevate ASIS on affected side

- without using trunk



- visualise ASIS or PSIS

- stand on good leg

- opposite ASIS should rise

- stand on bad leg

- cannot raise opposite ASIS
- either fall or have to lean trunk over


False negative test

- able to maintain abduction with no abductor function

- fixed abduction contracture

- arthrodesed hip in abduction


Invalid if

- poor balance

- generalised weakness

- lack of co-ordination or understanding

- costo-pelvic impingement




1. Pain

- painful disorder of hip

- centre over hip to decrease abductor pull

- decrease joint reaction forces  


2. Pivot

- dislocation or subluxation of hip

- shortening of femoral neck 

- abductors cannot work correctly


3. Power 

- weakness of abductors







- shoulder drops on ipsilateral side

- head up and down



- abductor lurch


Rigid / Stiff

- hip

- knee



- shortened stance phase



- back knee gait

- foot drop


Supratentorial (CNS)


Supine on Examination Bed




Along line of inguinal ligament from medial to lateral

- masses (dislocated femoral head, hernias, aneurysms, lymph nodes)

- tenderness (LCFN)


Along posterior greater trochanter

- tenderness (trochanteric bursitis)




Exclude FFD of knee

- allows assessment of leg length (correct with pillow)

- allows assessment of FFD of hip (must put knee over bed)


Valgus knee

- difficulty measuring LL

- will be unable to put other leg in same position

- must measure components




Normal ROM

- Flexion / extension 140o

- adduction / abduction 400

- IR / ER


Thomas' Test


Angle through which thigh is raised from couch is angle of fixed flexion


Fixed flexion deformity of knee

- place patient at edge of couch

- when assessing FFD, move heel over edge of couch

- lower heel below level of couch

- to eliminate effect of knee FFD



- passively flex both knees to 45o

- place hand behind back and

- ask patient to clutch unaffected knee to chest

- ensure lumbar lordosis eliminated

- this fixes pelvis



- gently extend affected hip passively

- lift heel off bed

- stop when painful

- fixed flexion deformity of (x)o



- ask patient to actively flex affected hip

- gently passively maximise flexion

- comment

- flexes to (y)o

- flexion arc of (x)o FFD to (y)o


Abduction / Adduction in Extension



- hip and knee extended

- fix pelvis by abducting unaffected hip so that leg dangles over edge of couch

- palpate ipsilateral ASIS

- abduction / adduction both sides

- know at extremes of limit when ASIS / Pelvis begins to move


Internal and External Rotation in Flexion



- hip flexed to 90o

- hold leg with one hand

- hand in popliteal fossa

- leg resting on forearm

- assess pelvis movement with other hand

- palpate contralateral ASIS

- internal rotation, turn foot out

- external rotation, turn foot in

- examine contralateral side 


Leg Length


Make pelvis square with bed

- attempt to make legs square with pelvis and straight

- ensure buttocks not in dip in bed

- ensure normal heel height

- ensure no asymmetrical buttock wasting


Apparent LL 

- leg length measured without correcting for sagittal or coronal plane deformity

- from umbilicus to medial malleolus

- tape measure


True LL 

- leg length measured once coronal & sagittal plane deformity corrected for 

- sum of intercalated segments

- ASIS to medial malleolus


Correct for 


1.  Abduction contracture

- comment on contracture

- unable to place legs perpendicular to pelvis because of abduction contracture

- must place other leg in same position

- abduct unaffected hip same degree

- measure leg length


2.  Adduction contracture

- comment on contracture

- unable to place legs perpendicular to pelvis because of adduction contracture

- must place other leg in same position

- measure leg lengths sequentially

- cross one leg and measure

- cross other leg and measure


3.  FFD Hip or Knee

- correct with pillows


4.  Equinus foot

- look below medial malleolus

- difference in effective heel height because of equinus contracture


5. Coronal plane deformity knees

- cannot correct for 

- must measure intercalated segments


Galeazzi's sign


Identify level of leg length discrepancy


Flex knees to 90o with hips and ankles at 45o

- put malleoli at same level

- any hindfoot asymmetry makes test inaccurate


Femurs parallel

- tibias same height

- discrepancy above knee


Tibias parallel

- femurs same length

- discrepancy in tibia

- knees at different levels


LLD above GT


1.  Bryant's triangle

- identify ASIS with thumb & tip of greater trochanter with forefinger

- drop imaginary lines down to floor

- distance between the lines

- difference in distance between ASIS and GT suggests discrepancy proximal to GT

- assess perpendicular distance between points with fingers of other hand

- perpendicular distance between points is different by (x) fingerwidths


2.  Schoemaker's line 

- line from greater trochanter thru ASIS

- projection from each side should cross proximal to umbilicus

- if shortening above gr trochanter then the lines will cross below the umbilicus


3.  Nelaton's line 

- ischial tuberosity to ASIS

- with patient lying on the side

- the greater trochanter should lie on the line


Knee Exam




Walking aids




Knee alignment 

- physiological valgus


Patellar rotation 

- squinting (inwards, increased PFA) 

- grasshopper eyes (high and lateral)



Quads Wasting



Knee effusion




Knee attitude

- flexion

- recurvatum

- push knees back


Knee FFD Standing


Step foot forward and bear weight

- examine arch






Hindfoot valgus

Swelling popliteal fossa

Wasting of hamstrings or calf

Level popliteal creases


Other Side


Knee attitude

- flexion

- recurvatum

- push knees back


Step foot forward






Rigid / Stiff

- decreased flexion / extension range




Weak knee

- back knee gait


Medial or lateral thrust

- valgus or varus moment about the knee


Foot progression angle


Sit on Edge of Bed


Patella tracking

- crepitus


J tracking

- patellar sharply deviates laterally in terminal extension

- or travel laterally until jumps into trochlea at midrange of flexion





- quads wasting

- alignment

- scars



- swipe, ballot, tap



- FFD / Recurvatum / lift foot in air

- active extension / quads lag

- range of flexion bilaterally


Knee FFD LyingKnee FFD Fixed



- effusion

- entrapped meniscus

- ACL stump

- loose body





- Extensor mechanism

- patella

- tibial tuberosity



- Joint lines, MCL, LCL

- tibial and femoral condyles

- popliteal fossa


Palpate distal femur for osteochondromas


Examine Ligaments




Test at 0 and 30o

- if loose at 0, loss of secondary stabilisers



1+   Surfaces separate 5mm or less

2+   5 - 10 mm

3+   10 mm or more





- 85% sensitive awake

- 100% asleep


Check loss of tibial step off

- posterior sag

- MTP normally 1 cm anterior to MFC


Quadriceps active

- knee at 90o

- stabilise foot & ask to slide foot down bed

- N < 1mm / PCL > 3mm


Anterior / Posterior drawer

- restore tibial step off


Posterolateral drawer

- 30o IR

- tightens PLC


Posteromedial drawer

- 15o ER

- tightens PMC


Pivot Shift

- valgus stress with IR + axial compression

- knee moved from extension to flexion

- in chronic ACL deficiency, the LTC is subluxed anteriorly

- at 30o it reduces backwards

- this is when ITB passes behind axis of rotation and becomes flexor

- grade pivot glide / 1 / 2 / 3


Must have 4 things

- MCL to pivot about

- intact ITB

- no FFD

- ability to glide i.e. no meniscal pathology


PCL / Posterolateral Corner (PLC)


External rotation / Recurvatum

- hold big toe and assess PLC

- knee moves into recurvatum, tibia externally rotates & subtle varus

- indicates PCL + PLC + LCL


Reverse pivot shift 

- with valgus and ER

- flexion to extension

- in flexion, the LTP is posteriorly subluxed

- ITB become extensor

- reduces as extend

- must compare with other side

- present in 30% normal population especially ligamentous lax


Dial test / Prone

- measure thigh foot angle

- examiner holds knees together

- increase at 30o only  - PLC

- increases at 30 then again at 90 - PLC + PCL

- isolated PCL - no increase

- >10o compared with normal side





- Flexion to extension

- Full IR - LM

- Full ER - MM

- i.e. test meniscus heel is pointing towards

- positive test is palpable / audible thud, snap, click


Squat test

- feet IR and ER




Concealed / popliteal fossa


Cephalad / Hip

- rotation in flexion

- adduction / abduction in extension






PFJ Exam



Stigmata Generalised disease

- Marfan's


Ligamentous laxity Wynne Davies

- positive if 3/5 pairs

- thumb touches volar forearm

- fingers parallel to forearm dorsally

- elbow hyperextends past 0o

- knee hyperextends past 0o

- ankle dorsiflexes > 45o




VMO bulk


Scars of previous surgery i.e. TTT


Planovalgus Feet / Hyperpronation


Genu Valgum


Squinting patella 

- Proximal Femoral Anteversion  (PFA)

- patellae point inwards when standing


Grasshopper eyes 

- patellas sit high & lateral

- due to patella alta 

- patella subluxed laterally 




Flexed attitude Knee





Level Popliteal creases

Valgus Heels




Foot Progression Angle

- Normal 10° (0-30°)

- any in-toeing

- indicative of PFA


Sit on ege of Bed


Patella Tracking

- J sign

- lateral subluxation in terminal extension








3 signs in Extension


1.  Tenderness

- tibial tuberosity

- lateral patella retinaculum

- patella

- Bassett's sign (MPFL on med epicondyle)

- pain with patella grind (compression)


2.  Clark's test

- gentle pressure on superior pole

- patient asked to contract quadriceps

- compare with other side


3.  Patellar Tilt Test

- Patient supine and relaxed with knees extended

- Trans- epicondylar axis placed parallel to table

- Lateral edge of patella elevated & medial edge depressed

- normal is lateral tilt 0-20°

- Abnormal if unable to tilt to horizontal

- indicated lateral retinaculum tightness


3 Signs in 30o Flexion


1.  Q angle 

- Knee at 30° flexion so patella engages femoral sulcus

- ASIS to centre of patella to tibial tuberosity

- abnormal > 15° in males 

- abnormal > 20° in female


2.  Patellar glide test (Sage Mobility)

-  Graded by number of 1/4 widths that patella displaces

- > 3 insufficient medial restraints

- < 1 tight lateral retinaculum

- > 3 insufficient lateral restraints


3.  Apprehension test

- patient supine and relaxed

- patella pushed laterally while knee flexed 30o

- positive if patient uncomfortable (pain or apprehension)


Prone / Rotational profile


Best is all assessed prone


1.  Lateral border of foot

- metatarsus adductus


2.  Tibial Torsion

- thigh foot angle > 15o

- trans-malleolar axis > 30o


3.  Femoral anteversion 

- excessive IR

- increased Gage's trochanteric angle




Sciatic Nerve Exam



Wasting of anterior & lateral compartments leg

Scars at fibula head


Feet for dystrophic changes

Back - surgery / dystrophic changes

Hip - scars




Foot drop gait, high stepping, slapping




Along CPN




Sensation Tibial nerve

- sole of foot


Sensation CPN

- SPN dorsum of foot

- DPN 1st webspace




Tibial nerve

- hamstrings

- T. Ach





- T. Ant (L4)

- EHL (L5) – often 1st damaged as most prox br

- EDL (L5,S1) – isolated with ankle in DF

- PL & PB (L5,S1) – eversion & palpate




L5 v Sciatic / Tibial

- examine Abductors (L5)


CPN above knee v below knee

- short head biceps EMG