Examination of Anterior Ankle Pain

Differential Diagnosis

Common

1. Tibialis Anterior Tendinopathy

2. Anterior Impingement

3. Inferior Tibiofibular joint injury

Less Common

1. Anterolateral Impingement Syndrome

2. Posterior Impingement Syndrome

3. Recurrent dislocation of Peroneal Tendons

4. Stress Fracture of Talus

5. Referred pain from lumbar spine, Peroneal Nerve, or Superior Tibiofibular Joint

Not to be Missed

1. Stress Fracture of Distal Fibula

2. Cuboid Syndrome

3. Complex Regional Pain Syndrome (following surgery)_

History

• History of Overuse

• Sensory Symptoms

Physical Examination

Remember that a complete examination should include the joint above and below. Always examine the knee to rule out knee injury or ligamentous disruption.

Inspection

1. Assess for swelling

2. View ankle from behind: loss of definition of acchilles tendon indicates significant swelling

3. Check condition of skin

Palpation

1. Tibialis Posterior Tendon

2. Flexor Hallicis Longus

3. Navicular Tubercle

4. Ankle Joint

5. Midtarsal joints

6. Careful palpation of the peroneal tendon.

Motion

Remember to check flexion of the First Metatarsalphalangeal Joint

Muscular Strength

Muscular strength is graded on the MRC Scale

1. Plantarflexion; Gastrocnemius and Soleus,

2. Dorsiflexion; Tibialis anterior, extensor digitorum longus, extensor hallicis longus, peroneus tertius

3. Inversion; Tibialis anterior,

4. Eversion; peroneus longus, peroneus brevis

Neurovascular

1. Check the Heel Jerk Reflex (S1 S2) and grade

2. Check Distal Sensation

Special Tests

1. Anterior Drawer Sign to rule out ankle instability

2. Inversion test to rule out ankle instability

3. Eversion Test to rule out eversion instability

4. Ottawa Ankle Rules to assess need for ankle Xray

5. Ottawa Foot Rules to assess need for foot Xray

6. Proprioception Test

7. Tinel's Test of the Ankle

Quick Field Test

1. If there is no significant swelling, a normal Anterior Drawer Sign, and the athlete can walk without a limp, it is safe to assess hopping ability. Move on to step 2.

2. If the athlete can hop without pain, test runnin and cutting ability on sideline. If this is performed without difficulty, the athlete may return to play.

Investigations

1. Plain Films: Consider if posterior impingement is suspected; confirm the presence of a large posterior process of the Talus ro and os trigonum. A lateral view with the foot fully plantarflexed may confirm bony impingement.

2. Bone Scan: May show increased uptake at the posterir talus in impingement.

3. MRI: May be useful for tendinopathy.

4. Ultrasound: May be useful for tendinopathy

5. Nerve Conduction Studies: If tarsal Tunnely Syndrome is suspected.

Appendix

Muscular Movers of the Ankle

Index

Whois Dr Frankenstein

Search Judy