Ankle Joint Assessment Including How To Rule Out Or In A Ankle Syndesmosis
Making sense of your objective assessment can be confusing at the best of times. With the ankle joint it can be made even more difficult by the number of different issues you have to consider.
In this article I’ll give you clarity on how to spot some serious ankle problems you’ll encounter in your day-to-day work.
With an acute ankle injury there will usually be some kind of swelling but this is also a good determinate in return to play. I am incredibly reluctant to get an athlete back to the training ground whilst swelling is still present. Motor adaptations will kick in and ultimately it will hinder progress.
So you want to work on the swelling. I have seen a lot of value with icing but you shouldn’t just be applying ice to the ankle. I have had great results covering the full foot in an ice bath and I would pick this over any other method.
What you really need to do is identify troubling tissues. Start by inverting the ankle. In lengthening those tissues it will be tender.
A lot of athletes have ruptured the ATFL. To try and pinpoint this I’ll use my finger to strum the tissue. I’ll also check the tip of the fib head, navicular and the base of the 5th metatarsal but in the case of tenderness when strumming it will be tender and you know there is an issue with the ATFL.
The next possible injury you need to rule out is a syndesmosis. To check this you can plant the foot on the bed and use a squeeze test. The syndesmosis ligament is placed between the distal third of the tibia and fibula. What you want to do is put force through and squeeze the tibia and fibula to gap the tissues lower down. If there is a tear or trauma in these tissues when it lengthens there will be a positive pain experience.
I would rather be aggressive with this test than miss something.
If you do miss this and the athlete walks on it there will be further gapping of the tibia and fibula causing swelling and instability.
You could also perform a dorsiflexion external rotation test. You’ll need to cup the calcaneus, put your hand on the knee and ER the tibia and fibula. This will cause the talus bone to rotate. When the talus does rotate it will cause this tissue to gap again. If you do get a positive pain experience with this test then it can indicate trauma with the syndesmosis.
If you have a positive with both of these tests then I would recommend offloading the ankle for at least 48 hours. Ultimately it is their decision but you need to advise to prevent more gaping of the tissue.
Beware, continuing to walk on a foot with syndesmosis can cause synovitis.
Further Syndesmosis Tests
If you do believe your athlete has an injury of the syndesmosis then there are a few more tests we can use to gather more information on the condition.
A great giveaway for syndesmosis is a calf raise. If we consider with a syndesmosis that there is some compromised stability with the tibia and fibula. When we go up into plantar flexion those two bones have to work around as the talus works under them. If there is trauma then the athlete will not be able to do a calf raise and there will most likely be a pain experience.
ATFL and Inverted Ankle Sprain
If there wasn’t a syndesmosis and your athlete had an ATFL or inversion ankle sprain you still want to check the ability to go up on the toes. In this case what you need to look for is does the athlete have good intent through the ball of the big toe and the ball of the little toe.
Most athletes with an ATFL or ankle sprain will tend to bias one of these. You can see when they are over on the inside or outside of their foot.
If you find this it is important that you reassure the system and restore the ability to load through these tissues and allow the perennials to generate torque.
When assessing an athlete you need to identify the troubling tissues immediately. Use the squeeze test, dorsiflexion external rotation and calf raise to make sure you catch this kind of issue. If you miss it, it can be catastrophic to any athlete’s return to play.
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