Medial Malleoli: Begin by locating the medial aspect of the tibia and follow this bone inferiorly until you access this bulbous structure on the medial aspect of the ankle/foot complex. Appreciate the inferior tip, the anterior, and the posterior boundaries.
Lateral Malleoli: Begin by locating the lateral aspect of the fibula and follow this bone inferiorly until you access this bulbous structure on the lateral aspect of the ankle/foot complex. Appreciate the inferior tip, the anterior, and the posterior boundaries.
Structures That Attach Here: The medial and lateral malleoli serve as the attachment site for numerous ligaments that support the talocrural, hindfoot, and midfoot joints. Please see sections that follow regarding pertinent ligaments.
Calcaneus
Calcaneus
How to Palpate
Position of Partner: Prone, sitting
Directions: Locate the heel of the foot. Palpate the posterior aspect of the foot complex, appreciating the medial, lateral, posterior, and inferior aspects of this large hindfoot bone.
Structures That Attach Here: Plantar fascia, deltoid ligament, short and long plantar ligaments
Calcaneal Tuberosity
How to Palpate
Position of Partner: Prone
Directions: Begin by locating the Achilles tendon and palpate inferiorly along the tendon until it inserts on the calcaneus at the calcaneal tuberosity. Feel for the dissipation of the tendon as it attaches to the calcaneus on the inferior aspect of the posterior calcaneus.
Muscles That Attach Here: Gastrocnemius, soleus, plantaris
Sustentaculum Tali
How to Palpate
Position of Partner: Sitting
Directions: Palpate the medial malleolus as described above and move your fingers inferiorly until a shelf-like bony ridge is felt. This structure is located approximately 1–1½ inches inferior to the tip of the medial malleolus. This skeletal landmark creates a groove for the flexor hallucis longus tendon to run underneath.
Structures That Attach Here: Plantar calcaneal ligament, deltoid ligament.
Fibular Tubercle/Trochlea
How to Palpate
Position of Partner: Sitting
Directions: Orient yourself to your partner’s lateral ankle. Locate the lateral malleolus and travel on a downward and slightly anterior diagonal about 1 inch from this landmark. A small protuberance can be felt here. Have your partner evert their foot so these tendons become more prominent, and then they may be able to guide you to this landmark.
Structures Located Near This Landmark: The distal tendons of the fibularis longus and fibularis brevis muscles hinge around this landmark as they travel to their insertions.
Navicular
Navicular Tuberosity
How to Palpate
Position of Partner: Sitting, supine
Directions: Start by locating the midpoint of the medial malleolus and palpate 2 inches inferiorly at approximately 45–60 degrees toward the medial midfoot until the tuberosity of the navicular bone is appreciated. Alternatively, you may begin by palpating the 1st metatarsal and gradually moving proximally along the medial aspect of the foot. Pass along the medial cuneiform and palpate the navicular bone. This tuberosity should feel like a prominent elevation to the bone and, in some cases, may even be visible as it protrudes from the medial foot.
Muscles That Attach Here: Tibialis posterior
Structures That Attach Here: Spring ligament, deltoid ligament
Talus
Head of Talus
How to Palpate
Position of Partner: Sitting
Directions: Begin by locating the navicular bone and the medial malleolus. Draw a line between these two structures and appreciate the bony indentation between the navicular tubercle and the prominent medial malleolus. By everting and inverting the foot, you will appreciate the head of the talus extending into your fingers, during eversion specifically.
Trochlea of Talus
How to Palpate
Position of Partner: Sitting
Directions: Appreciate the talus deep on the medial and lateral aspects of the anterior compartment tendons (i.e., tibialis anterior, extensor hallucis longus, extensor digitorum) by palpating with your thumb and fingers, respectively. Locate the midpoint of the medial and lateral aspects of the talus, and plantarflex and invert the foot to better expose the articular surface of the talus.
Medial Tubercle of Talus
How to Palpate
Position of Partner: Sitting, supine
Directions: Begin by locating the medial malleolus and palpate in an inferior and posterior direction on the foot at roughly a 45-degree angle. Appreciate the bony tubercle of the talus to locate this landmark.
Structures that Attach Here: Deltoid ligament (posterior talotibial ligament)
Metatarsals
1st–5th Metatarsals
Palpation Directions
Position of Partner: Sitting, supine
Directions: Orient to the proximal phalanx of digits 1–5. Palpate proximally over the metatarsophalangeal joint and onward to the metatarsal bones. Appreciate the distal and proximal aspects of the bone, concluding at the tarsometatarsal junction.
5th Metatarsal: Fibularis brevis, flexor digiti minimi brevis
Plantar and dorsal interossei also attach to different areas of the digits.
Styloid Process of 5th Metatarsal
How to Palpate
Position of Partner: Sitting, supine
Directions: Locate the shaft of the 5th metatarsal using the strategy described above. Palpate proximally along the 5th metatarsal until the large bulbous bony process on the lateral aspect of the midfoot is appreciated.
Muscles That Attach Here: Fibularis brevis, fibularis tertius
Phalanxes
Proximal, Middle, and Distal Phalanxes
How to Palpate
Position of Partner: Sitting, supine
Directions: Locate the distal phalanx at the most distal aspect of each of the phalanges. Appreciate the proximal, middle, and distal phalanxes by palpating distally.
Proximal Phalanx of Digit 5: Abductor digit minimi, flexor digiti minimi brevis
Plantar and dorsal interossei also attach to different areas of the phalanges and metatarsals.
Medial, Middle, and Lateral Cuneiforms
How to Palpate
Position of Partner: Sitting, supine
Directions: Locate the medial cuneiform by palpating toward the proximal end of the 1st metatarsal. Then roll over the base of the 1st metatarsal onto the medial cuneiform. Move laterally along the midfoot to appreciate the middle and lateral cuneiforms, aligning with the 2nd and 3rd metatarsals, respectively.
Directions: Locate the styloid process of the 5th metatarsal and palpate superiorly and posteriorly on an imaginary line toward the center point of the lateral malleolus. After rolling off the ridge of the 5th metatarsal, appreciate the cuboid bone along the lateral aspect of the foot.
Muscles That Attach Here: Tibialis posterior, flexor hallucis brevis
Structures That Attach Here: Long and short plantar ligaments
Joints
How to Palpate The individual metatarsophalangeal and interphalangeal joints can be palpated. First, using Figure 8.6, identify which joint to palpate, and feel around the joint surfaces from all accessible points.
Insertion(s): Tendons of extensor digitorum longus 2–5
Action(s): Digit extension 2–5
Innervation(s): Deep fibular nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Palpate anterior to the lateral malleolus, over the cuboid and lateral cuneiform, on the dorsum of the foot. Instruct the patient to extend digits 2–5 their 2nd–5th digit against resistance and palpate the muscle bulk that emerges on the dorsal side of the foot.
Flexor Digitorum Brevis
Origin(s): Medial tubercle of calcaneal tuberosity, plantar aponeurosis
Insertion(s): Middle phalanx of digits 2–5
Action(s): Digit 2–5 flexion
Innervation(s): Medial plantar nerve
How to Palpate
Position of Partner: Supine
Directions: Starting at the medial calcaneus, palpate along the longitudinal arch of the plantar surface of the foot toward the 2nd–5th digits. Instruct your partner to perform digit flexion against your resistance, and simultaneously palpate along the longitudinal arch. The muscle is difficult to isolate but may be appreciated by pressing into the tissue of the plantar surface of the foot.
Abductor Hallucis
Origin(s): Medial tubercle of calcaneus, plantar aponeurosis, flexor retinaculum
Insertion(s): Base of proximal phalanx of 1st digit
Action(s): 1st digit abduction, flexion
Innervation(s): Medial plantar nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Appreciate the muscle tissue by palpating from the origin to insertion along the medial aspect of the foot. Instruct your partner to abduct or flex their 1st digit while you palpate along the medial aspect of the foot to better feel the muscle belly.
Abductor Digiti Minimi
Origin(s): Medial and lateral tubercles of calcaneus, plantar aponeurosis
Insertion(s): Base of proximal phalanx of 5th digit
Action(s): 5th digit abduction, flexion
Innervation(s): Lateral plantar nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Appreciate the muscle tissue by palpating from the origin to insertion along the lateral aspect of the foot. Instruct your partner to abduct or flex their 5th digit while you palpate along the lateral aspect of the foot to appreciate the muscle belly.
Directions: Locate the calcaneal tuberosity on the posterior aspect of the calcaneus and palpate superiorly along the Achilles tendon. Appreciate the medial and lateral borders and the thickness of the tendon. Alternatively, you can start proximally at the medial and lateral heads of the gastrocnemius and palpate as they come together distally to form the primary bulk of muscle tissue. Then continue to palpate inferiorly until you meet the superior aspect of the Achilles tendon.
Deltoid Ligament
How to Palpate
Position of Partner: Supine, sitting
Directions: Locate the medial malleolus and the attachment sites of the deltoid ligament, which are the navicular bone, talus, and calcaneus. Palpate inferior to the medial malleolus along the broad space between this ligaments’ distal attachments to fully appreciate this ligament.
Directions: Locate the tunnel-like space between the talus and calcaneus, anterior and inferior to the lateral malleolus. Have your partner dorsiflex their ankle to make this depression become even more prominent.
Figure 8.10. Sinus Tarsi by Dan Silver is used under a CC BY 4.0 License.
Anterior Talofibular Ligament
How to Palpate
Position of Partner: Sitting
Directions: Locate the lateral malleolus and palpate along the lateral aspect of the foot toward the neck of the talus. The anterior talofibular ligament traverses these landmarks and lies deep in the sinus tarsi.
Directions: Locate the lateral malleolus and palpate in an inferior, posterior direction at approximately a 30-degree angle toward the calcaneus. The calcaneofibular ligament can be palpated as it traverses these landmarks.
Plantar Aponeurosis/Fascia
How to Palpate
Position of Partner: Prone
Directions: Begin by palpating the medial and lateral aspects of the plantar surface of the calcaneus and follow the superficial tissue along the plantar surface of the foot toward the digits. You may better appreciate this tissue by using one hand to collectively extend the digits of the foot while simultaneously palpating along the plantar surface of the foot with the other hand.
Directions: Begin by locating the extensor hallicus longus tendon, which has been previously described, just distal to the talocrural joint on the dorsal aspect of the foot. Alternatively, you may locate the dorsal aspect of the navicular bone and move posterolaterally in the direction of the laterally malleolus. Appreciate the dorsalis pedis along either pathway.
Posterior Tibial Artery
How to Palpate
Position of Partner: Sitting, supine
Directions: Locate the posterior aspect of the distal medial malleolus and the insertion of the Achilles tendon on the calcaneus. Palpate directly posteriorly to the medial malleolus, moving toward the midpoint between the medial malleolus and calcaneus to appreciate the posterior tibial artery.
These motions come from the talocrural joint, between the distal end of the tibia and the talus. Always remember to encourage your partner to reach their full end range if you are assessing an active or resistive range of these motions.
Ankle Inversion and Eversion
This motion occurs at the subtalar joint, so it’s important to focus on the hindfoot when assessing these ranges. For instance, when performing a passive range of motion assessment for these ranges it’s important to grab the hind heel and move it in the frontal plane in the direction of inversion and eversion.
Flexion and Extension of the Toes
Flexion and extension occur at the metatarsophalangeal and interphalangeal joints. Depending on the purpose of these assessments, it may be appropriate to isolate individual joints or to assess all toes at once.
Abduction and Adduction of the Toes
Abduction and adduction occur at the metatarsophalangeal joints. It’s important to recognize that the midline for these motions is defined as being through the third toe, and the other toes either move toward this midline (adduction) or away from this midline (abduction).
Background: Ankle sprains are a common traumatic injury of the foot and ankle complex. A lateral ankle sprain is the most common ankle sprain, which typically occurs when the ankle and foot are forced into a position of excessive plantarflexion and inversion. Structures on the lateral side of the ankle and foot experience injury as they try to resist these forces. Specifically, the anterior talofibular ligament is the most common ligament affected by lateral ankle sprains.
Ankle and Foot Fractures Using the Ottawa Ankle Rules
Background: The Ottawa Ankle Rules are a highly sensitive screening tool to determine the need for radiographic imaging for a foot and/or ankle fracture following trauma. A healthcare professional will screen a patient to detect if any of the following are present: 1) bony tenderness from the tip of the medial malleolus to 6 centimeters superiorly along the posterior edge of the tibia, 2) bony tenderness from the tip of the lateral malleolus to 6 centimeters superiorly along the posterior edge of the fibular, 3) bony tenderness at the navicular bone, 4) bony tenderness at the base of the 5th metatarsal, and 5) inability to bear weight for four steps immediately after the injury and in the emergency department. If any of these symptoms are found on a clinical examination, the patient should be referred to an emergency department for radiographic imaging.
Achilles Tendinopathy
Background: Achilles tendinopathy is a common overuse injury, resulting in histological tendon changes and pain during walking, running, and/or jumping. It typically affects individuals in their third through fifth decades, and most commonly affects active patient populations. Palpation of the Achilles tendon may be useful to appreciate changes in the thickness of the Achilles tendon, detect pain along the midportion or insertion of the tendon, and differentiate Achilles pain from pain in other locations of the foot and ankle complex.
Review Questions: Skeletal Landmarks of the Ankle and Foot
The sustentaculum tali is located on the (medial / lateral) aspect of the foot, and the sinus tarsi is located on the (medial / lateral) aspect of the foot.
The medial malleolus is an extension of the (tibia / fibula), and the lateral malleolus is an extension of the (tibia / fibula).
The (head of the talus / trochlea of the talus / medial tubercle of the talus) is the articulating surface of the talus with the tibia to form the proper ankle joint.
The navicular bone is (medial / lateral) to the cuboid bone.
The anterior talofibular ligament is located (superior and anterior / superior and posterior / inferior and anterior / inferior and posterior) to the calcaneofibular ligament.
The tibia extends down the shank (medially / laterally) to the fibula.
The 5th metatarsal aligns with what tarsal bone proximally?
What bony landmark does the gastroc-soleus complex insert on to?
The plantar surface of the distal 1st phalanx is the insertion site for (flexor digitorum longus / flexor hallucis longus / tibialis posterior).
Arrange the following landmarks from proximal to distal: proximal phalanx of 1st digit, navicular, medial cuneiform, calcaneus.
Review Questions: Musculature of the Ankle and Foot
What is the muscle action of the tibialis anterior?
What nerve innervates the fibularis longus muscle?
Arrange the following muscles in order from superficial to deep: tibialis posterior, gastrocnemius, soleus.
Which of the following muscles does not facilitate ankle dorsiflexion as a primary or secondary movement: tibialis anterior, fibularis tertius, or extensor digitorum brevis?
The lateral plantar nerve innervates which of the following muscles: abductor hallucis, flexor digitorum brevis, or abductor digiti minimi?
Arrange the following muscles from medial to lateral as they appear in the posterior compartment: flexor hallucis longus, tibialis posterior, flexor digitorum longus.
What are the two actions of the fibularis brevis muscle?
If an individual were to complain of muscle weakness and pain with ankle dorsiflexion, which of the following nerves would most likely be involved? deep fibular nerve, superficial fibular nerve, medial plantar nerve, or tibial nerve.
Flexor hallucis longus performs flexion of the digit(s), and flexor digitorum longus performs flexion of the digit(s).
Flexor digitorum brevis is innervated by what nerve?
