Complete ankle examination covering lateral ligament stability, syndesmosis assessment, Achilles tendon integrity, and evaluation of common conditions including sprains, fractures, and arthritis.
The ankle examination requires systematic assessment of the lateral ligament complex, syndesmosis, Achilles tendon, and subtalar joint. Common scenarios include chronic lateral instability, syndesmosis injury, and Achilles pathology. Always compare with the uninjured side.
High-Yield Exam Summary
Patient Positioning:
Exposure: Both lower legs exposed from knee to toes
Consent Script: "I'm going to examine your ankles. I'll look at both sides, feel around the joint and tendons, and test the stability and movements. Please tell me if anything is painful."
Key Anatomy:
Bruising Pattern: Lateral bruising suggests inversion injury (lateral ligament complex). Medial bruising is concerning for medial malleolus fracture or deltoid injury. Posterior bruising tracks to the heel with Achilles rupture.
Lateral Structures (Anterior to Posterior):
Medial Structures:
Anterior Structures:
Posterior Structures:
Bony Landmarks:
| movement | normalRange | technique | keyPoints |
|---|---|---|---|
| Dorsiflexion | 0-20° | Bring foot toward shin | Test with knee extended (gastrocnemius) and flexed (soleus) |
| Plantarflexion | 0-50° | Point toes down | Full ROM usually preserved |
| Inversion | 0-30° | Turn sole inward (subtalar) | Test at subtalar joint |
| Eversion | 0-20° | Turn sole outward (subtalar) | Often painful in lateral injury |
Silfverskiold Test Concept: Dorsiflexion with knee extended tests gastrocnemius (crosses knee). Dorsiflexion with knee flexed 90° eliminates gastrocnemius contribution. If dorsiflexion improves with knee flexion, the gastrocnemius is tight (isolated gastrocnemius contracture). If equinus persists, soleus is tight.
ATFL integrity (anterior lateral stability)
Increased anterior translation compared to other side, soft endpoint
ATFL rupture or laxity (chronic lateral instability)
Ability to detect true positives
Ability to exclude false positives
CFL integrity (lateral ankle stability)
Increased talar tilt compared to other side (greater than 10° difference)
CFL rupture, combined lateral ligament injury
Ability to detect true positives
Ability to exclude false positives
Syndesmosis (high ankle sprain)
Pain at the distal syndesmosis (anterolateral ankle)
Syndesmosis injury (high ankle sprain)
Ability to detect true positives
Ability to exclude false positives
Syndesmosis injury
Pain at the syndesmosis
Syndesmosis disruption
Ability to detect true positives
Ability to exclude false positives
Syndesmosis/deltoid injury
Increased lateral translation compared to opposite side
Syndesmosis disruption, deltoid injury (mortise widening)
Ability to detect true positives
Ability to exclude false positives
Achilles tendon continuity
No plantarflexion of foot (Thompson's positive)
Complete Achilles tendon rupture
Ability to detect true positives
Ability to exclude false positives
Achilles tendon rupture
Affected foot falls into more dorsiflexion than normal side
Achilles tendon rupture (loss of tenodesis effect)
Ability to detect true positives
Ability to exclude false positives
Gastrocnemius vs soleus tightness
Dorsiflexion improves with knee flexion = isolated gastrocnemius tightness. No improvement = soleus/combined
Differentiates gastrocnemius from soleus contracture (important for surgical planning)
Ability to detect true positives
Ability to exclude false positives
Peroneal tendon instability
Visible or palpable subluxation of peroneal tendons over lateral malleolus
Peroneal retinaculum injury, peroneal tendon instability
Ability to detect true positives
Ability to exclude false positives
Motor:
| Nerve | Root | Action | Test |
|---|---|---|---|
| Deep peroneal | L4,5 | Ankle dorsiflexion, EHL | Heel walk, great toe extension |
| Superficial peroneal | L5,S1 | Ankle eversion | Resist eversion |
| Tibial | S1,2 | Ankle plantarflexion | Toe walk, resist plantarflexion |
Sensory:
Reflexes:
Always state to the examiner:
"To complete my examination, I would like to:
"25-year-old female netball player with persistent lateral ankle pain 6 months after inversion injury."
| condition | look | feel | move | specialTests |
|---|---|---|---|---|
| Lateral Ligament Sprain | Lateral swelling/bruising | ATFL/CFL tenderness | Painful inversion | Anterior drawer +, Talar tilt + |
| Syndesmosis Injury | Minimal swelling | AITFL tenderness, prox fibula | Painful external rotation | Squeeze test +, ER stress + |
| Achilles Rupture | Gap in tendon, bruising | Palpable gap | Weak plantarflexion | Thompson's + |
| Achilles Tendinopathy | Fusiform swelling | Tender nodule, crepitus | Painful plantarflexion | Arc sign (moves with dorsiflexion) |
| Ankle OA | Anterior osteophytes | Anterior joint line tenderness | Reduced dorsiflexion | Anterior impingement |
High-Yield Exam Summary