Anthony Luke MD, MPH
The ankle is one of the most commonly injured joints of the body and is frequently observed with activities that involve jumping or running. An examination of the ankle should also include a thorough evaluation of the foot. This includes an assessment of gait pattern, standing posture, and shoe wear pattern. Any obvious gross deformity, malalignment, or atrophy should also be observed and noted. Acute injuries to the ankle commonly result in swelling and the development of ecchymosis. Accumulation of swelling typically occurs around the lateral and/or medial malleoli, and may move distally into the foot.
Palpation of the ankle is important in identifying which structures are injured. Bony structures to palpate should include the shaft of tibia and fibula, traveling down the borders of both the medial and lateral malleoli. Palpation of the neck and dome of the talus should also be performed. This can be done by inverting and everting the foot, and palpating just anterior to the medial and lateral malleoli. Soft tissue palpation should include all the ligamentous structures: the anterior talofibular ligament, the posterior talofibular ligament, the calcaneofibular ligament, the deltoid ligament complex, and the anterior tibiofibular syndesmosis. Palpation of the muscle tendons that cross the ankle joint should also be performed. The peroneus longus and brevis tendon can be palpated as it passes posterior to the lateral malleolus and courses below the distal pole towards the base of the fifth metatarsal. On the medial aspect of the ankle, palpation of the posterior tibialis, flexor digitorum longs, and flexor hallucis longus can be done. These three tendons pass posterior to the medial malleolus. The posterior tibial artery and nerve can also be palpated here. Finally, along the anterior aspect of the ankle, the body and tendon of the tibialis anterior, extensor hallucis longus, and extensor digitorum longus can be palpated.
Range of Motion
Assessment for ankle range of motion typically begins with an evaluation of active, passive and resistive range of motion. There are four main motions that occur at the ankle joint: dorsiflexion, plantar flexion, inversion, and eversion. To assess the passive range motion, have the patient seated with their foot off the exam table. While stabilizing the lower leg, passively apply pressure to assess soft tissue mobility. Range of motion should always be compared bilaterally and any deficits should be noted. Normal motion for passive dorsiflexion is 10° to 15°, while normal passive plantar flexion is 50 to 70°. Normal passive inversion is approximately 40° and eversion is around 10°. Any pain during passive movement may indicate musculotendinous or ligamentous. Limitation of motion may be a result of pain, swelling, or scar tissue from a chronic injury. Finally, resistive range of motion should be tested to assess for any muscular weaknesses or injuries.
Talar Tilt Test
Description: The Talar Tilt Test is a ligamentous stress test that examines the integrity of the lateral ankle ligaments, particularly the calcaneofibular ligament.
Maneuver: Have the patient in the seated position, with their knee bent and foot in a neutral or slightly dorsiflexed position. Stabilize the distal tibia with one hand while applying an inversion force to the foot.
Positive Findings: Positive findings include any pain in the ankle or increased joint laxity. Depending on the positioning of the ankle, pain may be experienced over either the calcaneofibular ligament or the anterior talofibular ligament.
Description:The anterior drawer test is used to examine the integrity of the anterior talofibular ligament, which is frequently injured during an inversion ankle sprain.
Maneuver: Have the patient seated with their knee bent and their ankle in a neutral position at 0° or 90° to the leg. Stabilize the distal tibia with one hand, while grasping the heel with the other hand. Apply an anterior force to the heel. This test should be performed bilaterally to compare for differences in anterior translation.
Tip: In order to gain a better feel for the translation of the foot in relation to the lower leg, the index finger can be placed behind the heel with the thumb over the front of the ankle. Also, a firm, steady load during testing can be more sensitive than a higher, quick load.
Positive Findings: Pain or increased joint laxity in the injured ankle indicates disruption of the anterior talofibular ligament. A dimple may also be visually seen by the clinician while performing this test.
External Rotation or Kleiger’s Test
Description:The test is used to help identify syndesmotic injuries.
Maneuver: Have the patient seated with their knee bent on the exam table. Stabilize the distal tibia while externally rotating the foot. External rotation of the talus applies pressure to the lateral malleolus, causing a widening of the tibiofibular joint.
Tip: The examiner may be able to feel the talus displace from the medial malleolus, which indicates there may be a disruption of the deltoid ligament.
Positive findings: Increased external rotation of the foot when compared bilaterally, or any pain in the anterolateral ankle joint is considered to be a positive finding.
Description:This test is utilized to evaluate the integrity of the heel cord.
Maneuver: Have the patient lying prone on a table with their foot extended off the edge. Squeeze the calf muscle at position slightly distal to the place of widest girth. Examine the movement at the foot.
Positive Findings: A positive test occurs when the calf is squeezed and no plantar movement occurs at the foot. This indicates a heel cord rupture.
Description:This test examines the integrity of the distal tibiofibular joint. It can also assess for fractures of the tibia and fibula.
Maneuver: Have the patient sitting supine with their foot on the table. Grasp the mid-calf and squeeze the tibia and fibula together. Gradually move distally towards the ankle while continuing to apply the same amount of pressure.
Positive findings: Any pain in the lower leg may be indicative of a fracture or syndesmotic sprain.