Ankle Flashcards
Ankle AROM
- Plantar flexion (50°)
- Dorsiflexion (20°)
- Toe Extension
- Toe Flexion
- Toe Abduction
- Toe Adduction
- Eversion (20°)
- Inversion (30°)
Ankle PROM
- Plantar flexion – Talocrural joint (tissue stretch)
- Dorsiflexion – Talocrural joint (tissue stretch)
- Inversion – Subtalar joint (tissue stretch)
- Eversion – Subtalar joint (tissue stretch)
- Adduction and Abduction - Toes (tissue stretch)
- Flexion – Toes (tissue stretch)
- Extension – Toes (tissue stretch)
Thompson’s Test
Purpose: – To assess for tears (Grade III strain) of the Achilles tendon
Procedure: –
- Part 1: • The patient lies prone with the feet over the edge of the examination table
- The examiner stands adjacent to the patient’s affected leg
- With the patient relaxed, the examiner squeezes the calf muscle
- Part 2:
- The patient lies prone with the knee of the affected leg flexed to 90°
- With the patient relaxed, the examiner squeezes the calf muscle
- Indication of Positive Test: – Absence of plantar flexion when the patient’s calf muscle is squeezed indicates possible transverse rupture of the Achilles tendon
Note: –
- The practitioner should not assume that the Achilles tendon is intact if the patient can actively plantar flex the ankle (non-weight bearing) as this action can be performed by the long flexors even if the Achilles tendon is ruptured – The second part of the test reduces the affect of the hamstring muscles on the gastrocnemius m.
Test for Peroneal Tendon Dislocation
- Purpose:
– To assess for Peroneal tendon dislocation over the lateral malleolus
- Procedure:
– The patient is placed in the prone position on the examination table with the knee flexed to 90 degrees
– The postero-lateral region of the ankle is inspected for swelling
– The examiner stands adjacent to the patient’s affected leg and places the patient’s foot into a neutral position but adds eversion
– The practitioner places his/hand on the lateral aspect of the sole of the patient’s foot
– The patient is then asked to actively dorsiflex and plantarflex the ankle along with eversion against resistance from the examiner
- Indication of Positive Test:
– Visualisation of peroneal tendon subluxating over the lateral malleolus indicating peroneal retinaculum or peroneal tendon injury
- Note:
– The practitioner’s role is to not only provide some resistance to the patient’s movements but to also maintain the patient’s foot in the everted position during the maneuver
Tinel’s Sign at the ankle (Percussion Sign)
• Purpose:
– To assess for neuropathy of the posterior tibial or anterior tibial branch of the deep peroneal nerve
• Procedure:
– Posterior tibial nerve:
- The patient lies supine on the examination table
- The examiner percusses firmly behind the medial malleolus for approximately 5-10 seconds
– Deep peroneal n. (Anterior tibial branch):
- The patient lies supine on the examination table
- The examiner percusses firmly just medial to the extensor hallicus longus tendon and inferior to the ankle joint for approximately 5-10 seconds
- Indication of positive test:
– Tingling or paresthesia at or distal to the site of percussion indicates tarsal tunnel syndrome (posterior tibial nerve) or peripheral neuropathy or the Deep Peroneal n.
Homan’s Sign
• Purpose:
– To assess for deep vein thrombophlebitis (DVT)
• Procedure:
– The patient lies supine with the feet over the end of the examining table – Part 1: The examiner passively dorsiflexes the patient’s foot while maintaining knee extension
– Part 2: The practitioner palpates the patient’s calf while looking to elicit areas of tenderness
• Indication of Positive:
– Pain in the calf along with relevant history items indicates possible DVT – Calf tenderness, pallor, swelling and loss of dorsalis pedis pulse are additional findings
Anterior Drawer Test of the Ankle
• Purpose:
– To test for injury to the Anterior Talofibular ligament (ATFL)
– ‘Low ankle sprain’
• Procedure:
– The patient lies supine with the knee flexed to 90 degrees
– The practitioner stands adjacent to the test ankle
– The examiner contacts the patients tibia and fibula with a web contact of the primary hand and stabilises the foot and talus with the secondary contact
– With the ankle positioned in approximately 20 degrees of plantar flexion the examiner pushes the tibia and fibula posteriorly on the stabilised foot and talus
– The practitioner takes note of any movement that is available and compares this with the unaffected side
• Indication of a Positive Test:
– Excessive posterior movement of the tibia and fibula on the talus
– Anterior or anterior-rotary talus instability associated with collateral ligament sprain:
- Usually the ATFL of the lateral ligaments
Talar Tilt (Inversion) Stress Test
• Purpose:
– To assess for injury of the Calcaneofibular ligament (CFL)
• Procedure:
– The patient lies supine with the foot relaxed
– The examiner stands adjacent to the patient’s test foot – The practitioner holds the foot in the anatomical position (mid way between plantar- and dorsiflexion) and stresses the hind foot into adduction
– The procedure is repeated with the ankle in varying degrees of plantarflexion and dorsiflexion
– The practitioner takes note of any movement that is available and compares this with the unaffected side
• Indication of a Positive Test:
– Laxity +/- pain
– Lateral collateral ligament sprain:
- Anatomic position: – Calcaneofibular ligament (CFL)
- Dorsiflexion: – Posterior Talofibular ligament (PTFL)
- Plantarflexion: – Anterior Talofibular ligament (ATFL)
Talar Tilt (Eversion) Stress Test
• Purpose:
– To determine if the medial ankle ligaments are damaged
• Procedure:
– The patient lies supine with the foot relaxed
– The examiner stands adjacent to the patient’s test foot – The practitioner holds the foot in the anatomical position (90°) and stresses the hind foot into abduction
– The procedure is repeated with the ankle in varying degrees of plantar flexion
– The procedure is repeated again with the ankle in dorsiflexion
– The practitioner takes note of any movement is available and compares this with the unaffected side
• Indication of a Positive Test:
– Laxity +/- pain – Deltoid ligament sprain:
- Anatomic position: – Tibiocalcaneal ligament (TCL)
- Dorsiflexion: – Posterior Talotibial ligament (PTTL)
- Plantarflexion: – Tibionavicular ligament (TNL)
Squeeze Test of the Leg
• Purpose:
– To test for potential injury to the syndesmosis between the tibia and the fibular – ‘High ankle sprain’
• Procedure:
– The patient lies supine
– The examiner stands adjacent to the patient’s test leg
– The practitioner interlocks his or her digits behind the patient’s calf and grasps the lower leg squeezes the tibia and fibula together
– The practitioner should start down low near the ankle mortise and work superiorly up towards the knee
– The patient is asked to report any tenderness associated with the maneuver
– The practitioner compares this with the unaffected leg
- Indication of a Positive Test: – Pain:
- Syndesmosis injury
- Fracture
- Contusion
- Compartment syndrome
- Note:
– Fracture, contusion and compartment syndrome must be ruled out in order to correctly attribute a positive test result to a syndesmotic injury
Kleiger Test
• Purpose:
– To test for an injury to the syndesmosis between the tibia and the fibula
• Procedure:
– The patient is seated on the examination table with knees flexed to 90° with the feet dangling off the examination table
– The practitioner kneels adjacent to the test ankle
– The examiner places the patient’s foot in the anatomical position (90°)
– The examiner then stabilises the patient’s tibia and fibula with the secondary contact, and grasps the patient’s foot with the primary contact – The practitioner then rotates the patient’s foot laterally using the primary contact
• Indication of Positive:
– Pain (medially, laterally or about the syndesmosis) and talar displacement
– Deltoid ligament injury
– Syndesmosis injury
Talus Neutral (Weight-bearing)
• Purpose:
– To determine the neutral position of the talus, which is often referred to as subtalar neutral or the balanced position of the foot, and the affect that this neutral position has on any observed deformity of the knee, lower leg, ankle, or foot
• Procedure:
– The patient stands with their feet in a normal relaxed position e.g. normal stance width and fick angle
– The examiner observes (AP, PA, and lateral and medial) for any obvious deformity anywhere in the lower quadrant
– The examiner kneels adjacent to the patient’s test leg
– The examiner palpates the head of the talus on the dorsum of the foot with the thumb and forefinger of one hand. The thumb is placed on the lateral aspect of the talus, and the index finger is placed on the medial aspect of the talar head
– The patient is asked to slowly rotate the trunk to the right and then to the left until the practitioner feels that the talus is midway between supination and pronation
– The practitioner then observes for changes (as a result of the neutral subtalar joint) in the positioning of the knee, lower leg, ankle and foot – The two feet are compared
• Indication of a Positive Test:
– If deformity or misalignment is observed, the practitioner takes note of the influence that a neutral subtalar joint has on any observed deformity or misalignment
– If the observed deformity or misalignment is not corrected by the subtalar neutral position there is a higher probability that it is of structural origin with functional overlay
– If the observed deformity or misalignment does reduce in response to the subtalar neutral position there is a higher probability that it is a functional problem
Talus Neutral (Supine)
- Purpose:
– To determine the neutral position of the talus, which is often referred to as subtalar neutral or the balanced position of the foot and the affect that this position has on any observed deformity in the hindfoot, midfoot, or forefoot
• Procedure:
– The patient lies supine with the feet over the end of the examining table
– The examiner stands at the base of the examination table
– The examiner observes for any deformity in the hindfoot, midfoot or forefoot
– The examiner grasps the patient’s foot over the fourth and fifth metatarsal heads, using the thumb and index finger of one hand.
– The examiner palpates the head of the talus on the dorsum of the foot with the thumb and forefinger of one hand. The thumb is placed on the lateral aspect of the talus, and the index finger is placed on the medial aspect of the talar head
– The examiner passively dorsiflexes the foot until resistance is felt
– While the examiner maintains the dorsiflexion, the foot is passively moved through an arc of supination and pronation until the subtalar joint is midway between supination and pronation
– The two feet are compared
• Indication of a Positive Test:
– If deformity or misalignment is observed, the practitioner takes note of the influence that a neutral subtalar joint has on any observed deformity or misalignment in the rearfoot in relation to the forefoot
– If the observed deformity or misalignment is not corrected by the subtalar neutral position there is a higher probability that it is of structural origin with functional overlay
– If the observed deformity or misalignment does reduce in response to the subtalar neutral position there is a higher probability that it is a functional problem
Talus Neutral (Prone)
• Purpose:
– To determine the neutral position of the talus, which is often referred to as subtalar neutral or the balanced position of the foot and the affect that this position has on any observed deformity in the hindfoot and/or leg
• Procedure:
– The patient lies prone with the feet over the end of the examining table – The examiner stands at the base of the examination table
– The examiner observes for any deformity in the hindfoot/leg
– The examiner grasps the patient’s foot over the fourth and fifth metatarsal heads, using the thumb and index finger of one hand
– The examiner palpates the head of the talus on the dorsum of the foot with the thumb and forefinger of one hand. The thumb is placed on the lateral aspect of the talus, and the index finger is placed on the medial aspect of the talar head
– The examiner passively dorsiflexes the foot until resistance is felt
– While the examiner maintains the dorsiflexion, the foot is passively moved through an arc of supination and pronation until the subtalar joint is midway between supination and pronation
– The two feet are compared
• Indication of a Positive Test:
– If deformity or misalignment is observed, the practitioner takes note of the influence that a neutral subtalar joint has on any observed deformity or misalignment in the hindfoot in relation to the leg
– If the observed deformity or misalignment is not corrected by the subtalar neutral position there is a higher probability that it is of structural origin with functional overlay
– If the observed deformity or misalignment does reduce in response to the subtalar neutral position there is a higher probability that it is a functional problem
Navicular Drop Test
• Purpose:
– To test for hyperpronation
• Procedure:
– The patient sits on a chair with the feet resting comfortably (normal fick angle and normal stance width) on the floor
– The examiner kneels adjacent to the patient’s test leg
– Part 1: The examiner measures the height from the navicular tubercle to the floor and takes note of that measurement
– Part 2: The patient is then asked to stand in a relaxed position (normal fick angle and normal stance width)
– The practitioner again measures the height from the navicular tubercle to the floor and takes note of the new measurement
• Indication of a Positive Test:
– A decrease >10mm between the sitting and standing measurements is considered positive abnormal foot pronation
