Ankle Examination

Case Management 2 Spring - 2007

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Ankle Examination

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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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Ankle Examination

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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
2. 3. 4. 5.

 R/O
2.

6. 7.

Achilles tendon rupture Anterior talofibular (ATF) ligament injury Calcaneal fracture Deltoid tear/avulsion fracture of the medial malleolus Fibular fracture Fifth metatarsal fracture

3. 4. 5. 6. 7.

Lateral ligament complex tear/avulsion of the lateral malleolus Navicular fracture Neurovascular damage Subluxed peroneal tendon Tibia fracture Interosseus membrane/syndesmosis tear
5

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Ankle Examination

Bones of Foot

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Ligaments of the Ankle
Ant. tibiotalar Post. tibiotalar

Tibionavicular

Tibiocalcaneal

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. 2. 3. 4.

5.

6. 7.

First put the patient's foot in the 90-degree (neutral) position. Let the foot rest along your forearm. The hand cupping the heel pulls anteriorly while the opposing one stabilizes the lower leg. 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. You can also validate instability of the interosseus membrane and/or syndesmotic joint by hyperdorsiflexion of the foot. Extreme pain locally over the area during hyperflexion signals a positive result. 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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