Examination


 

Assessment

Subjective

  • Mechanism of Injury
    • Position of Foot / Ankle
    • Direction of force
  • Initial Symptoms and Progression
    • Degree and location of pain
    • Clicks, cracks or pops
    • Ability to WB
    • How quickly swelling develops – severe swelling within 1-2 hours, versus slowly developing swelling
    • Aggravations and Eases – ie pain behaviour
  • Past Ankle History
    • Both that foot / ankle and other side, including operations.

 


 

Objective Assessment

GENERAL CONSIDERATIONS

  • In an acute injury:
    • Often everything hurts
    • Weightbearing is usually difficult
    • Active and passive movement is often painful
    • The patient will probably use extensive muscle guarding to prevent further pain

OBSERVATION

  • OBS – HR, BP, TEMP (IF INDICATED)
  • Distal Neurovascular function (pedal pulse, capillary return, sensation, movement, warmth)
  • Swelling
  • Effusion (watery fluid; slow onset)
  • Haemarthrosis
  • Color – is it red?
  • Bruising / deformity

FUNCTIONAL TESTS

  • Ability to WB (hop, jump)

GENERAL TESTS

  • Range of motion (Active vs Passive)
    • Dorsiflexion / Plantarflexion
    • Inversion / Eversion
  • Palpation, in particular:
    • Posterior tip of both the medial and lateral malleoli
    • Base of fifth metatarsal
    • Navicular
    • Junction of first and second metatarsals
    • Lateral and medial ligament complexes
    • Superior and inferior tibiofibular joints
    • Ensure that you palpate the entire length of the fibula

SPECIAL TESTS

  • Ligament stability
    • Anterior Drawer
    • Talar Tilt (inversion, eversion)
    • Tib / Fib glides
  • Muscle Strength and Integrity Tests
    • Resisted eversion, inversion, PF, DF
    • Thompson / Simmonds Test
  • Muscle Length Tests
    • Calf
    • Lunge
  • Impingement
    • Posterior impingement test
  • Arch / Plantar Fascia / Supination
    • Jack’s test
    • Manual supination resistance

 


 

Ligament Stability Tests

Anterior Drawer Test

Technique

  • Ankle plantarflexed approximately 20-30 degrees and stabilise the shin
  • Either by holding on to the talus from the anterior aspect (which can be quite painful in an acute injury, but extremely useful in assessing long term stability) or via the calcaneus posteriorly, draw the talus/calcaneus anteriorly

Interpretation

  • Increased anterior translation and loss of normal endfeel may indicate more significant damage to the anterior talofibular and calcaneofibular ligaments

Talar Tilt Test – Inversion

Technique

  • With the ankle in plantarflexion (stresses ATFL more), plantargrade (CFL) or dorsiflexion (PTFL), “tilt” the talus by applying an inversion type force
  • Assess for pain and laxity

Interpretation

  • Laxity on testing dictates grade:
    • Grade I sprain = pain without laxity
    • Grade II sprain= pain with mild laxity
    • Grade III sprain =significant laxity +/- pain

Talar Tilt Test – Eversion

Technique

  • With the ankle in plantarflexion, plantargrade or dorsiflexion, “tilt” the talus by applying an eversion type force
  • Assess for pain and laxity

Interpretation

  • Laxity on testing dictates grade:
    • Grade I sprain = pain without laxity
    • Grade II sprain= pain with mild laxity
    • Grade III sprain =significant laxity +/- pain

Tibiofibular Joint Stress Tests

Technique

  • Attempt to sublux the fibular head and lateral malleolus anteriorly or posteriorly.
  • This can be performed in supine or sidelying (which is easier for the patient to relax)

Interpretation

  • If increased movement, pain with assessment or subluxation is possible, this indicates laxity at this joint.

Muscle Integrity

Thompson / Simmond’s Test
Technique

  • Have the patient in prone, or kneeling on a chair, with their foot off the edge of the bed
  • Squeeze the calf and observe the achilles tendon / foot

Interpretation

  • If the foot does not move significantly (compare to the other side), this may indicate achilles tendon rupture
  • Use in conjunction with passive dorsiflexion, resisted plantarflexion and palpation to accurately diagnose potential ruptures.

Supination Force Tests

Jack’s Test
Technique

  • Begin with the patient in standing relaxed
  • Dorsiflex the first toe at the MTP joint until the medial longitudinal arch raises

Interpretation

  • Grade the level of resistance to this movement from 1-5 (1 being minimal force required, 5 being significantforce required to dorsiflex the first MTP and raise the medial arch)
  • The greater the resistance to this movement, the more force generation will be required by the foot supinatorsto convert the foot into a rigid lever for push off (and hence greater chance for overload)
  • This test may also be painful for patients with plantar fascia / structure tears or tendinopathy

Manual Supination Resistance Test
Technique

  • Begin with the patient in standing and relaxed
  • By using two fingers adjacent to the tuberosity of navicular, attempt to supinate the foot and raise the medial arch (ensure that the patient does not assist)

Interpretation

  • The force is rated from 1 to 5 (1 being minimal force and 5 being significant force required to supinate the foot)
  • Implications are for overuse injuries of the structures which assist to supinate the foot in order to convert it to a rigid lever for push off.

Other Tests

Tinel’s Sign

Technique

  • Repeatedly tap over the tibial nerve where it lies posterior to the medial malleolus

Interpretation

  • Reproduction of tingling sensation or pain in the medial foot or heel is suggestive of tarsal tunnel syndrome

Mulder’s Sign

Technique

  • Grasp the forefoot between the fingers and thumb and squeeze

Interpretation

  • Reproduction of interdigital pain is suspicious for Morton’s neuroma

Strength Tests

Inversion
Eversion
Dorsiflexion
Plantarflexion


Length Tests

Calf
Achilles