Clinical examination of the lower leg, ankle and foot
History
Although the main question is the current problem – where the pain is now – it is best to try to obtain a chronological account, as summarized in Box 55.1. In order to work out the problem systematically, the questions asked should follow the order given below.
• What has been the evolution since the onset? No change? Gradually worse or gradually better? Ups and downs, with complete or no recovery between attacks? Do changes depend on exertion?
The present complaints should be investigated further:
• Where do you feel the pain now? Posterior, middle or anterior segment? Medial, lateral or all over the joint(s)?
• Is there pain at rest or during the night? Pain at night indicates a high degree of inflammation.
• Is there long-standing morning stiffness? This also suggests a serious inflammatory disorder.
• What brings the pain on? Is there any pain during normal walking or normal running? Can you participate in your usual sports?
• Is there equal pain on walking and standing?
• Can you walk on uneven surfaces? Because walking upstairs and downstairs demands normal mobility of the ankle joint, it is worth asking if the patient can do so without problems.
• Is the pain provoked by particular movements?
• Is the pain felt at the beginning of, during or after exertion?
• Does the pain depend on the sort of shoes you wear? Sometimes an in-built wedge relieves or aggravates the pain. In Achilles tendinitis or plantar fasciitis, a raised heel with a horizontal surface relieves the stress on these affected tissues and therefore relieves the pain.
Further questioning should establish whether there are ‘twinges’ or instability:
• Do you have twinges, and when? A twinge in the foot is a very important symptom. It is a sudden, sharp pain, mostly occurring during walking. It should always be differentiated from ‘giving way’. In a twinge, there is only momentary pain and not a feeling of instability. By the time the patient realizes it, the pain has disappeared. A twinge is very often an indication of a momentary impaction of a loose body in the ankle or subtalar joint. If localized in the forefoot, it can be a symptom of Morton’s metatarsalgia or sesamoiditis.
• Do you have a feeling of instability? If so, describe it. Real instability of the ankle or foot is only important in sports. Normal walking or even running on a flat surface hardly ever causes a feeling of giving way. In the occasional case where this does happen, it is the result of neurological weakness of the peronei muscles, rather than of a ligamentous lesion.
