How To Do It
How do you know if they pass this test? Compare to the other side? If they are lacking, what can they do to help improve these results?
Ottawa Foot And Ankle Rules
Ottawa Ankle Rule determine the need for radiographs in acute ankle sprains. It is an accurate instrument for excluding fractures of the ankle and mid-foot, but the test has some limitations:
- High accuracy is true for the first 10 days post-injury
- High sensitivity is detected for patients younger than 55- years- old
Detailed information can be found on the Ottawa Ankle Rule page.
Reliability And Validity Of Ligament Tests
1. Sensitivity values for the Anterior Drawer test have been shown to be between 32% to 80% while specificity value has been reported as 80%.
2. A positive drawer test done 5 days after the injury, has been shown to be more sensitive and specific than the test done withing the 24-48 hours.
3. A sensitivity of 52% has been reported in a single study for the inversion talar tilt test.
4. In acute injuries, the eversion stress test may be of limited clinical value. However, the accuracy of the test when done after 5 days of injury increases to 96% sensitivity and 84% specificity.
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Orthopedic Tests For Examining Sprains Of The Lateral Collateral Ligaments Of The Ankle
The extent of soft tissue damage that occurs to the lateral collateral ankle ligaments after trauma may help determine the severity of the injury. After injury, patients may experience pain, swelling, weakness, instability, functional loss, or a combination of symptoms. Testing the lateral ankle after injury should include specific tests designed to examine the integrity of its structures. The following tests are intended to assess injury to the lateral ankle ligament complex: anterior talofibular ligament , calcaneofibular ligament , and posterior talofibular ligament.
Anterior drawer test
The anterior subluxation of the talus, which later became known as the anterior drawer sign, was first described by Dehne,4 Anderson et al,5 and Landeros et al.6 Anderson et al5 noted that strain on the ankle joint in the coronal plane with the foot in plantar flexion produced an anterior subluxation and that the amount of translation was most increased with the ankle plantar flexed 20 degrees. Landeros et al6 provided more detail, but a contrasting approach, writing that the anterior drawer sign must be tested for with the knee flexed and the ankle held at a right ankle. With plantar flexion of the ankle, a positive anterior drawer sign usually becomes negative.
Common Ankle Tests In Orthopedic Examination
The following is a list of the many common tests used by physical therapists / physiotherapists and other orthopedic/orthopaedic practitioners when examining the ankle. The tests will eventually have links to descriptions of the tests as well as video demonstrations. Before learning about the examination of the ankle it is useful to review basic ankle anatomy. If you know of a test that should be included in this list, please let us know.
Lateral View of the Ankle
The ankle consists of three joints talocrural joint, the subtalar joint, and the Inferior tibiofibular joint. The talocrural joint is commonly known as the ankle proper and is a synovial hinge joint. The ankle consists of three bones the talus, the fibula and the tibia. The movements of the joint are dorsiflexion and plantarflexion. The following is a list of some of the many special tests that have been developed for the ankle.
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Osteochondral Defect Of Talar Dome
To assess for an osteochondral defect we must first locate the talar dome and then palpate to elicit tenderness.
To locate the talar dome we must identify the lateral malleolus and then move anteriorly from it, up to the anterior recess. From here we can move medially and anteriorly along the joint line. The talar dome will be right beneath this point.
Any tenderness elicited by palpating at the level of the anterior joint line is indicative of an osteochondral defect.
Ankle Anterior Drawer Test Accuracy
A Prospective, blinded, diagnostic-accuracy study by Theodore Croy to investigate the accuracy of the anterior drawer test of the ankle in patients with lateral ankle sprain, he found that the ankle anterior drawer test provides limited ability to detect excessive anterior talofibular ligament injury, the sensitivity and specificity was as following:
- Sensitivity: 74 %
- Specificity: 38 %
A study on 66 patients with history of lateral ankle sprain and 20 healthy controls, the sensitivity and specificity was 33% and 73%, respectively.
However, it may provide useful information when used in side-to-side ankle comparisons and in conjunction with other physical exam procedures, such as palpation.
The ATFL can be palpated two to three finger-breadths anteroinferior to the lateral malleolus. This is usually the area of most extreme tenderness following an inversion sprain. The anterior aspect of the distal tibiofibular syndesmosis may also be tender following this type of sprain.
Van Dijk et al. reported that when the combination of pain on lateral ligament palpation, hematoma formation of the lateral ankle, and a positive anterior drawer test were used a lateral ligament lesion was correctly diagnosed in 95% of cases.
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What Are The Different Types Of Ankle Sprains
After your sprained ankle is diagnosed, your doctor will determine the grade of your sprain to help develop a treatment plan. Sprains are graded based on how much damage has occurred to the ligaments.
Grade 1 Sprain
- Slight stretching and microscopic tearing of the ligament fibers
- Mild tenderness and swelling around the ankle
Grade 2 Sprain
In a Grade 2 sprain, some but not all of the ligament fibers are torn. Moderate swelling and bruising above and below the ankle joint are common.
- Partial tearing of the ligament
- Moderate tenderness and swelling around the ankle
- If the doctor moves the ankle in certain ways, there is an abnormal looseness of the ankle joint
Grade 3 Sprain
What Is A Lateral Ankle Sprain
- Pain: Lateral ankle around malleolus and sinus tarsi
- Onset: Acute
- Mechanism: Inversion
- Swelling around lateral joint capsule
- Ecchymosis around lateral malleolus
- Pain with palpation of lateral ligaments and sinus tarsi
- Active ROM: pain with plantarflexion and inversion
- Passive ROM: pain with platerflexion, inversion in neutral, inversion with dorsiflexion
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Should I Be Concerned If I Have Sprained My Ankle And It Is Not Better After Six Weeks
Yes. It is probably worth seeing a foot and ankle orthopaedic surgeon to assess if any other injuries have occurred. Sometimes high ankle sprains can take that long or longer to heal, but it is wise to make sure that another injury has not occurred.
Contributors/Reviewers: Nicholas Cheney, DO David Porter, MD
The American Orthopaedic Foot & Ankle Society offers information on this site as an educational service. The content of FootCareMD, including text, images, and graphics, is for informational purposes only. The content is not intended to substitute for professional medical advice, diagnoses or treatments. If you need medical advice, use the “Find a Surgeon” search to locate a foot and ankle orthopaedic surgeon in your area.
Return To Activities After Ankle Sprain
It is often thought that ankle sprain is a harmless injury, but we have previously seen that it can be the cause of subsequent pathologies such as osteoarthritis or chronic ankle instability.
Some protocols and standardizations for Return To Sport have been used for situations such as post- LCA operation or hamstring injury, but still remains unknown to many subjects. Evidence-based medicine is missing, particularly related to foot injuries and ankle, to assist in the decision to allow an athlete to RTS. Thanks to a recent systematic review by Tessigol et al. we know that there are currently no published evidence-based criteria to inform RTS decisions for patients with an LAS injury.
Even if the literature doesn’t help us have the usual bases on a return to sport after ankle sprain, it doesn’t mean that athletes are not to be tested.
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Single Leg Heel Raises X 40 Repetitions
This test the strength of your ankle. The most basic movement of our ankle is to perform heel raise kind of movements. So here are the steps to test your strength:
You may place your hands on a wall to minimise the effect of balance on this test.
Step 1: Perform the task by lift both heels off the floor to check for your maximum lift Your knees should be straight and the shin bone should be in line with the second toe.
Step 2: Repeat the task while standing on one leg. You should be able to achieve the same lift as per when done with both legs) and lowering with control. Repeat this task 40 times.
If you have a lot of difficulty doing 40 repetitions, you need some serious training!
Lateral Ankle Ligaments Anatomy:
Lateral ankle ligaments function as a restraint to varus / inversion forces at ankle, besides maintaining lateral ankle stability, the lateral ankle ligaments play a significant role in maintaining rotational ankle stability.
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Tests For Ankle Syndesmosis
A:B:C:
Ankle syndesmosis consists of 4 ligaments: 1. Anterior inferior tibiofibular ligament 2. Posterior inferior tibiofibular ligament 3. Interosseous ligament The 3 ligaments other than deltoid ligament is often referred to as lateral ligament.
Interpretation: Positive if pain is reproduced in the area of syndesmosis
Maneuvers:
Grading of syndesmotic injuries:
Nd Metatarsal Stress Fracture
The most common site for a stress fracture in theforefoot is the 2nd metatarsal, given that most of the bodyâs weightis transferred on this particular bone during every given gait cycle.
To uncover a stressfracture on physical exam, carefully palpate the 2nd metatarsal inall its length. Tenderness upon palpation would be a sign that a fracture ispresent.
Compress the metatarsal heads. Image credit
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Pathoanatomy And Mechanisms Of Injury
The most common mechanism of injury in ankle sprains is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular and posterior talofibular ligaments, are most often damaged. The anterior talofibular ligament is the most easily injured. Concomitant injury to this ligament and the calcaneofibular ligament can result in appreciable instability.5 The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.5,7
The anterior drawer test can be used to assess the integrity of the anterior talofibular ligament8 , and the inversion stress test can be used to assess the integrity of the calcaneofibular ligament .
Medial ankle stability is provided by the strong deltoid ligament, the anterior tibiofibular ligament and the bony mortise . Because of the bony articulation between the medial malleolus and the talus, medial ankle sprains are less common than lateral sprains. In medial ankle sprains, the mechanism of injury is excessive eversion and dorsiflexion.
Atfl Rupture: Anterior Drawer Sign
This is a provocative test done to check for the integrity of the ATFL. One hand holds the leg down, while the other hand pulls the foot upwards and anteriorly. It is important to compare one side with the other. The presence of tenderness or laxity on one side only indicates an ATFL rupture.
Anterior drawer sign.
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Achilles Tendon Pain / Achilles Tendonopathy
Foot and Ankle Exam
Achilles tendinopathy is one of the most common foot pathologies. It can affect both athletes and recreational exercisers, being reported in inactive people as well. Clinically it manifests with foot pain on exertion associated with swellings, nodules and tenderness on palpation of the tendon.
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How Do You Perform An Anterior Drawer Test Of The Ankle
- The ankle drawer test is performed with the patient seated at the end of the bed or lying supine with their knee flexed to neutralize the pull of the gastrocnemius â soleus muscles and the foot supported perpendicular to the leg.
- With the ankle joint held at 10 to 15° of plantar flexion, the examiner grasps around the heel with one hand and stabilizes the tibia from the anterior side with the other.
- After asking the patient to relax the muscles, the examiner pulls the heel forward while continuing to stabilize the tibia with the other hand.
The anterior drawer test of the ankle may be performed with the patient supine, but the knee must be kept in a minimum of 30° flexion to eliminate the influence of the gastrocnemius muscle. The tibia can be pushed posteriorly as the calcaneus is drawn anteriorly.
See Also: Posterior Drawer Test of the ankle
Ankle Bracing And Taping
Ankle Bracing and taping is often used as a preventative measure which has gained increasing research. Ankle taping may be used to help stabilise the joint by limiting motion and proprioception. Ankle taping is said to have a greater effect in preventing recurrent strains rather than an initial sprain. A study on basketball players detailed the effectiveness of ankle taping on reducing the risk of re-injury in athletes who have a history of ankle-ligament sprains. The large sample size of the study and identification of 40 ankle injuries adds reliability to the results expressed. Tropp et al, 1985, undertook a study in soccer players who wore an ankle brace. The subjects in the brace group experienced a significant decrease in the incidence of ankle sprains when compared to no intervention. Surve et al, 1994, described similar effects in their prospective study with bracing but noted there was no difference in the ankle sprain severity in the braced and unbraced groups.
Reports are inconclusive on the effective of ankle taping. Several reports have suggested the ineffectiveness of taping. Its effectiveness is also affected by the experience of the taper. Some of the advantages of bracing over taping are cost, reusability, no expertise is required for application and minimal effect of an allergic reaction.
- The Sprained Ankle from the Connecticut Centre for Orthopedic Surgery contains a range of resources on Ankle Sprains including patient resources and surgical techniques.
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How Is A Sprained Ankle Diagnosed
Your doctor will diagnose your sprained ankle by performing a careful examination of your foot and ankle. This physical exam may be painful.
- Palpate. Your doctor will gently press around the ankle to determine which ligaments are injured.
- Range of motion. He or she may also move your ankle in different directions however, a stiff, swollen ankle usually will not move much.
If there is no broken bone, your doctor may be able to tell the severity of your ankle sprain based upon the amount of swelling, pain, and bruising.
Summary Of 4 Functional Tests For Ankle Sprains
As strength and conditioning coaches, our main objective is to do no harm. When we are working with athletes that are coming off injuries, we need to not only strengthen the area that is hurt, but everything surrounding the injured area. We want to eliminate any setbacks. If that means holding the athlete out for a little bit longer, this can help them stay safe in the long run.These are only four tests, many others exist. Also, the actual sport is another test, likely the most aggressive and specific for the athlete. This makes knowing the sport and being open minded to going to a practice helpful for the athletes. For you athletes, be smart, you know your body. Protect your body, if its not a 100% tell someone so theses injuries wont prolong.
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