Documentation of Exam
This may be used as a template or example of what you may want to include in the documentation of your foot and ankle exam. See below to download a PDF version of the documentation for printing.
Inspection:
Documentation of gait, deformity or defect (such as pes planus or cavus or overpronation)(Absence/presence) of effusion, swelling, or ecchymosis.
Range of Motion of the Ankle and Resisted Strength Testing:
Dorsiflexion
Plantarflexion
Inversion
Eversion
Flexion/extension of toes
Palpation:
(Tenderness/no tenderness) to palpation of specific areas or landmarks (medial or lateral malleoli, base of the fifth metatarsal, lateral ligaments, deltoid ligament, proximal fibula, Achilles, posterior tibial or peroneal tendons, navicular or any region of injury).
Specific Testing:
(Positive/Negative) Anterior Drawer, (Positive/Negative) Talar Tilt
(Positive/Negative) Squeeze Test, (Positive/Negative) Kleiger's Test
(Positive/Negative) Midfoot Torsion Test
(Positive/Negative) Mulder's Test
(Positive/Negative) Calcaneal Squeeze Test
(Positive/Negative) Tinel's Test at the Tarsal Tunnel
(Positive/Negative) Thompson's Test
Neurovascular Exam:
Document dorsalis pedis and posterior tibial pulses and capillary refill. Sensory exam.