Ankle/Leg Regional Exam Patient:_________________________________ date: _________

Check normal, circle & describe abnormal

Insurance: _____________________________________ (dd/mm/yr)
CC & significant history: ____________________________________________________ Date of birth: ____________________________________ M/F
__________________________________________________________________________
Fracture screen (tuning fork, percussion, torsion test, 5-step test): □ WNL □ Refer for X-ray: __________________________________________

Observation:: □ WNL Palpation:: □ WNL, □ pain (circle), □ spasm (s), □ edema (e), □ fibrotic
brotic (f), □ MFTP (x), □ ache (a), □ tingling (t)
Development: □ good, □ fair, □ poor
□ Posture: _________________________ Palpation L R L R
□ Skin (bruising, scars): _______________ Tibial tub./fibular haed Subtalar joint
□ Swelling: _________________________ Tibial crest Midtarsal joint
□ Asymmetry: _______________________ Lateral malleolus Tarsometatarsal joints
Medial malleolus MP joints
Observation □ WNL L R
Navicular PIP joints
Toe in / out
Cuboid DIP joints
Arch low / high
Cuneiforms Gastroc/soleus
Patella position (med, lat, ↑, ↓) Talus (head, neck, trochlea) Lateral leg muscles
Q-angle Calcaneus Anterior leg muscles
Genu varum / valgum Sustentaculum tali Achilles tendon
Femur rotated int. / ext. Metatarsals Fibularis tendons
Iliac crest height Phalanges TDH muscles
Lumbar hyper / hypolordosis Sinus tarsi Tarsal tunnel
Knee hyperextended Ant. talofibular lig. Tib. anterior/posterior
Leg length Calcaneofibular lig. Calcaneal bursa ________________________________
Gait analysis Post. talofibular lig. Plantar fascia ________________________________
Spring ligament Plantar muscles ___________________________________________________________
___________________________________
Deltoid ligament Saphenous vein ___________________________________________________________
___________________________________
____________________________________________
__________________________________________ Vascular Screen:: □ WNL Orthopedic:: □ WNL
ROM & Joint Play:: □ WNL Pulses (0-4) L R L R
□ Pain at end ROM: __________________ Popliteal pulse Anterior drawer plantarflexed
□ Abnormal motion: __________________ Tibial pulse Anterior drawer neutral
Dorsal pedial Inversion talar tilt plantarflexed
Active Passive Inversion talar tilt neutral
ROM Blanch test
L R L R Eversion talar tilt
Plantarflexion (40°) Rotational stress (Kleiger)
Neurologic: □ WNL
Dorsiflexion (20°) Hoffa’s sign

Inversion (20°)
Sensation, □ WNL L R Thompson/Simmond’s test
Light touch Achilles squeeze
Eversion (10°)
Sharp/dull Calcaneal squeeze x 3
Joint Play L R Comments Homan’s sign/calf squeeze
Reflexes (0-5), □ WNL L R Buerger’s claudication test
Inferior tib-fib
Patellar (L4) Morton’s foot squeeze
Ankle joint
Hamstring (L5) Tinel’s test at ankle
Subtalar joint
Patellar (S1)
Midtarsal joint _____________________________________________
Babinski
Navicular-cuneif. _____________________________________________
_______ ______________________________________
Cuneiform-meta Motor (0-5), □ WNL L R ________________________________________________
________________________________________________
Intermetatarsal Plantarflexion (L4-S2)(tibial)
Hallux-metatarsal Dorsiflexion (L4-S1)(deep fibular) Additional procedures:: □ WNL
Metatarsophalang. Inversion (L4-L5)(deep fibular) □ Hip exam: __________________________________
PIP Eversion (L4-S1)(superficial fib.)
□ Knee exam: _________________________________
DIP □ Lumbosacral: _______________________________
Toe flexion (L5-S2)(tibial)
___________________________________ Toe extension (L4-S1)(deep fib.)
___________________________________ Toe abd./add. (S1-S2)(tibial) DDx: ____________________________________
___________________________________________________ other: _____________________________________________
This form is a comprehensive checklist of examination procedures. Each item should be utilized as a diagnostic option based on the patient’s presenting
symptoms and the clinical discretion of the examiner. Every procedure does not have to be performed on every patient. Some procedures may be
contraindicated in certain situations. Patient information contained within this form is considered strictly confidential. Reproduction is permitted for personal use, Signature: Date:
not for resale or redistribution. www.prohealthsys.com ©2005 by Professional Health Systems Inc. All rights reserved. “Dedicated to Clinical Excellence.”