Now that you have a basic understanding of the structural anatomy of the feet and ankles, you are equipped to learn the detailed procedures for assessing them. As stated previously, the assessment process should begin with a verbal assessment.
When assessing the feet and ankles it is important to gain insight into how clients perceive their condition and/or pain in isolation, as well as in relation to other structures or when performing activities. As such, you should ascertain the following information during your assessment. As you conduct your verbal assessment, be sure to write down any pertinent information on a Client Assessment Diagram (CAD).
- Ask clients if they ever experience pain in the feet or ankles. Ask them to be specific (i.e., is the pain at the side or front of the ankle, under the heel or arch of the foot, back of the foot on the Achilles tendon, pain in the toes or on top of the foot). Encouraging verbal descriptions and details about the pain will help you better understand your client and their individual needs. For example, if a client has pain on the underside of her foot it may be a sign that her medial longitudinal arch is stressed. This will prompt you to check this client for signs of overpronation when you perform the visual and hands-on assessments.
- Ask clients if they have arthritis. This information will help you understand the integrity of their feet and ankles. However, do not let a diagnosis of arthritis make you think that you cannot help a client reduce his pain and improve his functional capabilities. Alignment is always the key to reducing any sort of stress or pain in the joints – including arthritis.
- Ask clients about their level of physical activity and the types of physical activities they perform. Ascertain specifics about how often they engage in those activities and to what degree of intensity and duration. This information will help you understand the type and amount of stress a client places on his or her feet and ankles throughout the day. For example, if a client with plantar fasciitis is an avid runner and she continues to keep up the same amount of running during her corrective exercise program, it will directly impact her potential success.
- Ask clients about their occupation or job. This information will help you further understand the level of stress being placed on the structures of the body. For example, a postman will have more stress on his feet and ankles than a computer technician.
- Ask clients whether the condition of their feet or ankles ever prevents them from engaging in an activity or limits their function. The answer to this question will help you understand their underlying motivation for coming to see you for help. If foot pain is preventing a client from playing tennis, for example, then knowing this from the outset will enable you to always relate the benefit of certain exercises to how the client can to get back to playing tennis.
- Ask clients if pain in their ankles or feet coincide with any other pains or symptoms in the body. This will help you establish causal links between symptoms and activities or circumstances, and also gets clients to start thinking about the interrelatedness of the body’s parts. For example, if a client is complaining of ankle pain but also notices that her back hurts when her ankle hurts, then she will be more likely to perform the exercises you design to help align her hips and lower back, knowing that this will also help her ankle feel better.
- Ask clients what aggravates their condition and what makes it feel better. This information will help you establish the source and/or cause of the pain. For example, if a client’s foot pain is worse after wearing particular type of shoes then it might be a good idea to review the client’s footwear choices as part of their corrective exercise program.
Once you have concluded the verbal portion of the assessment, ask the client to remove their shoes and socks in preparation for the visual and hands-on assessments.
Visual and Hands-On Assessments
When assessing the feet and ankles it is important to be able to have a very clear view of the structures you are evaluating. However, as a reminder, you should always ask permission prior to touching a client or performing any hands-on assessments.
Visual Assessment Procedures
Begin the visual portion of the assessment by asking the client to stand in front of you and facing you. Explain that you will be carefully looking at the condition of their feet and ankles. Specifically, you will be looking for any swelling, calluses, or irregularities between the feet, ankles and toes.
1. Evaluate for Overpronation
In order to visually determine the extent and type of pronation in a client’s feet, ensure the client is standing on both feet and facing you. Look at the area that runs along the inside of each foot. If the arch is dropped or absent and/or a bulge of flesh sticks out on the inside of one, or both, of the client’s feet this is indicative that the client overpronates (see Figure 3).
Figure 3: Example of Overpronated Foot Position
2. Look for Foot Abduction or Adduction
While the client is still standing in front of you, check the position of his feet. Make a note of whether one or both feet are facing forward, if one or both feet are turned inward (adducted or “like a pigeon”) or if one or both feet are turned away (abducted or “like a duck”) from the midline of the body. An abducted or adducted position of the foot/feet may indicate an imbalance (see Figure 4). For example, a client with an overpronated foot may also abduct his foot when he is standing. This is because overpronation causes the knee to orient toward the midline of the body. Consequently, the client may turn his foot outward in order to re-align the knee to face forward (Price & Bratcher, 2010).
Figure 4: Example of Abducted Foot Position
It is important to note that most people who overpronate will abduct rather than adduct their feet. Occasionally though, you may come across a client that adducts one foot. This problem is usually also caused by overpronation. As previously discussed, when a person overpronates, the foot and ankle move toward the midline of the body. This causes the knee to also move toward the midline. To compensate for this change in knee position, the person will turn their foot outward to align the knee so that it faces forward. However, if a client is “bow-legged” then his knee(s) may actually be pointed toward the outside of the body. In this case, the client may overpronate, but will also turn their foot inward to help move the knee further inward to align it forward.
3. Check the Big Toes
Calluses, bunions, and crooked toes may also be evidence of the common musculoskeletal imbalances for feet and ankles, so it is important to ascertain the condition of your client’s toes. Look at the big toe of each foot to determine if the first joint of that toe is swollen, has a bunion, and/or looks as though it abducts (i.e., points away from the midline) rather than pointing straight ahead (i.e., hallux valgus) (see Figure 5). If the big toe on one, or both, feet is not straight this may be an indication that the client overpronates. When a person overpronates, the foot collapses into the ground and the weight of the body is transferred toward the center line of the body. This transfer of weight across the foot, before it can pass over the end of the big toe, can cause inflammation on the inside of the first joint of the big toe, resulting in the formation of a bunion. Furthermore, abduction of the big toe toward the second tower can compress the nerves that lie between the big toe and lesser toes resulting in symptoms of Morton’s neuroma.
Figure 5: Example of Hallux Valgus and a Bunion
4. Check the Lesser Toes
The term “lesser toes” refers to all the toes but the big toes. Structural imbalances of the feet/ankles and certain types of footwear can cause many abnormal conditions to occur in the lesser toes. These irregularities are often called hammer toes, claw toes or mallet toes and can sometimes be very painful (see Figure 6). To assess whether your client has any of these issues, look at her lesser toes to see if they curl up and/or form a claw and/or look bent as though they are always flexed. Visual abnormalities of the lesser toes may be an indication that the client overpronates as weight is no longer passing correctly over the forefoot and end of the toes.
Figure 6: Example of Irregularities of the Lesser Toes
Hands-On Assessment Procedures
Once the visual assessments are complete, begin the hands-on portion of the assessment process. Inform the client that you will now be manually evaluating their feet and ankles in order to confirm or refute your visual assessment findings. Specifically, you will be looking for any irregular joint positions in the ankle and excessive tension in the soft tissue structures of the feet and lower legs.
1. Talus Bone Assessment
The talus bone lies in the ankle and helps dissipate some of the side-to-side stress of the foot and ankle during weight bearing activities. Assessing the position of the talus bone will help confirm whether a client overpronates (Price, 2008).
- To assess the position of this bone, ask the client to stand facing you with both feet straight and pointed forward. Kneel down and place the thumb and index finger of your right hand on either side of the client’s left ankle just below the ankle bones (i.e., malleolus). You will feel a dimple or indentation on both sides. On the inside of the ankle, the dimple is just below the large tendon of the muscle that pulls the big toe toward the shin (i.e., extensor hallucis). On the outside of the ankle, the dimple lies just below the tendon that lifts the lesser toes toward the shin (i.e., extensor digitorum).
- Position your thumb and forefinger and press firmly in the center of the dimples on the inside and outside of the ankle. Then ask the client to roll their foot from side to side in order to raise and lower the arch of their foot (pronate and supinate). As they collapse the arch (pronate) you will feel pressure under your thumb on the inside of the ankle. This is the talus bone pushing into your thumb. As they raise their arch (supinate) you will feel pressure under your forefinger. This is the talus bone moving the other way. Coach your client to pronate and supinate until the pressure under your thumb and forefinger feels even.
Figure 7: Assessing the Position of the Talus Bone
- When you feel even pressure under your thumb and forefinger, instruct your client to hold the foot and ankle in that position. This is the neutral position for the talus bone and the correct position for the foot and ankle in an upright standing position. If the person you are assessing habitually overpronates, then a neutral foot and ankle position will likely feel awkward (e.g., as though their weight is all on the outside of their foot). Reassure the client that it is normal to feel that way since their feet and ankles are used to collapsing under the weight of the body (overpronating) rather than supporting and transferring it correctly.
- Now switch hands and use your left thumb and forefinger to assess the position of the talus bone on the client’s right foot (see Figure 7).
Once the assessment is complete, teach the client visually and kinesthetically how to find the neutral position so they can feel what it is like to stand with their feet and ankles in alignment. Teaching them how to perform the assessment themselves will ensure that they know how to achieve this desired position at home or when they are not under your supervision. As a side bonus, they might also demonstrate the technique to a friend or family member which may result in another interested person becoming a client.
2. Assessing the Calf Muscles
Musculoskeletal imbalances in the feet and ankles will adversely affect the condition of a client’s calf muscles. As the foot overpronates, the heel rolls inward pulling on the Achilles tendon and the calf muscles on the back of the lower leg that attach to the heel via that tendon (i.e., gastrocnemius and soleus). This excessive pulling causes these calf muscles to become sore and lose their ability to perform optimally. If the calf muscles at the back of the leg cannot stretch fully (i.e., lengthen effectively), then the foot and ankle will not be able to dorsiflex well. This lack of dorsiflexion can lead to compression of the structures at the front of the ankle (i.e., ankle impingement) and inflammation and irritation of the Achilles tendon (i.e., Achilles tendinitis).
- Ask the client to lie on the floor with their knees bent. Lift the lower part of one of the client’s legs and use your fingers to palpate the client’s calf muscles. You are looking specifically for the presence of trigger points, nodules, or excessive muscle tension. Repeat the assessment on the other leg. Note any findings, including tenderness, on the CAD.
3. Assessing the Plantar Fascia
The plantar fascia is a broad, dense, fairly rigid tissue that runs the length of the underside of the foot and helps give the arches of the feet their shape and structure. Forces from the body above and ground reaction forces from below put stress on the plantar surface of the foot when a person is weight- bearing, walking, or running. Overpronation places enormous pressure on the plantar fascia and, over time, leads to the tissue becoming overstressed, dysfunctional, and painful (i.e., plantar fasciitis).
- Assess the condition of a client’s plantar fascia by pressing your thumbs/ fingers into the arch and sole of each of the client’s feet from heel to toes (see Figure 8). Note any tenderness or painful areas on the CAD. The sorest spot for most people is usually just forward of the heel at the highest part of the arch or just behind the first joint of the big toe.
Figure 8: Assessing the Plantar Fascia
How the Feet and Ankles Relate to the Rest of the Body
By now it should be clear that the feet and ankles literally form the foundation of the human body. As with any structure, the integrity of the foundation will affect everything above it and the weight it must bear will have a direct impact on the structures of the foundation. Therefore, the condition of the feet and ankles will influence the performance of any weight bearing exercises that the body performs (i.e., standing, squatting, walking, running, and lunging).
When the foot overpronates, it causes the tibia and femur (i.e., shin bones) to internally rotate and the heel bone (i.e., calcaneus) to roll inward toward the midline of the body (i.e., evert) too much. Since the Achilles tendon attaches the posterior calf muscles to the calcaneus, the calf muscles can be pulled out of alignment via the heel when the foot overpronates. When the calf muscles get pulled and twisted, these tissue becomes inflamed, damaged and begin to lack flexibility. A lack of flexibility in the posterior calf directly impacts the ability of the foot and ankle to dorsiflex and could lead to symptoms of Achilles tendinitis, plantar fasciitis, heel pain and ankle impingement.
However, the impact of deviations in the feet and ankles is not limited to just these areas. The internal movement of the tibia and femur also results in a medial (inward) displacement at the knee. As the knee moves medially, it can cause stress to the knee joint and may result in tracking and alignment problems. This may result in popping and grinding noises and often pain. The inward rotation of the lower leg creates an inward rotation of the upper leg (i.e., femur) which can also cause the top of the femur (i.e., hip) to be displaced within the hip socket (acetabulum). This shift of position in the hip socket affects the movement of the hip, pelvis, and lower back. Consequently, this pulls the lumbar spine out of alignment which disrupts the alignment of the thoracic spine. Compensatory movements of the thoracic spine cause disruption to the position of the rib cage, shoulder blades, glenohumeral joint, neck and head. As such, musculoskeletal imbalances in the feet and ankles can lead to pain, dysfunction and injury anywhere in the body (Kendall et al., 2005, Price & Bratcher, 2010).
Once you have completed the visual and hands-on portion of the assessment process, explain to your client how the condition of their feet and ankles might be affecting the function (and aches and pains they feel) in the rest of their body. Helping your client become aware of the interconnectedness of their body will help them understand the benefits of corrective exercise and the need to address musculoskeletal imbalances anywhere in their body as they arise.
The checklist below is a useful tool to help you determine whether you have completed the foot and ankle assessment process successfully. Upon completion of your assessment of a client’s feet and ankles you should be able to all of the following questions.
Do you fully understand what types of pains your client is experiencing in their feet and ankles and what affect this has on the function of their feet and ankles?
- Are the client’s feet overpronated?
- Are the client’s feet abducted or adducted?
- What is the condition of the client’s big and lesser toes?
- What is the condition of the client’s calf muscles and plantar fascia?
- Does the client know how to achieve a neutral foot and ankle position when standing?
- Do you know how the client’s feet and ankles relate to aches and pains they may be experiencing in the rest of their body (and can you explain it to the client)?