Pediatric Orthopaedic Exams: The Foot and Ankle

David Horn, MD, Orthopaedic Surgeon at Children's Hospital of Philadelphia (CHOP), demonstrates how to properly perform a foot and ankle exam on a pediatric patient, including assessment for tarsal coalition, neurological conditions, calcaneal apophysitis (Sever's disease), high ankle sprains and other injuries to the ligaments, distal fibula fractures and other fractures, and more.

Transcript

Pediatric Orthopaedic Exams: The Foot and Ankle

David Horn, MD: I'm Dr. David Horn. I'm one of the Attending Orthopedic Surgeons here at The Children's Hospital of Philadelphia, and I’ll be performing a foot and ankle exam on Stewart over here. Stewart, how are you? 

Stewart, patient: Good. 

Dr. Horn: How are you doing? 

Stewart: Good. 

Dr. Horn: All right. So what we'll start off with is an assessment of his gait. Stewart, why don't you climb down here, please? I want you to walk towards the doorway. So what we're looking for is any differences in the gait from side to side, any sign of pain or limping, particularly if he's putting less … spending less time on the affected side when he's standing on it. That could be a sign of a painful gait. So any differences is what you're looking at. You're looking also for the position of the foot and the angle of the foot when he walks, whether it's rotating inward or outward also can give you clues to pathology. 

Next, we're going to look at the mobility of the hind joints. If you could just stand up and turn around for a second. And just go up on your tiptoes, and stand flat again. And if you notice … if you look at his heel right here … go up on your tiptoes one more time. You can see how it inverts or it turns in when he goes up on his toes. You can stand flat again. That's a normal finding that's known as the heel rise test. And what that shows is that the subtalar joint is mobile and that the posterior tibial tendon is functioning. And so, if the heel does not go in when he does that, you'd be concerned about something that would be affecting the subtalar joint, perhaps a tarsal coalition or some pathology or stiffness in that joint. All right. You can sit here. 

The next step in the exam is just first observing. Look for any areas of discoloration, swelling, redness. You can gently palpate it. Look for any areas of warmth or hypersensitivity. I could see if there is reflex sympathetic dystrophy or nerve vascular dystrophy or some neurological condition. 

Once you do that, then I usually systemically palpate the different regions of the foot. Typically, if there is any injury or area of complaint, I will palpate that last to avoid unnecessarily causing pain, or also gain confidence so the child does not start reacting and causing problems. So, it's a systematic palpation, starting at the toes, moving on to the forefoot and the midfoot.

You can look at lisfranc, a joint which is the joint just where the metatarsals meet the tarsal bones right here. Medially you can look at the medial tuberosity of the navicular. This is where the tibialis posterior tendon inserts. It's a common site of pain if there is an accessory navicular in kids.

On the lateral side of the foot is the base of the fifth metatarsal, which is right about here. The peroneal brevis tendon inserts on here, and this is a common site of fractures and injuries. Actually you’re doing a good job. What were you doing? Push against me here. And you can see that tendon coming up very nicely as he everts against me. And that, you can follow that down, right to the base of the fifth metatarsal. 

Once I do that, I’ll typically go to the calcaneus, or the heel bone. We'll go this way. And you palpate the posterior aspect of the calcaneus, looking for any tenderness over the calcaneal apophysis. This is a common site of calcaneal apophysitis, which is a common cause of heel pain in kids. And here's the Achilles tendon, and you can see very nicely, and you can palpate that for any tenderness and look at that for any swelling. 

Other places to palpate is … look at the bone, look at the ankle joint itself, so medially the deltoid ligament from the medial tibia going to the talus, and that's right about here. That can get injured. More commonly you're going to find anterolateral ankle ligaments with the anterior talofibular ligaments, the calcaneal fibular ligament, and the syndesmotic ligaments, which are between the tibia and fibula. It's right about here. And that's the so-called high-ankle sprain — easily injured. 

Another test you can do to assess that is the so-called “squeeze test,” where you take the tibia and fibula and push them together, looking for any tenderness or pain with that maneuver. Once I do that you can palpate the anterior ankle chain joint as well, looking for any tenderness or swelling. Then looking at bony tenderness, you can look at the medial side of the ankle at the medial malleolus right here and the medial distal tibial physis.

Then you can start palpating the bony regions of the distal tibia of the ankle joint. So you have the medial malleolus right here which is subcutaneous. You can palpate that for any areas of tenderness, particularly if you palpate the subcutaneous border of this, you can feel oftentimes a small ridge of the depression, which is the growth plate itself. You can palpate that.

Oftentimes I find it helpful to look at the child while you're palpating it, because sometimes they won't say something hurts, but their face will show some wincing or their eyes will get a little bit bigger, or some non-verbal sense of pain or discomfort.

Moving on to the lateral side of the ankle, here's the fibula here. The lateral malleolus, and here's the tip. And then again, you can usually palpate the physis, or growth plate, by a little irregularity in the subcutaneous border. You can palpate that. A very common site of ankle injuries in children is the distal fibial physis. 

Next, we're going to look at motion. There's really two important things I think when assessing motion. One is the actual ankle joint motion. To do that, you can keep the knee extended, and you want to invert the foot, and what that does, that locks the small joints of the mid-foot and creates a stable environment that … so when you bring the ankle up, you're truly testing ankle motion, not just motion from the foot itself. So you invert the foot, extend the knee, then you dorsiflex the ankle. And he dorsiflexes very nicely. He's probably about 20 degrees above neutral. So about a 90-degree angle from the line of the tibia would be zero. If it doesn't reach zero, you're in plantar flexion or an equinus contracture. If it goes above … he goes about 20 degrees. 

The second sort of type of motion that requires a little bit of care to assess is the subtalar joint motion, which is the joint between the talus and calcaneus. And to do that, you would dorsiflex the ankle. What that does is that sort of locks the ankle bone or talus in the ankle joint itself so you don't get any rocking or motion through that joint, and then you just palpate the heel bone, and then you rock that sort of side-to-side. And looking at him he's not exhibiting any pain or discomfort, and it moves very smoothly. 

Now, if I have trouble quantifying the amount of motion someone has in their subtalar joint, so oftentimes it's very useful to compare it to the other side and say is it the same or is it less. Last thing I’ll do in the examination is — well. the last two things I’ll do is — first I’ll do a neurological exam. So look at sensation, so the bottom of the foot; the medial aspect of the foot; lateral side of the foot; the dorsum of the foot, particularly, this dorsal first web space, which is a unique area for sensation for the deep branch of the peroneal nerve. 

And then, as part of that, look at the muscle strength, look for your neural motor exam. So, you can push in this way, push in against me. There you go. And push out, and push up, and push down. So you're looking at invertors, evertors, push out again, dorsal flexors, and plantar flexors. 

And that's how you do a foot and ankle examination.

Related Centers and Programs: Division of Orthopaedics, Foot and Ankle Program