The posterior tibial pulse is the beat you can feel on the inside of the ankle, tucked behind the bony bump there. Finding it takes the right spot and a light touch more than strength. It is also one of the trickier pulses to feel, even for trained examiners.1PubMed Central. Should we palpate foot pulses? Not feeling it is a cue to look more closely, not a verdict on someone’s circulation.
The Exact Spot Behind the Inner Ankle Bone
Two landmarks box in the spot. The first is the knob on the inside of the ankle. Behind it runs the Achilles tendon, the thick cord at the back of the heel.2BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings The pulse sits in the soft groove between these two, just behind and slightly below the ankle bone.3BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings
That location makes sense because the posterior tibial artery runs down the back of the calf and curves around the inner ankle into the sole of the foot. About 3 cm (roughly 2 to 4 cm) below the lowest tip of the ankle bone, it splits into branches for the sole.4PubMed Central. Anatomical study of the distal course of the posterior tibial artery: A cadaver study Feeling too far down toward the heel can therefore miss the main vessel.
To find the landmarks on your own ankle, run a finger down the inside of your shin until it meets the round ankle bone. Then pinch the back of your heel to locate the Achilles cord. The pulse lies in the hollow between them.
The artery lies deep in a tunnel of tissue at the inner ankle, alongside tendons, veins and a nerve, so beginners often mistake one of those for the pulse.5BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings A pulse taps rhythmically in time with your heartbeat. A tendon feels like a firm cord and moves when the toes curl. A vein feels soft and squashy and doesn’t beat.
How to Press and Feel the Pulse
Have the person lie down or sit with the foot relaxed and the toes tilted slightly up toward the shin.6BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings Rest the heel on a bed or the caregiver’s knee so the calf muscles are loose, because a tense or dangling foot tightens the tissue over the groove and hides the beat. Support the foot with your free hand under the heel or sole so it stays still while the other hand works.
Place the pads of the index and middle fingers in the groove behind and below the inner ankle bone.7BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings Avoid the thumb, which has its own pulse and will confuse the result. The artery is deep, so you need firm but not heavy pressure.8BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings Pressing too hard can squash the artery and stop the beat you’re feeling for.9BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings
A good method is to rest the fingertips on the groove with almost no weight, then slowly add pressure. The pulse often appears at a particular depth and can vanish again if you go past it. If you feel nothing, ease up slightly rather than pushing harder, since a squashed artery gives the same result as an absent one. Once you feel something, keep your fingers still. Sliding around makes it hard to tell a faint beat from skin movement.
Expect a soft, small tap rather than the strong thump you get at the wrist or neck. Hold still for at least several seconds before deciding anything, and count against a watch if you want a rate. Warm hands and a warm room make faint pulses easier to sense.
Feel both ankles, ideally at the same time, to compare strength.10Pressbooks. Inspection and Palpation of Feet and Legs Comparing presence, strength and symmetry gives a picture of blood flow to the legs.11Pressbooks. Inspection and Palpation of Feet and Legs A pulse clearly weaker on one side is more telling than one that is faint on both.
When You Can’t Feel It
Turning the foot slightly inward relaxes the band of tissue over the artery.12BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings Bending the knee or trying a different hand position can also help.13Appropedia. NREMT Skillset/Posterior Tibial Pulse Palpation If that doesn’t work, try feeling a little above or below the ankle bone along the same groove.14Appropedia. NREMT Skillset/Posterior Tibial Pulse Palpation
Some ankles make it genuinely hard. The pulse is harder to feel in people with heavier ankles or swelling.15OrthoFixar Orthopedic Surgery. Posterior Tibial Pulse: Location, Palpation Technique & Clinical Guide Swollen ankles add a cushion between fingers and artery, and pressing a dent into swollen skin isn’t the same as finding a pulse. Raising the leg for a while can sometimes reduce the swelling before you check.
Advanced artery narrowing also makes the pulse faint or absent,16OrthoFixar Orthopedic Surgery. Posterior Tibial Pulse: Location, Palpation Technique & Clinical Guide because the strength you feel depends on the pressure inside the artery.17PubMed Central. Peripheral pulse palpation: an unreliable physical sign And in about 5% of legs of people imaged for leg artery problems, the posterior tibial artery is underdeveloped or missing from birth.18PubMed. Anatomical variations of the popliteal artery and its tibial branches: analysis in 1242 extremities
Cold can hide it too. Cold narrows the small vessels in the foot and lowers the beat you can feel, so a chilly room or bare cold feet can make a normal pulse seem faint. Warm the foot with a blanket, or wait a few minutes in a warm room, before deciding anything is wrong. If a foot stays cool and pale even after warming, and the other foot does not, that difference is worth noting.
A caregiver who still can’t find the pulse after these steps shouldn’t conclude that circulation is poor. A better next step is to check the pulse on top of the foot and note how the foot looks and feels: its colour, warmth and any sores. If both foot pulses are missing, or the foot looks pale and cold or has a sore that won’t heal, ask a clinician for a proper test.
Why This Pulse Is Harder Than the One on Top of the Foot
Examiners agreed on whether this pulse was present in only about 70% of healthy legs, yet they agreed on every top-of-foot pulse in the same group.19PubMed Central. Should we palpate foot pulses? In another study, examiners detected a present posterior tibial pulse only 33% to 60% of the time, depending on experience.20PubMed Central. Peripheral pulse palpation: an unreliable physical sign A “can’t feel it” result can reflect the difficulty of the exam, not only an artery problem.
The top-of-foot pulse is usually easier to feel, and it is checked as well. Clinicians routinely feel both as a pair, which gives two chances to confirm flow.
A Doppler is a small ultrasound probe that turns blood flow into a whooshing sound.21BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings When the pulse can’t be felt, clinicians use a handheld Doppler to confirm whether flow is there.22BackTable. Posterior Tibial Pulse in Vascular Exams: Technique & Findings Gel goes on the skin over the groove, and the probe is angled until a rhythmic whoosh is heard. It’s painless, takes under a minute, and many clinics and wound nurses keep one on hand. Feeling by touch is still faster, taking about 6 seconds less per artery.23PubMed. Palpation versus hand‑held Doppler for identifying lower‑limb peripheral arteries: Time‑efficiency and reliability in healthy adults
What a Weak or Missing Pulse Can Mean
Peripheral artery disease (PAD) means narrowed leg arteries that reduce blood flow. In people with leg symptoms, an abnormal foot pulse makes the disease several times more likely.24JAMA. Does the Clinical Examination Predict Lower Extremity Peripheral Arterial Disease? Normal pulses make it less likely, especially moderate or severe disease.25JAMA. Does the Clinical Examination Predict Lower Extremity Peripheral Arterial Disease? But the exam is imperfect: a full foot-pulse exam misses about 4 in 10 people who have the disease,26PubMed Central. The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease and when it does flag disease it is right about 8 times in 10.27PubMed Central. The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease A normal exam shouldn’t reassure someone who has symptoms.
Risk rises with smoking, diabetes, high blood pressure, high cholesterol and older age, so a missing pulse in a person with these carries more weight. In a young, healthy person with no symptoms, it is more likely an anatomy or technique issue. Clinicians read the pulse together with the person’s history and symptoms.
Diabetes changes the picture. About half of people with a diabetic foot ulcer also have narrowed leg arteries, which is linked to wounds not healing and to amputation.28PubMed. Diagnosis and assessment of peripheral arterial disease in the diabetic foot Yet in these patients pulse checks alone tell little either way.29PubMed. Clinical examination and non-invasive screening tests in the diagnosis of peripheral artery disease in people with diabetes-related foot ulceration
Some warning signs matter more than a faint pulse: calf pain on walking that eases with rest, a foot that feels cold or looks pale compared with the other, and sores on the feet or toes that heal slowly. Any of these with a missing pulse deserves a doctor’s visit soon.
A suddenly cold, pale, painful foot with no pulse needs emergency care, even if the pulse is only missing on one side. And a felt pulse doesn’t rule out a serious injury, since people with severe pain after a leg injury can have a pressure buildup even while pulses are still present.
Tests That Go Beyond Touch
The ankle-brachial index (ABI) compares blood pressure at the ankle with pressure in the arm. For the ankle, the higher of the two pressures from the posterior tibial and top-of-foot arteries is usually used.30The New England Journal of Medicine. Ankle–Brachial Index for Assessment of Peripheral Arterial Disease Some researchers average the two instead, which better reflects walking ability.31PubMed. Lower ankle/brachial index, as calculated by averaging the dorsalis pedis and posterior tibial arterial pressures, and association with leg functioning in peripheral arterial disease
The result is a ratio: ankle pressure divided by arm pressure, so a lower ratio means less pressure is reaching the foot. A result around 0.9 or lower usually points to narrowed leg arteries, and lower values generally mean more severe narrowing. The number is read alongside symptoms and the examination, not alone.
For the test, you lie flat for several minutes first. Blood pressure cuffs go on both arms and ankles, and a handheld Doppler listens at each ankle artery. It takes about 15 minutes and doesn’t hurt. People with diabetes and foot problems should ask for it, as should smokers or ex-smokers with walking calf pain, and anyone whose ankle pulses can’t be found on both sides.
The test can mislead in some people, especially those with long-standing diabetes or kidney disease. Their ankle arteries stiffen and resist the cuff, giving a falsely high reading. A normal number in such a person doesn’t fully clear them if they have symptoms or foot wounds, and a clinician may choose other tests.