Ankle examination

• Ottawa ankle rule
  
  1. Not 4 steps BOTH then & now
  2. poor historian (Young, Old, Pregnant, Drunk or Disabled)
  3. Tender on medial mall. or along the distal 6 cm of the posterior edge of the tibia
     Tender on lat mall. or along the distal 6 cm of the posterior edge of the fibula
     
     
• Medial ankle:
  
  • Deltoid (medial) ligament of the ankle: made up of 4-5 ligaments
    
    1. Posterior Tibiotalar
    2. Tibiocalcaneal
    3. Anterior Tibiotalar
    4. Tibionavicular
       
• Lateral ankle:
  
  • ATFL (Anterior Talofibular Ligament): first to go on plantar flexion, inversion
    
  • CFL (Calcaneal Fibular Ligament)
  • Inferior Tibiofibular ligaments (ATFL and PTFL)
    
    
• Ankle exam starts with knee and ends with the foot
  
  1. start with Proximal Fibula
     
  2. Squeeze test: Midshaft squeeze = syndesmosis injury if pain on lower Tib-fib
  3. Medial Malleolus
     
     • Deltoid (medial) ligament of the ankle
       
  4. Base of 5th MT: insertion point of peroneus brevis/tertius
     -S/J/A
     -neck of 5th MT: Dancer's
     
  5. Peroneal Retinaculum
     - if bursts or become chronically incompetent from recurrent sprains, may lead to peroneal tendon dislocation (poor eversion)
     - Peroneal Retinaculum Rupture: Curt Shilling
     
  6. Lateral structures
     - ATFL: #1 anterior TaloFibular Lig
     - CFL
     - lateral malleolus (distal fibular malleolus)
     
     
     Tests: S-E-A-T
     
  • Squeeze Test
    
  • External Rotation: pain on lower tibfib = Syndesmosis injury
    - flexed knee off the table
    - stabilize leg, externally rotate foot
  • Anterior Drawer: ATFL (lat) and Deltoid (medially)
    - too much translation
  • Talar Tilt Test: CFL (lat) and Deltoid (med)
    - tilting the talus laterally and medially with downward traction
    - grab calcaneus, >5 degrees of translation
    
    
    
• Achilles Tendon Rupture tests: gap above insertion of the tendon to calcaneus H-O-T
  - as if "somebody" hit patient's lower leg; cannot tiptoe
  
  • “Hyperdorsiflexion” sign – With the patient prone and knees flexed to 90º, maximal passive dorsiflexion of both feet may reveal excessive dorsiflexion of the affected leg.Simmond's/Thompson test: not very sensitive
    - squeeze gastrocnemius, plantar flexion, if none = Achilles Tendon tear
  • O’Brien needle test – Insert a needle 10 cm proximal to the calcaneal insertion of the Achilles tendon. With passive dorsiflexion of the foot, the hub of the needle will tilt rostrally (opposite of movement) when the Achilles tendon is intact (at least partially).
  • Thompson/Simmond's test – With the patient prone, squeezing the calf of the extended leg may demonstrate no passive plantar flexion of the foot if its Achilles tendon is ruptured
    
    
• Strain/Sprain Disposition
  
  • Ortho Now for neurovascular compromise
  • Ortho 1-2 days if unstable, Splint/Crutches/NWB
  • All others: if non improvement (returning patients), 2-3 weeks Ortho, may need to repeat imaging
  • RICE &WBAT (Rest, Ice, Compress, Elevate) (Weight Bear As Tolerated)
  • Restore Proprioception/Reflexes/Balances exercises BEFORE return to Sport