Leg and Foot — Palpation Landmarks

Palpation Landmarks

Tibial Plateau — Medial and Lateral

• How to find it: With the client supine and the knee flexed to 90 degrees, locate the joint line of the knee (the gap between the femoral condyles above and the tibial plateau below). The tibial plateau is the broad, flat surface immediately distal to the joint line. Place your fingertips along the joint line and then drop them approximately 1 cm inferiorly — you are now on the plateau.
• What it feels like: A broad, flat bony surface. The medial plateau is wider and concave (it receives the larger medial femoral condyle). The lateral plateau is narrower and slightly convex. The plateaus are partially covered by the menisci, so you are palpating the peripheral edge of the bone rather than the articular surface directly.
• Client position: Supine with the knee flexed to 90 degrees (foot flat on the table).
• Confirmation: The tibial plateau is immediately distal to the knee joint line. If you press on a structure and slide superiorly, you should feel the edge of the femoral condyle above — the gap between them is the joint line. The plateau is the flat surface below the gap.
• Common errors: Confusing the tibial plateau with the femoral condyles (which are proximal to the joint line and more convex). Also, not flexing the knee enough — in full extension, the patella covers the anterior joint and the condyles and plateau are harder to distinguish.
• Clinical significance: Joint line tenderness at the medial or lateral tibial plateau suggests meniscal pathology (the menisci sit on the plateaus) or tibial plateau fracture. The medial joint line is the most common site of meniscal tenderness. Tibial plateau fractures occur from axial loading with valgus or varus force (e.g., pedestrian struck by a car bumper).

Fibular Head

• How to find it: With the client supine or side-lying and the knee slightly flexed, locate the lateral aspect of the proximal leg. The fibular head is a prominent, rounded bony point on the posterolateral aspect of the proximal leg, approximately 2–3 cm below and posterior to the lateral tibial condyle. It is subcutaneous and easily palpable.
• What it feels like: A distinct, rounded bony knob approximately 1.5–2 cm in diameter. It projects laterally and is more posterior than most students expect. The biceps femoris tendon inserts on its superior surface — you can often feel this tendon as a thick cord approaching the fibular head from above.
• Client position: Supine with the knee slightly flexed, or side-lying with the affected side up.
• Confirmation: Palpate the biceps femoris tendon — follow it distally to its insertion on the fibular head. Alternatively, the fibular head has a small range of anteroposterior glide — gently push it anteriorly and posteriorly to confirm it is a mobile bony structure (the proximal tibiofibular joint allows slight motion).
• Common errors: Confusing the fibular head with Gerdy's tubercle (which is more anterior and on the tibia — see anatomy/bones/hip-and-thigh-landmarks). The fibular head is more posterior and more lateral. Also, pressing too aggressively — the common fibular (peroneal) nerve wraps around the neck of the fibula just distal to the head (see Nerve Passages).
• Clinical significance: The common fibular nerve wraps around the fibular neck immediately distal to the head — sustained compression here causes foot drop (inability to dorsiflex the ankle). When working near the fibular head, avoid sustained pressure on the posterolateral fibular neck. The biceps femoris inserts here — tenderness may indicate biceps tendinopathy. The lateral collateral ligament (LCL) attaches to the fibular head — varus stress at the knee loads this ligament.

Medial Malleolus

• How to find it: With the client supine, locate the medial (inner) side of the ankle. The medial malleolus is the prominent bony projection on the medial side of the distal tibia. It is clearly visible and easily palpable as the inner ankle bone.
• What it feels like: A broad, rounded bony prominence approximately 2–3 cm in vertical height. Its inferior tip is rounded. It is subcutaneous on its medial surface — you can palpate the entire contour from anterior to posterior.
• Client position: Supine with the foot in neutral or slight plantar flexion.
• Confirmation: The medial malleolus is fixed — it does not move with any ankle or foot motion (it is the distal end of the tibia). If the structure moves, you are on a tendon. Compare with the lateral malleolus — the medial malleolus sits approximately 1 cm more proximal than the lateral malleolus (the lateral malleolus extends more distally).
• Common errors: Confusing the medial malleolus with the tibialis posterior tendon or the sustentaculum tali (which is inferior and slightly posterior to the malleolus). The malleolus is the large, prominent bone; the sustentaculum tali is a smaller shelf below and behind it.
• Clinical significance: Landmark for true leg length measurement (ASIS to medial malleolus). The deltoid ligament attaches to the medial malleolus — tenderness at the malleolar tip after an eversion injury suggests deltoid ligament sprain (less common than lateral sprains but more significant because the deltoid is the strongest ankle ligament). Medial malleolus fractures can accompany severe ankle sprains. The tibialis posterior, flexor digitorum longus, and flexor hallucis longus tendons pass behind the medial malleolus (see Nerve Passages for associated structures).

Lateral Malleolus

• How to find it: With the client supine, locate the lateral (outer) side of the ankle. The lateral malleolus is the prominent bony projection on the lateral side of the distal fibula. It is the outer ankle bone and extends more distally than the medial malleolus.
• What it feels like: A pointed, triangular bony projection. Its tip extends approximately 1 cm more distal than the medial malleolus — and it sits slightly more posterior than the medial malleolus. It is subcutaneous and easily palpable on its lateral surface.
• Client position: Supine with the foot in neutral.
• Confirmation: The lateral malleolus is fixed and does not move with ankle motion. Compare its distal extent with the medial malleolus — the lateral always extends more distally. This asymmetry is why inversion sprains are more common than eversion sprains — the longer lateral malleolus blocks eversion but allows inversion.
• Common errors: Not recognizing that the lateral malleolus is more posterior and more distal than the medial malleolus. Students sometimes expect them to be symmetrical.
• Clinical significance: The anterior talofibular ligament (ATFL) attaches to the anterior border, the calcaneofibular ligament (CFL) attaches to the tip, and the posterior talofibular ligament (PTFL) attaches to the posterior border. Tenderness at the anterior border of the lateral malleolus after an inversion injury is the hallmark of ATFL sprain — the most commonly injured ligament in the body. The Ottawa Ankle Rules use lateral malleolar tenderness (posterior edge or tip of the lateral malleolus, within 6 cm) as a criterion for radiographic referral.

Calcaneus

• How to find it: The calcaneus is the large bone forming the heel. It is palpable from the posterior (where the Achilles tendon inserts), the plantar surface (the weight-bearing base of the heel), and the medial and lateral surfaces. Place your hands around the heel and you are holding the calcaneus.
• What it feels like: A large, block-shaped bone. The posterior surface is broad and has a prominent superior ridge where the Achilles tendon inserts. The plantar surface is the weight-bearing heel pad. The medial surface has the sustentaculum tali (described below). The overall shape is like a thick rectangle viewed from the side.
• Client position: Prone (for posterior calcaneus and Achilles insertion) or supine (for plantar and medial/lateral surfaces).
• Confirmation: The calcaneus is the largest tarsal bone and the most posterior structure of the foot. It is unmistakable — no other foot bone is this large or this easily grasped in the hand.
• Common errors: Not distinguishing between the calcaneus itself and the Achilles tendon attaching to it. The Achilles tendon is a thick, cordlike structure — it becomes softer as you slide distally along it, until you reach the hard bone of the calcaneal tuberosity where it inserts.
• Clinical significance: The Achilles tendon inserts on the posterior calcaneal tuberosity — tenderness at the insertion is a finding in insertional Achilles tendinopathy. The medial calcaneal tubercle on the plantar surface is the origin of the plantar fascia — tenderness here is the hallmark of plantar fasciitis (specifically at the medial plantar heel). Calcaneal stress fractures produce diffuse heel pain that worsens with the calcaneal squeeze test (compressing the calcaneus from both sides).

Sustentaculum Tali

• How to find it: Locate the medial malleolus. Drop your finger approximately 1–2 cm inferior and slightly posterior to the tip of the medial malleolus. The sustentaculum tali is a horizontal shelf of bone projecting medially from the calcaneus. It supports the talus from below.
• What it feels like: A small, shelf-like bony projection, approximately 1–1.5 cm wide. It is less prominent than the medial malleolus above it and can be difficult to distinguish from the surrounding tissue. It feels like a small, horizontal bony ledge.
• Client position: Supine or side-lying with the medial foot accessible. Slight eversion of the foot may make the sustentaculum more prominent.
• Confirmation: The sustentaculum tali is directly inferior to the medial malleolus, approximately one thumb-width below the malleolar tip. The flexor hallucis longus tendon runs in a groove on its inferior surface — if you press on the sustentaculum and ask the client to flex the great toe against resistance, you may feel the tendon tighten.
• Common errors: Confusing the sustentaculum tali with the medial malleolus itself (the malleolus is above and more prominent) or with the navicular tuberosity (which is more distal and anterior). The sustentaculum is between the malleolus (above and posterior) and the navicular (below and anterior).
• Clinical significance: The spring ligament (calcaneonavicular ligament) runs from the sustentaculum tali to the navicular — it supports the head of the talus and is critical for maintaining the medial longitudinal arch. Tenderness at the sustentaculum may indicate spring ligament pathology or subtalar joint dysfunction. The tibial nerve and posterior tibial artery pass behind the medial malleolus and over the sustentaculum — this is the tarsal tunnel zone (see Nerve Passages).

Navicular Tuberosity

• How to find it: With the client supine or seated with the foot accessible, locate the medial side of the midfoot. The navicular tuberosity is the most prominent bony projection on the medial foot, approximately 2–3 cm anterior and inferior to the medial malleolus. It is at the apex of the medial longitudinal arch.
• What it feels like: A distinct, rounded bony prominence approximately 1–1.5 cm in diameter, projecting medially from the navicular bone. It is subcutaneous and easily palpable in most individuals — in clients with a high arch, it is very prominent; in clients with a flat foot, it may be less pronounced and closer to the ground.
• Client position: Supine or seated with the foot in neutral.
• Confirmation: The tibialis posterior tendon inserts primarily on the navicular tuberosity. Ask the client to invert the foot and plantarflex against resistance — the tibialis posterior tendon tightens and you can feel it pulling at the navicular tuberosity.
• Common errors: Confusing the navicular tuberosity with the sustentaculum tali (which is more posterior and superior, under the medial malleolus) or the medial cuneiform (which is more distal, between the navicular and the first metatarsal base).
• Clinical significance: Insertion of the tibialis posterior — tenderness here indicates tibialis posterior tendinopathy, the most common cause of adult-acquired flat foot. The navicular tuberosity is the landmark used for the navicular drop test (arch height assessment): measure the height of the navicular tuberosity from the floor in seated non-weight-bearing, then in standing. A drop of >10 mm indicates excessive pronation. An accessory navicular bone (os tibiale externum, present in approximately 10% of the population) makes the tuberosity larger and more prominent — this is a normal variant but can be painful if irritated.

Cuboid

• How to find it: Locate the base of the 5th metatarsal on the lateral foot (the prominent bony bump on the lateral midfoot — see below). From the 5th metatarsal base, slide your finger proximally (toward the heel) approximately 1–2 cm. The cuboid is the bone between the calcaneus (posteriorly) and the 4th and 5th metatarsal bases (distally). It forms the lateral column of the midfoot.
• What it feels like: A broad, somewhat irregular bony surface on the lateral midfoot. It is less distinct than the 5th metatarsal base but can be palpated as a firm bony surface in the lateral midfoot between the calcaneus and the metatarsal bases. A groove on its plantar surface carries the peroneus longus tendon.
• Client position: Supine or seated with the lateral foot accessible.
• Confirmation: The cuboid is between the calcaneus (which you can palpate as the large heel bone posteriorly) and the 5th metatarsal base (which is the prominent lateral bump distally). The cuboid sits in the gap between them.
• Common errors: Confusing the cuboid with the calcaneus (more proximal and larger) or the 5th metatarsal base (more distal and more prominent). The cuboid is less prominent than either of its neighbors.
• Clinical significance: The peroneus longus tendon crosses the plantar surface of the cuboid — a cuboid subluxation (lateral midfoot pain with pain on forefoot loading) is theorized to involve altered cuboid-peroneus longus mechanics. Cuboid manipulation (cuboid whip or cuboid squeeze) is a treatment technique for lateral midfoot pain. Tenderness at the cuboid with peroneal activity may indicate peroneus longus tendinopathy as it crosses the cuboid groove.

Base of 5th Metatarsal (Styloid Process)

• How to find it: Run your finger along the lateral border of the foot from the heel toward the toes. Approximately halfway along the lateral foot, you encounter a prominent bony bump projecting laterally — this is the base (styloid process) of the 5th metatarsal. It is the most prominent lateral midfoot landmark.
• What it feels like: A sharp, prominent bony projection extending laterally from the foot. It is approximately 1 cm wide and very distinct. It is often visible through the skin in lean individuals.
• Client position: Supine, prone, or seated. The lateral foot is accessible in any position.
• Confirmation: The peroneus brevis tendon inserts on the base of the 5th metatarsal. Ask the client to evert the foot against resistance — you can feel the peroneus brevis tendon pulling at the base. The styloid process does not move independently.
• Common errors: Confusing the 5th metatarsal base with the cuboid (more proximal) or the 5th metatarsal shaft (more distal and less prominent).
• Clinical significance: The peroneus brevis inserts here — avulsion fractures of the 5th metatarsal base occur when an inversion sprain forcefully pulls the peroneus brevis, avulsing the bone fragment. This is a common missed injury during ankle sprain assessment. Tenderness at the 5th metatarsal base after an inversion injury should prompt palpation beyond the lateral malleolus — the Ottawa Foot Rules include 5th metatarsal base tenderness as an indication for radiographic referral. A Jones fracture (fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal, approximately 1.5 cm distal to the styloid) has a higher non-union rate and is a more significant injury than a styloid avulsion.

Metatarsal Heads — The Ball of the Foot

• How to find it: With the client supine, dorsiflex the toes — the metatarsal heads become prominent on the plantar surface of the forefoot as the rounded bony prominences forming the "ball of the foot." From the dorsal surface, the heads are palpable just proximal to the MTP joint creases (where the toes meet the foot).
• What it feels like: Five rounded bony prominences in a transverse line across the forefoot. The 1st metatarsal head (great toe side) is the largest — approximately 2 cm wide. The 2nd and 3rd heads are smaller. The 2nd metatarsal head typically extends the most distally, projecting slightly beyond the others.
• Client position: Supine with the foot accessible. Passive toe dorsiflexion brings the heads into prominence plantarly.
• Confirmation: Press on a metatarsal head plantarly and dorsiflex the corresponding toe — the toe articulates with the head at the MTP joint. You can feel the proximal phalanx glide on the metatarsal head.
• Common errors: Confusing the metatarsal heads with the proximal phalanges (which are more distal) or the sesamoid bones (which are under the 1st metatarsal head on the plantar surface — two small round bones embedded in the flexor hallucis brevis tendons).
• Clinical significance: The metatarsal heads bear body weight during push-off in gait. Metatarsalgia (pain at the metatarsal heads, typically 2nd and 3rd) results from excessive loading — associated with high heels, Morton's foot (short 1st metatarsal), or transverse arch collapse. Morton's neuroma produces pain between the 3rd and 4th metatarsal heads (the interdigital nerve is compressed). Stress fractures of the 2nd and 3rd metatarsal shafts (march fractures) produce focal tenderness along the shaft proximal to the head.

Achilles Tendon Insertion

• How to find it: With the client prone, locate the thick, cordlike structure running vertically in the posterior ankle — this is the Achilles tendon. Follow it distally to its attachment on the posterior surface of the calcaneus. The insertion is at the middle to upper portion of the posterior calcaneal tuberosity, approximately 2–3 cm above the plantar surface of the heel.
• What it feels like: The Achilles tendon gradually widens as it approaches the calcaneus and inserts as a broad, flat attachment on the posterior calcaneal surface. The tendon-bone junction feels firm — harder than the tendon itself but with a slight springiness from the tendon fibers.
• Client position: Prone with the feet extending off the end of the treatment table, or supine with the knee flexed.
• Confirmation: Ask the client to plantarflex the ankle against resistance — the Achilles tendon tenses prominently and its insertion tightens against the calcaneus. The Thompson test (squeezing the calf and observing ankle plantarflexion) tests the integrity of the Achilles-calcaneal connection.
• Common errors: Palpating the retrocalcaneal space (the soft tissue between the Achilles tendon and the posterior calcaneus, just above the insertion) and misinterpreting tenderness here as insertional tendinopathy. Retrocalcaneal bursitis produces tenderness anterior to the tendon (in the bursa between tendon and bone), while insertional tendinopathy produces tenderness at the bone-tendon junction itself.
• Clinical significance: Insertional Achilles tendinopathy produces tenderness at the calcaneal attachment with possible thickening and calcification. Distinguish from midportion tendinopathy (tenderness 2–6 cm above the insertion — the watershed zone with the poorest blood supply). Achilles tendon rupture typically occurs 2–6 cm above the insertion, not at the insertion itself. A positive Thompson test (no ankle plantarflexion when the calf is squeezed) indicates complete rupture — refer immediately.