Preparation
Expose both lower limbs sufficiently to assess alignment and gait. Examine footwear and any orthosis because wear patterns can reveal chronic loading abnormalities.
Standing inspection
Assess from front, side and behind:
- hindfoot alignment
- medial longitudinal arch
- forefoot abduction/adduction
- toe deformities
- callosities
- scars and swelling
- Achilles alignment
Ask the patient to perform a bilateral and, when safe, single-leg heel rise. Observe whether the heel moves into varus and whether the arch reforms.
Gait
Look for:
- antalgic pattern
- cadence and symmetry
- foot progression angle
- high-stepping gait
- inability to achieve heel strike or push-off
- rigid external rotation used to compensate for ankle stiffness
Observe:
- stride length
- heel strike
- progression angle
- stance-phase hindfoot motion
- push-off
- antalgia
- foot slap or high stepping
- ability to walk on heels and toes
A single-leg heel rise is particularly useful in assessing the tibialis posterior–Achilles complex and hindfoot flexibility. In a flexible valgus foot the heel should invert during a successful heel rise.
Sitting examination
Inspect soles and between the toes. Look at shoes, insoles and braces.
Palpate systematically:
- ankle joint line
- subtalar joint/sinus tarsi
- talonavicular and calcaneocuboid joints
- Achilles tendon
- posterior tibial tendon
- peroneal tendons
- plantar fascia
- metatarsal heads and MTP joints
Movement
Assess active and passive:
- ankle dorsiflexion and plantarflexion
- subtalar inversion/eversion
- midfoot motion
- first MTP motion
Compare dorsiflexion with the knee flexed and extended when gastrocnemius tightness is relevant.
Neurological and vascular examination
Document:
- dorsalis pedis and posterior tibial pulses
- light-touch sensation in major nerve distributions
- motor function, particularly tibialis anterior, posterior tibial, peroneal and calf muscles
Deformity tests
Use tests only when they answer a specific question:
- Coleman block test for cavovarus flexibility
- heel-rise test for posterior tibial tendon function
- Silfverskiöld test for isolated gastrocnemius tightness
Presentation
A strong summary states whether the foot is:
- plantigrade or non-plantigrade
- flexible or rigid
- neurologically normal or abnormal
- painful at a specific joint/tendon
- associated with proximal deformity
Examination sequence in an FRCS station
Start with the patient standing whenever possible. A foot examined only on the couch can conceal the deformity that is obvious under load.
From the front, assess:
- hindfoot and forefoot alignment
- toe deformity
- swelling, scars and skin condition
- arch height
- footwear and orthoses
From behind, assess:
- hindfoot varus or valgus
- Achilles alignment
- “too-many-toes” appearance
- calf wasting
- heel-rise mechanism
From the side, note:
- longitudinal arch
- equinus
- midfoot collapse
- prominence over the talar head or dorsal midfoot
Hindfoot and forefoot relationship
Determine whether the deformity is flexible or fixed.
The Coleman block test helps distinguish a forefoot-driven cavovarus deformity from a rigid hindfoot varus. Allowing the first ray to drop off the block removes its plantarflexion effect; correction of the hindfoot toward neutral implies a flexible, forefoot-driven component.
For flatfoot, assess whether hindfoot valgus corrects with heel rise or passive manipulation and whether forefoot supination becomes apparent when the hindfoot is corrected.
Range of motion
Assess:
- ankle dorsiflexion and plantarflexion
- subtalar inversion and eversion
- transverse tarsal motion
- first MTP movement
- lesser toe flexibility
Differentiate ankle from hindfoot movement by stabilising adjacent joints.
The Silfverskiöld test distinguishes isolated gastrocnemius tightness from a combined gastrocnemius-soleus contracture. Improvement of dorsiflexion with the knee flexed indicates a gastrocnemius-predominant restriction.
Tendons and power
Test:
- tibialis anterior
- tibialis posterior
- peroneals
- gastrocnemius-soleus
- EHL/FHL and lesser toe motors where relevant
Palpate tendon course and insertions, looking for tenderness, rupture, subluxation or weakness.
Neurovascular and skin assessment
Document pulses, capillary refill and sensation. In diabetes or neuropathy, examine:
- protective sensation
- callus
- ulceration
- pressure points
- deformity
- footwear
Never plan a reconstructive procedure without understanding vascular status and soft-tissue quality.
FRCS presentation
Summarise in terms of:
- primary deformity
- flexibility
- painful structure
- tendon function
- neurological or vascular deficit
- skin risk
- effect on gait and footwear
The key is to convert examination findings into a mechanical diagnosis rather than merely listing positive tests.