Ankle and Foot Assessment Essentials: ROM, Swelling, Strength, and Functional Stability

What this ankle/foot assessment targets

This chapter focuses on the most common ankle and foot deficits that drive pain, recurrent sprain, and “giving way”: limited talocrural dorsiflexion, impaired inversion/eversion control, swelling-related inhibition, and reduced functional stability in weight-bearing. The goal is to combine a quick visual screen, targeted ROM with substitution control, symptom/end-feel interpretation, graded strength testing, and a few simple functional tasks that reflect real-world demands.

Suggested test order when swelling or pain is present

Swelling and pain can distort ROM, reduce strength via inhibition, and increase guarding. Adjust the order to reduce symptom flare and improve accuracy:

• If significant swelling, bruising, or high pain: observe first, then gentle AROM, then light PROM (within tolerance), then defer heavy strength and higher-load functional tests until safe.
• If mild symptoms and good tolerance: observe → AROM/PROM → strength → functional tests.
• If weight-bearing is limited: prioritize non–weight-bearing ROM and strength; use seated balance/foot intrinsic control tasks instead of step-downs.

1) Observation: swelling, bruising patterns, and weight-bearing tolerance

Step-by-step observation

• Position: compare both sides in standing (if tolerated) and sitting with feet exposed to mid-calf.
• Swelling distribution: inspect around lateral malleolus, medial malleolus, anterior ankle (talar neck region), and along the Achilles/retrocalcaneal area. Note whether swelling is focal (localized) or diffuse (circumferential).
• Bruising pattern: look for ecchymosis tracking into the lateral foot, medial arch, or toes. Bruising that migrates distally can reflect gravity-dependent spread rather than the exact injury site—document location and extent rather than assuming structure.
• Skin changes: redness, warmth, shiny skin, or pitting with pressure (if present) can influence how aggressively you load the ankle.
• Foot posture: resting calcaneal position (varus/valgus), medial arch height, and forefoot abduction. These can hint at compensations you must control during ROM and strength testing.
• Weight-bearing tolerance: ask the patient to shift weight side-to-side, then attempt a comfortable single-leg stance (hands near support). Record whether they can accept load, how quickly symptoms rise, and whether they avoid heel contact or toe-off.

What to document from observation

2) AROM/PROM: dorsiflexion/plantarflexion and inversion/eversion (with substitution control)

Key idea: control substitutions to avoid false “normal” ROM

The ankle-foot complex can “borrow” motion from the midfoot, toes, and tibial rotation. Your job is to identify whether the motion is coming from the intended joint action or from compensations such as:

• Midfoot collapse/pronation: apparent dorsiflexion increases as the arch drops and the talus plantarflexes/adducts.
• Toe extension (especially hallux): can mimic forefoot rocker and make plantarflexion/dorsiflexion look larger.
• Hip/knee strategy: knee valgus, tibial rotation, or heel lift during weight-bearing dorsiflexion tasks.

AROM: step-by-step

• Position: seated with knee flexed ~90° for initial AROM (reduces gastrocnemius tension), then repeat key findings with knee extended if needed.
• Dorsiflexion/plantarflexion: cue “bring toes toward shin” and “point toes away.” Watch for toe extension dominance and midfoot collapse. Lightly stabilize the midfoot if needed to see true talocrural contribution.
• Inversion/eversion: cue “sole in” and “sole out” while keeping toes relaxed. Watch for toe clawing, forefoot twisting, or the whole leg rotating instead of the foot moving.
• Symptom capture: ask where they feel it (anterior ankle pinch, lateral ligament area, medial arch, Achilles) and whether it feels like stretch, pinch, or instability.

PROM: step-by-step (gentle and specific)

• Position: supine or seated. Support the calcaneus and control the midfoot to isolate the ankle/foot segment you are testing.
• Dorsiflexion PROM: stabilize the talus/mortise region and guide the foot into dorsiflexion without forcing pronation. Note if the heel everts and arch collapses early (substitution).
• Plantarflexion PROM: guide through available range while monitoring anterior talar glide sensation and toe extension substitution.
• Inversion/eversion PROM: move slowly; avoid high-velocity end-range. Observe whether the motion is primarily at the rearfoot or midfoot and whether symptoms reproduce along peroneals, deltoid region, or sinus tarsi.

Quick clinical checks to reduce substitution

• Midfoot control: place one hand around the midfoot/arch to prevent collapse while the other hand moves the rearfoot/ankle.
• Toe relaxation: cue “keep toes soft.” If toes extend/claw, repeat with gentle toe support.
• Compare knee flexed vs extended dorsiflexion: a noticeable drop in dorsiflexion with knee extended suggests calf-related limitation contributing to the dorsiflexion deficit.

3) End-feel and symptom interpretation: talocrural vs soft-tissue limits

How to interpret what you feel and what they report

Use end-feel and symptom location to decide whether the primary limiter is likely talocrural joint mechanics (often perceived as a firm “block” or anterior pinch) versus soft-tissue restriction (more elastic stretch) or protective guarding (abrupt resistance with pain).

Talocrural vs “foot” contribution: a practical note

If dorsiflexion appears adequate but you see early pronation/midfoot collapse, the patient may be achieving functional dorsiflexion through the midfoot rather than the talocrural joint. Document both: the observed strategy and the controlled ROM when you stabilize the midfoot.

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4) Strength testing: dorsiflexors, plantarflexors, invertors, evertors (graded resistance)

Principle: gradual resistance to avoid symptom flare and false weakness

In acute or irritable ankles, maximal resistance can provoke pain and reflex inhibition, making the muscle look weaker than it is. Use a ramp-up approach: isometric “hold” → light resistance → moderate resistance, stopping if pain spikes or form breaks.

Dorsiflexors (primarily tibialis anterior)

• Position: seated, heel supported.
• Action: “Pull your foot up and in slightly.”
• Resistance: apply downward and slightly outward pressure over the dorsomedial foot.
• Watch for: toe extension substitution (extensor dominance) and tibial rotation.
• Document: strength grade or descriptive (e.g., “4/5 with pain 2/10 anterior ankle”).

Plantarflexors (gastrocnemius/soleus complex)

• Preferred test: functional heel raises (see functional section) because manual resistance is often insufficient.
• If manual test needed: seated plantarflexion isometrics against your hand, graded gently.
• Watch for: toe flexor cramping, midfoot collapse, or avoidance of end-range due to anterior pain.

Invertors (tibialis posterior/anterior contribution)

• Position: seated; start in neutral.
• Action: “Turn the sole in.”
• Resistance: apply pressure toward eversion at the medial forefoot while stabilizing the lower leg.
• Watch for: hip rotation or toe clawing; ensure motion is at the foot/ankle rather than the whole limb.
• Symptom note: medial ankle/arch pain may indicate tendon irritation or overload—record location and intensity.

Evertors (peroneals)

• Position: seated; foot neutral.
• Action: “Turn the sole out.”
• Resistance: apply pressure toward inversion at the lateral forefoot.
• Watch for: dorsiflexion substitution (patient lifts foot instead of everting) and lateral ankle pain reproduction.
• Clinical emphasis: after lateral sprain, eversion strength and control are often inhibited; use gradual loading and note quality (smooth vs shaky).

How to document strength in a clinically useful way

Include force (grade or descriptive), pain (0–10 and location), and control (smooth/shaky/cramps). Example:

Eversion: 4-/5, pain 3/10 posterolateral ankle, shaky initiation; improves after 2 practice reps.

5) Simple functional tests: heel raise capacity, single-leg balance, controlled step-down (as safety allows)

General rules for functional testing

• Safety first: have a stable support nearby (wall/rail). Stop if sharp pain, near-fall, or rapid swelling increase.
• Quality matters: record compensations (heel whip, arch collapse, knee valgus, trunk lean) in addition to counts/time.
• Compare sides: use the uninvolved side as a reference when appropriate.

Heel raise capacity (plantarflexor endurance and foot control)

• Setup: barefoot if appropriate; fingertips on wall for balance only (not pushing).
• Task: single-leg heel raises through comfortable full range at a steady tempo.
• Record: number of good reps, height symmetry, pain location, and form breakdown (e.g., heel drifting inward/outward).
• Common compensations: reduced heel height, rapid tempo, knee flexion, foot rolling outward to avoid medial load, or excessive pronation.

Single-leg balance (static stability and proprioception)

• Setup: shoes off if safe; eyes open first.
• Task: single-leg stance up to 30 seconds.
• Progressions (only if safe): head turns, reaching with the opposite foot, or eyes closed (briefly) to challenge sensory reliance.
• Record: time, number of foot taps/steps, and strategy (ankle wobble vs hip strategy). Note whether the patient reports “about to give way” even if they do not lose balance.

Controlled step-down (dynamic control and dorsiflexion tolerance)

• Setup: low step (start 10–15 cm) near support; test the involved leg as the stance leg.
• Task: slowly lower the opposite heel to tap the floor and return, keeping the stance heel down if possible.
• Watch for: heel rise (limited dorsiflexion), knee valgus, arch collapse, trunk lean, or rapid drop.
• Stop criteria: sharp pain, repeated loss of control, or inability to maintain safe alignment.
• Record: step height, reps, pain, and primary fault (e.g., “heel lifts early” vs “knee collapses medially”).

Integrating swelling and pain into interpretation (and test selection)

How swelling changes what you see

• ROM: swelling can create an earlier “tight” end-range and increase discomfort, especially in dorsiflexion.
• Strength: pain and joint effusion can inhibit activation, particularly plantarflexors and evertors after sprain.
• Function: patients may adopt protective strategies (reduced stance time, avoiding heel contact, cautious toe-off) that mimic weakness.

Practical approach when swelling is obvious

• Use observation + gentle AROM as your baseline.
• Use PROM only to the first point of resistance/pain that is reproducible.
• Use isometrics at mid-range before dynamic or end-range strength.
• Choose low-risk functional tests (supported balance) before step-downs or repeated heel raises.

Documenting instability: subjective complaints vs objective findings

Separate what the patient feels from what you observe

“Instability” can mean different things: true mechanical laxity, neuromuscular control deficits, pain-related apprehension, or weakness. Your documentation should clearly distinguish:

• Subjective instability: giving way, fear on uneven ground, difficulty with cutting/turning, sense of wobble.
• Objective control deficits: excessive sway, repeated foot taps, poor step-down alignment, inability to maintain heel raise height, visible tremor or delayed eversion activation.
• Symptom reproduction: whether instability is accompanied by pain, and where.

Example documentation templates

Subjective: Reports ankle “giving way” 2–3x/week on uneven surfaces; avoids running. Objective: SLS 12 sec with 4 taps; visible rearfoot inversion wobble. Step-down from 10 cm: heel rise early + knee valgus; pain 3/10 anterolateral ankle. ROM: DF limited with midfoot collapse substitution; controlled DF reproduces anterior pinch.

Subjective: Feels unstable only when fatigued. Objective: Heel raises 18 reps with reduced height after rep 12; eversion strength 4-/5 with shaky initiation; balance 30 sec steady eyes open.