Knowledge · Clinical Examination

Foot and Ankle Examination: Alignment, Movement, Achilles and the Ottawa Rules

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

Examine the foot and ankle standing and lying, working from hindfoot to forefoot, then test movement, the Achilles tendon with the calf squeeze, and apply the Ottawa ankle and foot rules after injury.

Examine the foot and ankle with the patient standing, walking and lying, inspecting from hindfoot to forefoot before you palpate. Test ankle and subtalar movement, assess the Achilles tendon, and after injury apply the Ottawa ankle and foot rules, which NICE recommends for people over 5 years of age.

Key takeaways

NICE CKS asks you to inspect from the hindfoot forwards, assessing hindfoot alignment, arch height and the forefoot in relation to the hindfoot.
The Ottawa ankle rule needs pain in the malleolar zone plus bone tenderness at the posterior edge or tip of either malleolus, or inability to weight bear for four steps.
The Ottawa foot rule needs pain in the midfoot zone plus tenderness at the base of the fifth metatarsal or the navicular, or inability to weight bear for four steps.
BOFAS describes Simmonds' triad for acute Achilles rupture: calf squeeze, altered angle of declination and a palpable gap.
Tenderness 2 to 6 cm above the insertion suggests non-insertional Achilles tendinopathy, while tenderness in the distal 2 cm suggests insertional disease, according to NICE CKS.

What is the examiner marking at the foot and ankle station?

The Intercollegiate blueprint marks a physical examination station out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication and professionalism carry 4 marks each. The station also gets a separate global rating of pass, borderline or fail.

More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

The examiner is marking whether you examine the foot weight bearing as well as on the couch, and whether you can exclude the injuries that matter. Alignment changes when the patient stands.

This article was written from current guidance rather than from the legacy page, which held fewer than 160 words.

How should you start the foot and ankle examination?

Introduce yourself, gain consent, expose both legs from above the knees and ask about pain. NICE CKS asks for both legs to be examined standing and prone when the Achilles is in question.

Look at the shoes. NICE CKS suggests checking for increased wear and tear on parts of the soles, which records the patient's real loading pattern.

What am I looking for on inspection of the foot?

Inspect systematically from the hindfoot forwards, as NICE CKS sets out for foot examination.

Hindfoot alignment, valgus or varus
The height of the medial longitudinal arch, described as normal, high or planus
The forefoot in relation to the hindfoot: abducted, adducted, pronated or supinated
Toe deformities such as hallux valgus, hammer toe and claw toe, and gaping between the lesser toes
Skin, including scars, plantar callosities, ulcers and the nails

**Pes planus** is a flattened medial longitudinal arch, and pes cavus is an abnormally high one; both change where callus and pain form.

What should you assess in the gait?

Watch heel strike, mid-stance and toe off, which NICE CKS names as the phases to observe. The inability to bear weight on a flat foot points to where the pathology is.

Ask for a double and then a single heel raise, which loads the Achilles and tibialis posterior.

What should you palpate, and which movements should you test?

Palpate the malleoli, the base of the fifth metatarsal, the navicular, the metatarsophalangeal joints and the Achilles tendon along its length, asking the patient to point to the painful spot first.

Ankle dorsiflexion and plantarflexion, tested with the knee both flexed and extended
Subtalar inversion and eversion, holding the heel
Midtarsal movement, holding the heel and rotating the forefoot
Great toe and lesser toe movement, actively and passively

How do you examine for an Achilles tendon rupture?

Use Simmonds' triad, which the British Orthopaedic Foot and Ankle Society describes as the calf squeeze, an altered angle of declination and a palpable gap, and states that the combination of all three confirms the injury in most cases.

Position the patient prone with the feet over the end of the couch so both sides can be compared. NICE CKS notes that a review found Achilles rupture is missed by non-specialists in about 20% of cases, so examine for it whenever the calf hurts after a sudden load.

NICE CKS also lists fluoroquinolone antibiotics as a risk factor for tendon problems, which is worth asking about.

When does an injured ankle need a radiograph?

Apply the Ottawa ankle and foot rules, which NICE NG38 recommends for people over 5 years with a suspected ankle fracture.

Ankle series if there is malleolar zone pain plus inability to weight bear for four steps both immediately and when examined, or bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, or the same on the tibial side
Foot series if there is midfoot zone pain plus inability to weight bear for four steps, or tenderness at the base of the fifth metatarsal, or tenderness of the navicular
Use judgement in people who are confused or intoxicated, have polytrauma or head injury, have diminished sensation, or whose swelling prevents palpation, as NICE CKS advises

Stiell's 1993 validation in JAMA found the refined rules 100% sensitive for malleolar and midfoot fractures, with an estimated one-third reduction in radiographs.

What are the most common mistakes at this station?

Examining the foot only on the couch, so alignment under load is never seen
Missing an Achilles rupture because plantarflexion is still possible through the long flexors
Palpating without asking the patient to point to the pain first
Quoting the Ottawa rules without the weight-bearing criterion, which is half of each rule
Forgetting the neurovascular check, which NICE CKS includes with dorsalis pedis and tibial pulses and sensation

How should you finish the foot and ankle examination?

Offer to examine the knee and hip, complete the neurovascular assessment, and summarise with a differential and an imaging plan.

If a forefoot neuroma is suspected, NICE CKS describes Mulder's click, produced by squeezing the metatarsal heads together while holding the web space, and notes that its absence does not rule out a neuroma.

The MRCS Part B Questions bank has a foot and ankle examination station at /Sample-Questions.

Key evidence

Sprains and strains: assessment, including the Ottawa rules — NICE Clinical Knowledge Summaries (2025)
Achilles tendinopathy: assessment — NICE Clinical Knowledge Summaries (2025)
Achilles Tendon Acute Rupture, BOFAS hyperbook — British Orthopaedic Foot and Ankle Society (2026)
Stiell IG et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 269(9):1127-32 — JAMA (1993)

FAQ

What exactly are the Ottawa ankle rules?

An ankle radiograph is needed with malleolar zone pain plus one of: inability to weight bear for four steps immediately and when examined, bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, or the same on the tibia or medial malleolus. A foot series is needed with midfoot pain plus inability to weight bear, tenderness at the base of the fifth metatarsal, or navicular tenderness. NICE CKS states they apply to people aged over 5 years.

Can a patient still plantarflex after an Achilles rupture?

Yes, which is why ruptures are missed. The long toe flexors and tibialis posterior can produce some plantarflexion. BOFAS describes Simmonds' triad, calf squeeze plus altered angle of declination plus a palpable gap, as confirming the injury in most cases.

Where is the tenderness in Achilles tendinopathy?

NICE CKS places non-insertional tendinopathy 2 to 6 cm proximal to the insertion, with tenderness that moves with the tendon and reduces on active dorsiflexion. Insertional tendinopathy is tender over the distal 2 cm, often with redness, swelling and nodularity. About 30% of people have bilateral involvement.

Which drugs are associated with Achilles problems?

NICE CKS lists fluoroquinolone antibiotics among the risk factors for Achilles tendinopathy and rupture, and notes that co-administration with corticosteroids should be avoided. Ask about recent antibiotic courses in any spontaneous tendon injury. It is a mark most candidates miss.

How do I test for Morton's neuroma?

NICE CKS describes the thumb and index finger web space squeeze, which reproduces tenderness, and Mulder's click, produced by gripping the neuroma while squeezing the metatarsal heads together. A click is felt and heard as the nerve subluxes. Absence of the click does not exclude the diagnosis.

Should the foot be examined standing?

Yes. Arch height, hindfoot alignment and forefoot position all change under load, and NICE CKS bases foot inspection on hindfoot alignment, arch height and forefoot position. Watch gait through heel strike, mid-stance and toe off, then repeat the examination lying.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

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