Ankle Examination

Case Management 2
Spring - 2007

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Examination
 12 Step Evaluation
 Ottawa Ankle Rules

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Initial Examination
 Most common injury is the inversion ankle sprain,
which stresses the lateral ligament complex.
 If the patient is unable to bear weight and/or walk
4 steps immediately after the injury and at time of
presentation, that is a significant observation.
 Previous ankle injuries are important.
 Laxity makes repeat injuries more likely.

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 Elements of the History
 Patient's age
 Occupation
 Comorbid conditions
 Osteoporosis
 Neuropathy

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12 Point Examination
 R/O  R/O
2. Achilles tendon rupture 2. Lateral ligament complex
3. Anterior talofibular tear/avulsion of the lateral
(ATF) ligament injury malleolus
4. Calcaneal fracture 3. Navicular fracture
5. Deltoid tear/avulsion 4. Neurovascular damage
fracture of the medial 5. Subluxed peroneal tendon
malleolus 6. Tibia fracture
6. Fibular fracture 7. Interosseus
7. Fifth metatarsal fracture membrane/syndesmosis
tear
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 Bones of Foot

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Ligaments of the Ankle

Ant. tibiotalar

Post. tibiotalar

Tibiocalcaneal
Tibionavicular

Ant. talofibular

Post. talofibular Calcaneofibular

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Step #1
 Interosseous
membrane/syndesmosis
ligament binding the tibia
and fibula
 Head of the fibula
 Shaft of the fibula or tibia.

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Achilles Tendon Examination
 Keep the foot in a
90 degree position.

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Drawer Test
 Anterior Drawer Test
1. First put the patient's foot in the 90-degree
(neutral) position.
2. Let the foot rest along your forearm.
3. The hand cupping the heel pulls anteriorly
while the opposing one stabilizes the lower leg.
4. More than 0.5 cm of movement or lack of a
firm end point signals a positive drawer test.
 Problem with the ATF ligament or the
syndesmosis at the distal tibia-fibula
joint.
5. You can also validate instability of the
interosseus membrane and/or syndesmotic joint
by hyperdorsiflexion of the foot.
6. Extreme pain locally over the area during
hyperflexion signals a positive result.
7. Important Note:
 Avoid letting the foot slip into plantar
flexion, which leads to instability and
produces erroneous clinical information.

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 Step #4
 Apply pressure from the
hypothenar eminence of
your hand cupping the
heel against the base of the
fifth metatarsal.
 This maneuver may illicit
pain if a fracture is
present.

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Step #5
 Palpate over the tarsal
navicular bone with your
thumb.

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Step #6
 Compress the calcaneus.
 Pain indicates the
possibility of a fracture in
these areas.
 Achilles tendon rupture
 Sprain of the ATF ligament
 Fracture at the base of the
fifth metatarsal
 Tarsal navicular fracture
 Calcaneal compression
fracture.

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Step #7 and #8
 Keep the ankle in the 90-degree
neutral position.
 Attempt the talar tilt test by
everting and inverting the ankle
mortice, noting excessive motion.
 Motion that is 10% greater than
that in the normal comparison
ankle or the lack of a solid end
point indicates possible damage to
the deltoid (medial) or the
calcaneofibular (lateral) ligaments.
 Pain alone is not a sufficient basis
for the diagnosis:
 A mild sprain might produce
pain, but a complete rupture
might be nearly painless.

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 Step #7 and #8 (continued)
 Complete the palpation of the distal medial malleolus, then move to
the lateral malleolus.
 Palpations of the posterior aspects of the distal malleoli are the most
productive maneuvers for eliciting pain caused by fractures.
 Subluxation of the peroneal tendon may be suspected in a patient with
a hyperdorsiflexion injury, pain, and ecchymoses along the posterior
lateral malleolus in the absence of tenderness of the ATF ligament.
 Examination for:
 Medial malleolar avulsion fracture or deltoid ligament tear
 Lateral malleolar avulsion or lateral complex/ calcaneofibular
ligament tear
 Subluxation of the peroneal tendon.

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Step #9
 Peroneal tubercle is a
protuberance that gives
the appearance of slight
puffiness and bluish color
to an area that
coincidentally overlies the
ATF.
 Most commonly injured
structure in a sprained
ankle.

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