History of recent injury
History of past injury
No history of injury
Sprain of lateral ligament Complete tear of lateral ligament (Ankle fracture, fracture of the fifth metatarsal base) Tibiofibular diastasis
Ruptured Achilles tendon (tendo calcaneus)
Complete tear of lateral ligament Secondary osteoarthritis (e.g. previous ankle fracture)
Osteochondritis tali Rheumatoid arthritis Primary osteoarthritis Footballer's ankle Secondary osteoarthritis (e.g. from osteochondritis tali) Tenosynovitis Achilles tendinopathy Snapping peroneal tendons
12.1. Inspection (1): Look for (A) deformity of shape, suggesting recent or old fracture; (B) sinus scars, suggesting old infection, particularly tuberculosis.
12.2. Inspection (2): Look for deformity of posture (e.g. plantarflexion owing to short tendo calcaneus, talipes deformity, ruptured tendo calcaneus or drop foot).
12.3. Inspection (3): Look for bruising, swelling or oedema. If there is any swelling, note whether it is diffuse or localized. Note also whether oedema is bilateral, suggesting a systemic rather than a local cause.
12.4. Tenderness (1): When there is tenderness localized over the malleoli following injury, radiographic examination is necessary to exclude fracture.
12.5. Tenderness (2): After inversion sprains, tenderness is often diffuse. Swelling to begin with lies in the line of the fasciculi of the lateral ligament.
12.6. Lateral ligament (1): Complete lateral ligament tear: Swelling is rapid, and if seen within 2 hours of injury is egg-shaped and placed over the lateral malleolus (McKenzie's sign).
12.7. Lateral ligament (2): Stress testing for complete lateral ligament tears (1): Grasp the heel and forcibly invert the foot, feeling for any opening-up of the lateral side of the ankle between the tibia and the talus.
12.8. Lateral ligament (3): Stress testing for complete lateral ligament tears (2): If in doubt, have a radiograph taken while the foot is forcibly inverted.
12.9. Lateral ligament (4): Stress testing for complete lateral ligament tears (3): If tilting of the talus in the ankle mortice is demonstrated, repeat the examination on the other side and compare the films.
12.10. Lateral ligament (5): Stress testing for complete lateral ligament tears (4): If the injury is fresh and painful, the examination may be more readily permitted after the injection of 15-20 mL of 0.5% lignocaine widely in the region of the lateral ligament.
12.11. Lateral ligament (6): Stress testing of the anterior talofibular component of the lateral ligament (1):
Instability may sometimes follow tears of the anterior talofibular portion only of the lateral ligament. With the patient prone, press downwards on the heel, looking for anterior displacement of the talus, which is often accompanied by dimpling of the skin on either side of the tendo calcaneus.
12.12. Lateral ligament (6): Stress testing of the anterior tibiofibular ligament (2): Anterior displacement may be confirmed by radiographs taken in the prone position; alternatively, with the patient supine (and preferably with local anaesthesia), support the heel on a sandbag (1) and press firmly downwards on the tibia (2) for 30 seconds up to exposure. A gap on the radiograph between the talus and tibia of more than 6 mm is regarded as pathological (3).
12.13. Inferior tibiofibular ligament
(1): In tears of this ligament (which has anterior and posterior components) tenderness is present over the ligament just above the line of the ankle joint.
12.14. Inferior tibiofibular ligament
(2): In tears of the inferior tibiofibular ligament pain is produced by dorsiflexion of the foot, which displaces the fibula laterally.
12.15. Inferior tibiofibular ligament
(3): Grasp the heel and try to move the talus directly laterally in the ankle mortice. Lateral displacement indicates a tear of the ligament.
12.16. Ankle joint movements (1): First confirm that the ankle is mobile, and that any apparent movement is not arising in the midtarsal or more distal joints. Firmly grasp the foot proximal to the midtarsal joint; try to produce dorsiflexion and plantarflexion.
12.17. Ankle joint movements (2):
Measure plantarflexion from the zero position. This reference lies at right-angles to the line of the leg. Normal range = 55°.
12.18. Ankle joint movements (3):
Measure the range of dorsiflexion. Always compare the sides. Normal range = 15°.
12.19. Ankle join» movements (4): If dorsiflexion is restricted, bend the knee. If this restores a normal range, the Achilles tendon is tight. If it makes no difference, joint pathology (such as osteoarthritis, rheumatoid arthritis or infection) is the likely cause.
12.20. Ankle joint movements (5): If there is loss of active dorsiflexion (drop foot) a full neurological examination is required. The commonest causes are stroke, old poliomyelitis, prolapsed lumbar intervertebral discs, and local lesions of the common peroneal (lateral popliteal) nerve.
12.21. Tendo calcaneus (Achilles tendon): Suspected tendinopathy (1):
The patient should be prone, with the feet over the edge of the couch. Inspect and compare the sides. Note any local (a) or diffuse swelling, redness of the skin, or the presence of a Hagland deformity (b): this is an exostosis affecting the posterosuperior aspect of the heel on its lateral aspect. It is commonly associated with an Achilles insertional tendinitis, although it does not directly involve the tendon.
12.22. Suspected tendinopathy (2):
Now look for tenderness, which in the case of a tendinopathy is normally situated 3-5 cm proximal to the tendon insertion. Check for any increase in local heat. Palpate the tendon, noting any localized or fusiform swelling, and any nodularity. Gently squeeze the tendon (illus.); marked pain is a feature of tendinosis with an associated paratendinitis.
12.23. Suspected tendinopathy (3): If tenderness is found, note whether the site of maximum tenderness changes with dorsiflexion and plantarflexion of the foot. If the pain is secondary to paratendinitis the site of maximum tenderness will remain fixed (a). If it is due to tendinosus alone, it will move with the tendon (b). Note also any weakness of plantarflexion.
12.24. Suspected tendon rupture (1):
Again the patient should be examined with the feet over the end of the couch. Defects in the contour of the tendon may be obvious.
12.25. Tendo calcaneus (2): Test the power of pluntarflexion by asking the patient to press the foot against your hand. Compare one side with the other, and note the shape of each contracting calf and the prominence of each tendon.
12.26. Tendo calcaneus (3): Palpate the tendon while the patient continues resisted plantarflexion. Compare the sides. Any gap in the tendon (ruptured tendo calcaneus) should be obvious. The integrity of the tendon may also be tested by inserting a needle vertically into the middle of the calf. Normally the needle should tilt when the ankle is passively dorsiflexed and plantarflexed.
12.27. Tendo calcaneus (4): Thomson test: Normally when the calf is squeezed the foot moves as the ankle plantarflexes. Loss of this movement is pathognomonic of an acute rupture of the tendo calcaneus.
Look for tenderness along the line of the long flexor tendons. Tenderness is usually diffuse and linear in pattern. Note the site and extent of any local thickening.
Look for synovitis in relation to the flexor tendons. There may be obvious swelling. Demonstrate the presence of any excess synovial fluid by milking the tendon sheaths in a proximal direction.
Plantaflex and evert the foot. This may produce pain where tenosynovitis involves the tendon of tibialis posterior.
Force the foot into plantarflexion and inversion. This will give rise to pain and increased tenderness along the line of the peroneal tendons if tenosynovitis of the peroneal tendons is present.
With the foot held in the plantarflexed and everted position, look for tenderness or gaps in the line of the tendon of tibialis posterior. Spontaneous rupture is seen most frequently in association with flat foot and rheumatoid arthritis.
Feel for crepitus along the line of the tendon sheaths behind both malleoli as the foot is swung backwards and forwards between inversion and eversión. Confirm by auscultation.
Examine the peroneal tendons for tenderness and the presence of excess synovial fluid in their sheaths.
the peroneal tendons with the fingers; look and feel for displacement of the tendons as the patient everts the foot against light resistance. Displacement occurs in the condition known as 'snapping peroneal tendons'.
12.36. Articular surfaces (1): Forcibly plantarflex the foot to allow palpation of the anterior part of the superior articular surface of the talus. Tenderness occurs in arthritic conditions, and in osteochondritis of the talus. A tender exostosis may be palpable in cases of footballer's ankle.
12.37. Articular surfaces (2): Place a hand across the front of the ankle and passively dorsiflex and plantarflex the foot. Crepitus, which may be confirmed by auscultation, suggests articular surface damage.
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