Ankle Sprains: Physical Exam Tests

• The objective is to relate physical exam tests and findings to common ankle pathologies.

Ankle Sprains

• Supination or inversion is the most common mechanism of injury
• The anterior talofibular ligament is the most common affected structure in supination or inversion
• The anterior inferior tibiofibular ligament is involved in high ankle sprains and results in prolonged recovery
• Pronation or eversion affects the deltoid ligament

Squeeze Test

• Used to identify high ankle sprains
• High ankle sprains involve injury to the syndesmosis, the fibrous joint between the tibia and fibula, and the tibiofibular ligaments.
• The ankle exam begins by looking at the proximal fibula and tibia
• The proximal fibula and tibia are palpated, and compression is applied, squeezing the fibular head and proximal fibula and the tibia together
• Squeezing proximally causes widening distally, putting stress on the tibial fibular ligament
• Pain at the ankle during the squeeze indicates a positive squeeze test

Anterior Inferior Tibiofibular Ligament

• A figure compression or squeeze test determines if the anterior inferior tibiofibular ligament is compromised.
• In a normal ankle mortise X-ray, there should be symmetric spacing around the talar dome and its relation to the tibia and fibula.
• There should also be a normal spacing between the distal fibula and tibia
• Widening is an indication that the tibial fibular ligament has been compromised

Talar Tilt Test

• Tests the integrity of the calcaneofibular ligament
• Stabilize the lower leg with one hand and hold the calcaneus in the midfoot with the other, inducing inversion.
• Compare both sides to check for laxity.
• Pain or increased laxity indicates a positive test.
• The test can also be done in eversion to test the deltoid ligament.

Talar Tilt Test Under X-Ray

• The Talar tilt test can be performed under X-rays to induce stress on ligaments
• Normal ankle mortise shows even joint spaces around the ankle joint.
• A positive stress view reveals that the ligament has been compromised and the ankle is unstable.
• The eversion view shows some disruption of the deltoid ligament.

Anterior Drawer Test

• Tests the integrity of the anterior talofibular ligament
• Stabilize the lower leg with one hand and translate the calcaneus and talus anteriorly with the other hand.
• A positive test causes pain at the anterior talofibular ligament or laxity compared to the other side/increased translation

Achilles Tendinopathy

• A chronic issue not related to acute injury
• Types include mid-portion and insertional Achilles tendinopathy.
• Caused by repetitive running, jumping, or loads to the Achilles tendon over time
• The tendon gets thicker with scar tissue, and sometimes irregular calcification on the posterior calcaneus.
• Causes progressive pain with repetitive loads.

Achilles Tendon Tear

• An acute injury
• People describe being hit or kicked in the back of the calf or leg, with sudden pain.
• Sometimes, people feel a pop.
• On examination, swelling is completely taken away from the normal architecture of the Achilles tendon

Thompson Test

• Tests the integrity of the Achilles tendon.
• With an intact Achilles tendon, squeezing the calf musculature induces plantar flexion.
• With a torn Achilles tendon, squeezing the calf musculature will not induce plantar flexion or very little.
• A positive Thompson test occurs when squeezing the calf does not induce plantar flexion

Plantar Fasciitis

• Abductor hallucis longus, flexor digitorum brevis, and quadratus plantae muscles are all closely related to the plantar fascia
• All these muscles originate from the calcaneal tuberosity, which is also the origin point for the plantar fascia.
• Plantar Fascia supports the arch of the foot and absorbs shock during walking and running.
• Abductor Hallucis Longus abducts and flexes the big toe, contributing to the stability of the foot's arch.
• Flexor Digitorum Brevis flexes the middle phalanges of the toes 2-5, aiding in arch support.
• Quadratus Plantae assists in flexing the toes and helps stabilize the foot's arch.
• When these muscles are overworked or strained, they can cause increased tension on the plantar fascia, inflammation, and microtears
• Tightness or weakness in these muscles can alter foot mechanics, exacerbating and contributing to heel pain
• Regularly stretching and strengthening these muscles can help prevent plantar fasciitis by maintaining optimal foot mechanics
• Supportive footwear that provides adequate arch support can help distribute pressure evenly

Symptoms of Plantar Fasciitis

• Tenderness to palpation at the medial tuberosity of the calcaneus
• Pain with weight bearing, particularly in the morning
• Pain with dorsiflexion of the foot and extension of the toes
• These signs indicate plantar fasciitis, which is due to inflammation of the plantar fascia, often resulting from repetitive strain or overuse.