Ankle Joint Examination

Ankle Joint Examination includes examining the tibio-talar joint, subtalar joint and midtarsal joints. To be good at examining the ankle region, you should follow the rule of: Look, Feel and Move in addition to special tests for ankle joint region.

Ankle Joint Examination

Ankle Joint Examination includes taking patient history, inspection, palpation, Range of movement and testing for ankle stability.

History:

As well as asking patients with ankle problems about pain, stiffness, swelling and all the usual things, ask:

1. Does the ankle give way-how often, in what circumstances?
2. Does the ankle lock?
3. Does it feel as if something jumps or comes out of place in the ankle?

Inspection:

Look at the ankle for swelling, redness, deformity, sinuses, scars.

Palpation:

Feel the temperature of the joint and compare it with the other side. Feel for tender areas, systematically checking:

1. Anterior joint line
2. Lateral gutter and lateral ligaments
3. Syndesmosis
4. Posterior joint line
5. Medial ligament complex
6. Medial gutter

Feel for an ankle effusion, synovitis, deformity, bony prominence and loose bodies.

Range of movement:

First get the patient to move the ankle through their active range of movement and compare with the other side, then repeat passively. Check particularly for loss of dorsiflexion as this is more disabling and may be related to other problems in the foot. Loss of ankle dorsiflexion is commonly seen after an injury but may also accompany Achilles tendon problems, arthritis or flatfoot.

The actual block to dorsiflexion may be a tight Achilles tendon, anterior ankle impingement and incongruity or arthrofibrosis of the ankle. If the patient has anterior or posterior ankle pain, also check for impingement in the dorsiflexed (especially with the foot everted) or plantarflexed position. Local anesthetic injection may clarify this further.

See Also: Ankle Range of Motion

Stability:

Test for ankle stability using the anterior drawer and tilt tests. In the acute trauma situation pain makes these difficult. Sometimes local anaesthetic injection into damaged ligaments or the lateral popliteal nerve makes stress testing easier.

The anterior drawer test of the ankle should be done with the ankle plantarflexed 20°. Push posteriorly with one hand on the tibial shaft and draw the calcaneum forwards. Look for a sulcus forming in the anterolateral joint line as a vacuum iscreated in the joint by the subluxing talus. Drawer test is positive if there is more than 4 mm translation.

The tilt test can be done with the ankle in neutral. In many people it is possible to hold the talus and tilt it directly while holding the tibia. This allows you to be confident that any tilt is occurring in the ankle. In other patients it is necessary to tilt the heel while holding the tibia (inversion/eversion stress test). A finger on the talar neck will then give an impression of talar movement.

Instability of the syndesmosis may be palpable, usually on A-P translation of the distal fibula or valgus stress of the ankle. Abducting the talus or squeezing the tibia and fibula together (the squeeze test) may produce pain from an injured syndesmosis.

See Also: Squeeze Test

Irritability:

When you move the joint, does it reproduce the patient’s symptoms? This is a useful guide to know whether the symptoms are coming from the ankle. If you suspect the symptoms are coming from the syndesmosis the squeeze test can be useful.

Subtalar Joint Examination

Observe:

The shape of the hindfoot and its flexibility as described under general examination. Look for swelling, especially synovitis in the sinus tarsi and the broadening of the hindfoot that occurs after a calcaneal fracture. Look for scars and sinuses.

Palpation:

Compare the warmth of the lateral hindfoot with the opposite side. Palpate over each facet for tenderness, bony prominence and synovitis. Palpate the sinus tarsi.

Range of movement:

Hold the talar neck and ask the patient to move the heel from side to side. This should give you a rough idea of how much active motion occurs in the free position. Repeat using a hand on the heel to move the joint. A hypermobile joint is often associated with generalized joint laxity; a stiff joint should suggest inflammatory, post-traumatic or degenerative arthritis, post-traumatic arthrofibrosis or tarsal coalition. Pain in the sinus tarsi area maximal on varus tilt is usually due to talocalcaneal ligament injury; pain maximal on valgus stress is usually due to impingement in the calcaneofibular recess after calcaneal fracture, or in the sinus tarsi due to hindfoot valgus with or without inflammatory joint disease.

Stability:

The anterior draw or tilt tests holding the talar neck and manipulating the heel may occasionally give a feeling of subtalar laxity, but instability is difficult to demonstrate convincingly even on stress views or arthroscopy.

Irritability:

When you move the joint, does it reproduce the patient’s symptoms? This is a useful guide to whether the symptoms are coming from the subtalar joint. The injection of local anaesthetic into the joint can also be helpful if it relieves the symptoms.

Sinus tarsi:

Remember to examine the sinus tarsi carefully. The “sinus tarsi syndrome” of sinus tarsi pain and tenderness relieved by local anesthetic injection with subjective hindfoot instability is usually caused by injury to the interosseous talocalcaneal ligament (which may be torn, impinging in the subtalar joint, chronically inflamed or fibrosed) or the subtalar joint arthritis.

Remember that many patients with subtalar problems, especially after trauma, have problems with the ankle too, most commonly instability or anterolateral synovitis, so examine the ankle as well.

Midtarsal Joint Examination

Observation:

Look for midfoot deformity, swelling and osteophytes from the joint. Palpation: Compare the warmth of the midfoot with the opposite side. Palpate over the talonavicular and calcaneocuboid joints for tenderness, bony prominence and synovitis.

Range of movement:

Hold the heel and ask the patient to move the foot from side to side and up and down (it varies from patient to patient). Repeat the process holding the heel and moving the midfoot to estimate range of midtarsal movement. Adduction is 20° and abduction is 10°.

Stability:

The talonavicular joint may be unstable in the flat foot but this is multi-directional and not generally palpable. The navicular drop test gives an estimate of talonavicular instability. Vertical calcaneocuboid instability is occasionally seen, usually with post-traumatic lateral foot pain.

See Also: Navicular Drop Test

Irritability:

When you move the joint, does it reproduce the patient’s symptoms? This is a useful guide to whether the symptoms are coming from the subtalar joint. The injection of local anaesthetic into the joint can also be helpful if it relieves the symptoms.

Other structures:

If midfoot pain does not appear to be coming from the midtarsal joint, carefully examine the ankle, subtalar and tarsometatarsal joints, the tibialis posterior and peroneus longus tendons and the plantar fascia.

Tarsometatarsal Joint Examination

Observation:

Look for midfoot deformity, swelling and osteophytes from the joint.

Palpation:

Compare the warmth of the tarsometatarsal region with the opposite side. Palpate over the tarsometatarsal joints for tenderness, bony prominence and synovitis. Osteophytes dorsal to the first TMTJ are usually innocuous but may indicate instability or arthritis.

Range of movement:

Active movement at the TMTJs is almost always zero. Hold the midfoot and manipulate each metatarsal up and down to estimate passive range of movement. Also manipulate the first metatarsal in a valgus-varus plane. When manipulating the first metatarsal, be sure to hold the medial cuneiform in the other hand—the first ray is quite mobile in some people but often most of this movement is in the talonavicular or, usually, the naviculocuneiform joint.

Stability:

Stressing the TMTJs may give an impression of instability but this is rare.

Irritability:

When you move the joint, does it reproduce the patient’s symptoms? This is a useful guide to whether the symptoms are coming from the TMTJ. The injection of local anaesthetic into the joint can also be helpful if it relieves the symptoms.

Other structures:

If midfoot pain does not appear to be coming from the tarsometatarsal joints, carefully examine the subtalar and midtarsal joints, the tibialis anterior and posterior and peroneus longus tendons and the plantar fascia. The planovalgus foot may have some laxity at the tarsometatarsal level and a vague midfoot ache, which is not reproduced by TMTJ manipulation or blocked by local injection.

References & More

• Clinical Assessment and Examination in Orthopedics, 2nd Edition Book
• Alazzawi S, Sukeik M, King D, Vemulapalli K. Foot and ankle history and clinical examination: A guide to everyday practice. World J Orthop. 2017 Jan 18;8(1):21-29. doi: 10.5312/wjo.v8.i1.21. PMID: 28144575; PMCID: PMC5241541. Pubmed