import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # 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 ## Introduction and Setup **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 - **Lateral malleolus**: Swelling, bruising (fracture, sprain) - **Peroneal tendons**: Behind lateral malleolus - **Sinus tarsi**: Fullness (sinus tarsi syndrome) - **Hindfoot alignment**: Varus/neutral/valgus - **Medial malleolus**: Swelling (deltoid injury, fracture) - **Posterior tibial tendon**: Behind medial malleolus - **Spring ligament region**: Medial arch - **Achilles tendon**: Thickening (tendinopathy), gap (rupture) - **Calf bulk**: Wasting (rupture, neurological) - **Heel alignment**: Varus/valgus - **Haglund's deformity**: Posterosuperior calcaneal prominence **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) **Lateral Structures (Anterior to Posterior):** 1. **ATFL**: Anterior to lateral malleolus (most commonly injured) 2. **CFL**: Tip of lateral malleolus to calcaneus 3. **PTFL**: Posterior to lateral malleolus 4. **Peroneal tendons**: Behind and below lateral malleolus 5. **Base of 5th metatarsal**: Avulsion fracture site **Medial Structures:** 1. **Deltoid ligament**: Fan-shaped from medial malleolus 2. **Posterior tibial tendon**: Behind medial malleolus 3. **Navicular**: Insertion of tibialis posterior **Anterior Structures:** 1. **Anterior joint line**: Effusion, osteophytes 2. **Syndesmosis**: AITFL tenderness (2-3cm above joint line) 3. **Tibialis anterior tendon**: Anterior to ankle **Posterior Structures:** 1. **Achilles tendon**: Palpate full length, assess for gap or nodule 2. **Retrocalcaneal bursa**: Between tendon and calcaneus 3. **Calcaneal insertion**: Insertional tendinopathy **Bony Landmarks:** - Both malleoli (Ottawa ankle rules) - Proximal fibula (Maisonneuve fracture) - Base of 5th metatarsal - Navicular ## Move (Range of Motion) **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 ### Syndesmosis Assessment ### Achilles Tendon Assessment ### Other Tests ## Neurovascular Assessment **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:** - 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 - **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 ## Common Conditions Table ## Examiner Tips