Ankle Ax and Rx

Question 1

SQs

Answer 1

• MOI - Trauma/surgery/onset
• Neuro symptoms
• Locking/giving way/popping
• What type of shoes & their wear pattern
• Functional Limitations
• Sport Specifics – i.e. if a runner, distance, intensity and surface type
• Presence of hip or knee pain? (i.e., ankle pain can be referred from the hip or biomechanically affected by the ankle)

Question 2

Red Flags

Answer 2

• Bilateral P & N in LL
• B&B dysfunction / incontinence
• Paraesthesia in the groin/saddle anaesthesia
• Loss of pulses in the LL (vascular compromise)
• Obvious deformity & no investigations

Question 3

Observations + Functional Assessment

Answer 3

General:

• Erythema (Redness)
• Haematoma (Bruising)
• Oedema (Excessive build-up of fluid, normally feet/ankles)
• Excessive hair growth
• Oozing/weeping
• Effusion (Swelling)
• Bony Deformities
• Atrophy/Hypertrophy

Gait:

• Posture - foot posture (pes planus/pes cavus)
• Gait (calcaneal varus/valgus, pronation/supination, arches)
• Walking Aids

Functional Assessment:

• Walking Pattern
• Single Leg stand
• Squat
• Single Leg Squat

Question 4

AROM and PROM

Answer 4

• Plantarflexion 45-55
• Dorsiflexion 10-15
• Inversion 30 – 40
• Eversion 15-25
• Pronation
• Supination

Active:

• Muscle Control
• Pain

Passive:

• Resistance (end-feel)
• Pain
• Capsular pattern - pf, df

Question 5

Muscle tests

Answer 5

Power/strength:

• Gd I – V
• Through Range
• Resisted ROM

Length:

• Resistance
• End Feel
• Gastroc – Ax passive ankle DF with knee in full extension
• Soleus – Ax passive ankle DF with knee flexion (place towel under knee)

Control & Stability:

• Jerky
• Smooth
• SLS, SLD, Squat, Hopping/Jumping

Question 6

Neurological testing

Answer 6

• Myotomes (look for weakness not pain)
  
  • L2: Hip flexion
  • L3: Knee extension
  • L4: Dorsiflexion
  • L5: Great toe extension
  • S1: Eversion, contract buttock, knee flexion
  • S2: Knee flexion, toe standing
• Reflexes
  
  • Knee Jerk (L3-4, Femoral Nerve)
  • Ankle Jerk (S1-2, Tibial Nerve)
• Dermatomes
• UMNL Lesion:
  
  • ​Babinksi reflex
  • Clonus
  • Hoffman’s Sign

Question 7

Special tests

Answer 7

• Anterior Drawer Test
  
  • Tests: ATFL
  • Positive Sign: excessive laxity or increased anterior translation compared to the other ankle.
  • Procedure: Patient sitting with foot and ankle over the edge of table and foot in 20 degrees PF. Examiner stabilizes tibia and fibula and pulls calcaneus forward with other hand, it can be done also with the patient prone and pushing the calcaneus forward.
• Talar Tilt Test / Inversion Stress Test
  
  • Tests: CFL
  • Positive Sign: Increase in talar tilt compared with other ankle / soft end feel
  • Procedure: Patient supine with foot in neutral, examiner tilts talus side to side in add and abduction.
• Thompson’s Test
  
  • Tests: Achilles Tendon Injury
  • Positive Sign: decrease in ankle plantarflexion with squeeze
  • Procedure: patient in prone with the leg over the edge of the bed. Examiner squeezes muscle belly of gastroc and watches the foot for ROM. Compare with the unaffected side.
• Squeeze Test
  
  • Tests: interosseous ligament/syndesmotic ankle sprain
  • Positive Sign: reproduction of pain
  • Procedure: patient in prone or supine, examiner places hands approx 6 inches above ankle joint, squeezing tib and fib together working down towards the ankle joint.
• Homan’s Sign
  
  • ​Tests: DVT
  • Positive Sign: Pain in calf
  • Procedure: pt supine, passively extend knee, DF ankle and palpate calf tenderness

Question 8

Palpation

Answer 8

• Bony Landmarks
• Soft Tissue (including - ATFL, CFL, Deltoid Ligaments, tarsal tunnel)
• Pulses (dorsal pedal & Posterior tibial artery pulses)

When palpating, you are assessing for pain, tenderness or laxity in comparison to the healthy side.