Ankle and Leg Evaluation 1. History Chief Complaint: A. What happened? B. Is it a sharp or dull pain? C. How long have you had the pain? D. Can you pinpoint the pain? E. Do you have any numbness or tingling? Mechanism: A. How did it happen? B. What was felt or heard? Previous History: A. Have you injured this before? 2. Observation Swelling Discoloration Deformity Arches (wt bearing/non-wt bearing) A. Medial/ lateral longitudinal, transverse B. Pes Planus (flat feet) C. Pes Cavus (high arches) 3. Check the bones for fractures Proper location and palpation A. Tibia Medial Malleolus Shaft B. Fibula Lateral Mallelous Shaft Head of fibula C. Talus Talar head Dome of talus Medial tubercle D. Calcaneous Calcaneal tubercle Sustentaculum tali D. Supple flat feet E. Rigid flat feet Shoes A. Pronation and supination of the foot Alignment A. Forefoot valgus/varus B. Rearfoot valgus/varus E. Tarsals Navicular Navicular tubercle First cuneiform Second cuneiform Third cuneiform Cuboid F. Metatarsals Head of each metatarsals Base of each metatarasals Styloid process of the 5 th metatarsal (*base of the 5 th )
4. Check the ligaments Lateral aspect A. Anterior tibiofibular B. Posterior tibiofibular C. Anterior talofibular D. Posterior talofibular E. Lateral talocalcaneal F. Calcaneofibular Medial aspect A. Deltoid Tibiocalcaneal Anterior tibiotalar Posterior tibiotalar Tibionavicular B. Posterior talotibial C. Posterior talocalcaneal D. Plantar calcaneonavicular ( Spring Ligament ) 5. Check the muscular tendons and soft tissue Lateral aspect A. Peroneus Longus B. Peroneus Brevis C. Peroneal retinaculum (superior/ inferior) Medial aspect A. Tibialis posterior ( Tom ) B. Flexor digitorum longus ( Dick ) C. Flexor hallucis longus ( Harry ) Anterior aspect A. Extensor hallucis longus B. Extensor digitorum longus C. Tibialis anterior D. Extensor retinaculum (superior/ inferior) Posterior aspect Achilles tendon A. Gastrocnemius B. Soleus C. Plantaris 6. Compare the Range of Motion (ROM) Compare bilaterally Stabilize both legs when testing Active Range of Motion (AROM)
A. Dorsiflexion: 20 Primary muscle: tibialis anterior Secondary muscle: extensor hallucis longus, extensor digitorum longus B. Plantarflextion: 50 Gastrocnemius Soleus Plantaris C. Inversion: 5 Tibialis posterior Tibialis anterior D. Eversion: 5 Peroneus longus Peroneus brevis E. Forefoot adduction: 20 G. Forefoot abduction: 10 H. Toe flexion: 45 I. Toe extention: 70 ~90 Passive Range of Motion (PROM): Perform the same motion as AROM 7. Manual Muscle Testing o Stabilize both legs when testing o Compare bilaterally, starting with the non injured ankle o Perform both concentric and eccentric tests Dorsiflexion Tibialis anterior: Athlete supine or sitting. If the athlete has any gastrocnemius tightness, perform the test with their knee flexed. Plantarflexion Gastrocnemius: Athlete prone with knee extended, and the foot projecting over the end of the table Soleus: Athlete prone with the knee flexed at least 90 Inversion Tibialis posterior: patient supine and the foot in eversion Eversion Peroneus longus: patient supine and the foot in inversion Peroneus brevis: same as peroneus longus 8. Orthopedic Special Tests A. Anterior Drawer test This test checks the integrity of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) Position: athlete is either sitting or supine and passively position the ankle in about 20 plantar flexion Hand placement: stabilize the lower leg and grasp the calcaneus Procedure: pull the foot forward
Positive sign: the test will produce pain and laxity. It is common to see a dimple in the skin over the site of the ATFL during the test B. Talar tilt This test determines the integrity of the calcaneofibular (CFL) and deltoid ligaments Position: athlete can be positioned supine, sitting, or side lying, with the ankle in anatomical position Hand placement: support the lower leg and grasp the foot at the calcaneus Procedure: position the foot into varus (ADduct) and valgus (ABduct) position. Varus position will test the calcaneofibular ligament and valgus position will test the deltoid ligament Positive sign: pain and laxity C. Kleiger test This test assesses the integrity of the deltoid ligament Position: athlete is sitting with the knee flexed to 90, and the foot relaxed and non-weight bearing Hand placement: grasp the foot with one hand and stabilize the lower leg with the other Procedure: rotate the foot laterally Positive sign: medial or lateral ankle pain with or without palpated displacement of the talus D. Syndesmosis separation This test evaluates the integrity of the anterior tibiofibular ligament and the syndesmosis Position: athlete is laying down supine Hand placement: grasp the foot with one hand and stabilize the lower leg with the other Procedure: fully dorsiflex the ankle to end range, forcing the dome of the talus to stress the tibiofibular joint. Externally rotating the foot in a dorsiflexed position will further stress the joint Positive sign: pain over the anterior distal tibiofibular joint E. Tibia-fibula Compression test (Potts compression test) This test will reveal a fracture a Pott s fracture, which is a fracture that occurs in the distal lower leg, without any displacement. Position: athlete is supine on a table Hand placement: place hands around the upper aspect of the lower leg, with one hand just distal to the fibular head and the other at the same level on the medial tibia Procedure: push your hands toward one another to squeeze the tibia and fibula together
Positive sign: increase pain in the distal fibula or tibia F. Percussion test This test will identify any fractures in the tibia or the metatarsals Position: athlete lays down supine Hand placement: stabilize the lower leg or the toe with one hand Procedure: for checking a tibial fracture, apply a percussive force to the plantar surface of the heel. For checking a metatarsal fracture, apply a percussive force at the end of the toe Positive sign: increase pain in the fractured location G. Thompson test This test will assess the integrity of the Achilles tendon Position: athlete lays down prone with their foot over the end of the table Hand placement: grasp the belly of calf muscle Procedure: with the athlete relaxed, squeeze their calf Positive sign: lack of movement of the foot H. Tinel s sign This test identifies the nerve pathology, usually compression or entrapment Position: athlete has the ankle exposed Procedure: tap just behind the medial malleolus to test the posterior tibial nerve or tap the dorsum of the proximal foot over the anterior ankle to test the deep peroneal nerve Positive sign: the tapping will produce a paresthesia or tingling I. Homan s sign This test is used to identify deep vein thrombophlebitis Position: athlete lays down supine with the knee extended Procedure: passively dorsiflex the ankle Positive sign: increase pain in the calf
Anatomy Anterior Leg Muscles 1. Tibialis Anterior Origin: lateral epicondyle of tibia, superior 1/2 of tibia Insertion: 1 st (medial) cuneiform, base of 1 st metatarsal Inervation: deep peroneal nerve Action: doriflexion and inversion of foot 2. Externsor Digitorum Longus 3. Extensor Hallicus Longus 4. Peroneus Tertius Posterior Leg Muscles Superficial 5. Gastrocnemius O: lateral head lateral femoral condyle, medial head medial femoral condyle I: posterior calcanues A: knee flexioin and plantarflexion of ankle 6. Soleus O: posterior fibular head, upper border of posterior tibia I: posterior calcanues A: plantarflexion of ankle 7. Plantaris O: lateral supracondylar line of femur I: posterior calcanues A: knee flexioin and plantarflexion of ankle Deep 8. Flexor Hallucis Longus O: posterior fibula and interosseus membrane I: base of the distal phalanx of digit 1 A: flexion of big toe 9. Flexor Digitorum Longus O: posterior tibia I: bases of digit 2-5
A: flexion of toes, assist in ankle plantar flexion 10. Tibialis Posterior O: interosseus membrane, upper 1/2 of tibia and fibula I: tuberosity of navicular A: inversion and plantarflexion of foot Lateral leg Muscles 11. Peroneus Longus O: head of fibula, superior 2/3 of fibular shaft I: plantar aspect of base of 1 st metatarsal IN: superficial peroneal nerve A: eversion of ankle 12. Peroneus Brevis O: lower 2/3 of fibula I: styloid process of 5 th metatarsal (base of the 5 th metatarsal) IN: superficial peroneal nerve A: eversion of ankle