Ankle Examination
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.
Quick Reference One-Pager
Look
- Swelling (lateral, medial, posterior)
- Deformity (varus/valgus hindfoot)
- Skin (bruising, scars, ulcers)
- Muscle wasting (calf)
Feel
- Lateral ligaments (ATFL, CFL, PTFL)
- Medial ligaments (deltoid)
- Syndesmosis
- Achilles tendon
- Bony landmarks (malleoli, base 5th MT)
Move
- Dorsiflexion 0-20°
- Plantarflexion 0-50°
- Inversion/eversion (subtalar)
- Assess with knee flexed and extended
Special Tests
- Anterior drawer (ATFL)
- Talar tilt (CFL)
- Squeeze test (syndesmosis)
- Thompson's (Achilles)
- Silfverskiold (gastrocnemius)
Introduction and Setup
Before You Start
Patient Positioning:
- Seated with legs hanging off edge of bed for inspection and palpation
- Supine for stability testing
- Prone for Achilles assessment
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:
- Lateral ligament complex: ATFL, CFL, PTFL
- Medial (deltoid) ligament: Superficial and deep components
- Syndesmosis: AITFL, PITFL, interosseous membrane
- Achilles tendon: Gastrocnemius + soleus insertion to calcaneus
Look (Inspection)
- Swelling: Anterior joint line (effusion), lateral (ATFL injury)
- Deformity: Tibialis anterior wasting, anterior tibial tendon integrity
- Skin: Bruising pattern (lateral = inversion injury), scars
- Position: Equinus (foot drop), ankle position at rest
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.
Feel (Palpation)
Systematic Palpation Sequence
Lateral Structures (Anterior to Posterior):
- ATFL: Anterior to lateral malleolus (most commonly injured)
- CFL: Tip of lateral malleolus to calcaneus
- PTFL: Posterior to lateral malleolus
- Peroneal tendons: Behind and below lateral malleolus
- Base of 5th metatarsal: Avulsion fracture site
Medial Structures:
- Deltoid ligament: Fan-shaped from medial malleolus
- Posterior tibial tendon: Behind medial malleolus
- Navicular: Insertion of tibialis posterior
Anterior Structures:
- Anterior joint line: Effusion, osteophytes
- Syndesmosis: AITFL tenderness (2-3cm above joint line)
- Tibialis anterior tendon: Anterior to ankle
Posterior Structures:
- Achilles tendon: Palpate full length, assess for gap or nodule
- Retrocalcaneal bursa: Between tendon and calcaneus
- Calcaneal insertion: Insertional tendinopathy
Bony Landmarks:
- Both malleoli (Ottawa ankle rules)
- Proximal fibula (Maisonneuve fracture)
- Base of 5th metatarsal
- Navicular
Move (Range of Motion)
- normalRange
- 0-20°
- technique
- Bring foot toward shin
- keyPoints
- Test with knee extended (gastrocnemius) and flexed (soleus)
- normalRange
- 0-50°
- technique
- Point toes down
- keyPoints
- Full ROM usually preserved
- normalRange
- 0-30°
- technique
- Turn sole inward (subtalar)
- keyPoints
- Test at subtalar joint
- normalRange
- 0-20°
- technique
- Turn sole outward (subtalar)
- keyPoints
- 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.
Special Tests
Lateral Ligament Assessment
Special test
Anterior Drawer Test
ATFL integrity (anterior lateral stability)
Technique
- 1Patient seated or supine, knee flexed to relax gastrocnemius
- 2Stabilize distal tibia with one hand
- 3Cup heel with other hand, ankle in slight plantarflexion
- 4Apply anterior translation force to talus
Positive Sign
Increased anterior translation compared to other side, soft endpoint
Indicates
ATFL rupture or laxity (chronic lateral instability)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Talar Tilt Test (Inversion Stress)
CFL integrity (lateral ankle stability)
Technique
- 1Patient supine or seated
- 2Stabilize distal tibia
- 3Cup heel and invert (tilt talus into varus)
- 4Ankle in neutral position
Positive Sign
Increased talar tilt compared to other side (greater than 10° difference)
Indicates
CFL rupture, combined lateral ligament injury
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Syndesmosis Assessment
Special test
Squeeze Test (Hopkin's)
Syndesmosis (high ankle sprain)
Technique
- 1Compress tibia and fibula together at mid-calf level
- 2This spreads the distal tibia and fibula apart at the syndesmosis
Positive Sign
Pain at the distal syndesmosis (anterolateral ankle)
Indicates
Syndesmosis injury (high ankle sprain)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
External Rotation Stress Test
Syndesmosis injury
Technique
- 1Patient seated with knee at 90°
- 2Stabilize tibia
- 3Externally rotate the foot
Positive Sign
Pain at the syndesmosis
Indicates
Syndesmosis disruption
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Cotton Test (Fibular Translation)
Syndesmosis/deltoid injury
Technique
- 1Stabilize tibia
- 2Translate fibula laterally relative to tibia
Positive Sign
Increased lateral translation compared to opposite side
Indicates
Syndesmosis disruption, deltoid injury (mortise widening)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Achilles Tendon Assessment
Special test
Thompson's Test (Simmonds)
Achilles tendon continuity
Technique
- 1Patient prone with feet hanging off end of bed
- 2Squeeze the calf muscle belly
Positive Sign
No plantarflexion of foot (Thompson's positive)
Indicates
Complete Achilles tendon rupture
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Matles Test
Achilles tendon rupture
Technique
- 1Patient prone, both knees flexed to 90°
- 2Observe resting position of both feet
Positive Sign
Affected foot falls into more dorsiflexion than normal side
Indicates
Achilles tendon rupture (loss of tenodesis effect)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Silfverskiold Test
Gastrocnemius vs soleus tightness
Technique
- 1Test ankle dorsiflexion with knee extended
- 2Test ankle dorsiflexion with knee flexed to 90°
- 3Compare the two positions
Positive Sign
Dorsiflexion improves with knee flexion = isolated gastrocnemius tightness. No improvement = soleus/combined
Indicates
Differentiates gastrocnemius from soleus contracture (important for surgical planning)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Other Tests
Special test
Peroneal Tendon Subluxation
Peroneal tendon instability
Technique
- 1Patient seated, ankle in dorsiflexion
- 2Resist active eversion
- 3Observe behind lateral malleolus
Positive Sign
Visible or palpable subluxation of peroneal tendons over lateral malleolus
Indicates
Peroneal retinaculum injury, peroneal tendon instability
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Neurovascular Assessment
Neurological Examination
Motor:
- Root
- L4,5
- Action
- Ankle dorsiflexion, EHL
- Test
- Heel walk, great toe extension
- Root
- L5,S1
- Action
- Ankle eversion
- Test
- Resist eversion
- Root
- S1,2
- Action
- Ankle plantarflexion
- Test
- Toe walk, resist plantarflexion
Sensory:
- Deep peroneal: First web space
- Superficial peroneal: Dorsum of foot (lateral)
- Saphenous: Medial foot and ankle
- Sural: Lateral foot and heel
- Tibial: Sole of foot
Reflexes:
- Ankle jerk (Achilles reflex): S1
Vascular Assessment
- Dorsalis pedis: Lateral to EHL tendon on dorsum of foot
- Posterior tibial: Behind medial malleolus
- Capillary refill: Press toenail, should return within 2 seconds
Complete the Examination
Always state to the examiner:
"To complete my examination, I would like to:
- Examine the knee as the joint above
- Examine the foot and subtalar joint as the joint below
- Examine the proximal fibula (Maisonneuve fracture)
- Perform neurovascular assessment
- Obtain X-rays (AP, lateral, mortise views)"
Summary Presentation
“25-year-old female netball player with persistent lateral ankle pain 6 months after inversion injury.”
Common Conditions Table
- look
- Lateral swelling/bruising
- feel
- ATFL/CFL tenderness
- move
- Painful inversion
- specialTests
- Anterior drawer +, Talar tilt +
- look
- Minimal swelling
- feel
- AITFL tenderness, prox fibula
- move
- Painful external rotation
- specialTests
- Squeeze test +, ER stress +
- look
- Gap in tendon, bruising
- feel
- Palpable gap
- move
- Weak plantarflexion
- specialTests
- Thompson's +
- look
- Fusiform swelling
- feel
- Tender nodule, crepitus
- move
- Painful plantarflexion
- specialTests
- Arc sign (moves with dorsiflexion)
- look
- Anterior osteophytes
- feel
- Anterior joint line tenderness
- move
- Reduced dorsiflexion
- specialTests
- Anterior impingement
Examiner Tips
Do
- Test anterior drawer with slight plantarflexion
- Always check syndesmosis
- Compare endpoints bilaterally
- Test dorsiflexion with knee extended AND flexed
- Palpate proximal fibula
Don't
- Forget Thompson's test
- Miss peroneal tendon subluxation
- Ignore subtle syndesmosis tenderness
- Test stability in the wrong position
- Forget Ottawa ankle rules in trauma