Bond University Musculoskeletal Physiotherapy 1 PHTY71-402 2023
MUSCULOSKELETAL PERIPHERAL JOINT
MANUAL
Ankle & Foot
Assessment & Treatment
Manual
Contributers
Kevin Kemp-Smith ScD
James Furness PhD
Wayne Hing PhD
Some of the material in this manual has been made available in accordance with section
113P of the Copyright Act 1968 (Act) for the teaching purposes of the University.
For use only by the students of Bond University enrolled in the subject:
PHTY 71-402 Musculoskeletal Physiotherapy 1
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Bond University Musculoskeletal Physiotherapy 1 PHTY71-402 2023
Table of Contents
Assessment Techniques for the Ankle & Foot ........................................................................................ 6
Tendon Pain ............................................................................................................................................ 6
Tendon Rupture ...................................................................................................................................... 6
Inter tarsals ............................................................................................................................................. 6
Inter tarsal, tarsometatarsal and metatarsal phalangeal mobilization; AP PA glides, ........................... 6
Therapeutic Exercise for the Ankle and Foot .......................................................................................... 7
Return to Sport Criteria........................................................................................................................... 7
Functional Assessment........................................................................................................................... 7
Ankle and Foot ....................................................................................................................................... 8
Subjective Assessment (History)............................................................................................................ 9
Informed Consent ................................................................................................................................... 9
Clinical Reasoning Tool ........................................................................................................................ 11
Considerations of Findings before Physical Assessment .................................................................... 12
Objective Assessment (Physical) ......................................................................................................... 13
Clinical Objective Assessment of the Ankle & Foot .............................................................................. 18
TESTS Lateral and Medial Ankle Ligaments .......................................................................................... 18
ATFL Stress Test. ............................................................................................................................ 18
Anterior Drawer Test (alternate assessment technique to ATFL Stress Test) ............................... 18
Posterior Drawer Test ................................................................................................................... 19
Calcaneofibular (CFL) Test............................................................................................................. 19
Posterior Talofibular Ligament (PTFL) Test ................................................................................... 20
Talar Tilt (Eversion stress test) ...................................................................................................... 20
Syndesmosis Separation........................................................................................................................ 22
Rotational strains .................................................................................................................................. 22
Palpation of Syndesmosis.............................................................................................................. 23
External Rotation Stress Test ........................................................................................................ 24
Syndesmosis Squeeze Test ............................................................................................................ 25
Swelling Assessment ............................................................................................................................ 26
Gastro-Soleus Mobility.......................................................................................................................... 27
Knee to Wall Test (Weightbearing Lunge Test)............................................................................. 27
Ankle Arthrokinematics ........................................................................................................................ 29
Posterior Talar Glide Test .............................................................................................................. 29
Subtalar Joint Arthrokinematics.................................................................................................... 29
Balance Assessment .............................................................................................................................. 30
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Balance Error Scoring System (BESS) ............................................................................................ 30
Y- Balance Test .............................................................................................................................. 31
Distal Pulses of Importance .................................................................................................................. 32
Dorsalis Pedis Pulse ....................................................................................................................... 32
Posterior Tibial Artery ................................................................................................................... 32
Achilles Tendinopathy ........................................................................................................................... 33
Achilles Tendon Tear ............................................................................................................................. 33
Thompson or Simmons Test (calf Squeeze Test) ........................................................................... 33
Manual Assessment/Treatment Techniques for the Ankle and Foot ................................................ 36
Talocrural Joint (TCJ) ............................................................................................................................. 36
1.Traction TCJ ................................................................................................................................ 36
2. Anterior-Posterior - AP glide MWM to improve Dorsiflexion ................................................... 36
3.
Posterior-Anterior - PA glide to Improve Plantar Flexion ..................................................... 37
4. Posterior-Anterior - PA glide to improve Plantar Flexion .......................................................... 38
5.Talar Rock................................................................................................................................... 39
MWM in standing to Improve DF.................................................................................................. 39
Subtalar Joint (STJ) ................................................................................................................................ 40
1. Medial & Lateral Glide .............................................................................................................. 40
Compression TCJ and STJ............................................................................................................... 41
Inferior Tibiofibular Joint ...................................................................................................................... 42
Posterior-Superior Glide ................................................................................................................ 42
Distal Fibula Posterior Glide MWM in Weight-bearing............................................................... 43
Anterior Glide of Fibula MWM for Dorsi-flexion ........................................................................... 43
Posterior Fibula Glide Taping Technique....................................................................................... 44
Joints of the Foot .................................................................................................................................. 45
Inter tarsal accessory movements ................................................................................................ 45
MTP and IP gliding ........................................................................................................................ 46
Tarsal Bone Gliding ....................................................................................................................... 46
Myotherapy Sequence .......................................................................................................................... 47
Leg Massage ................................................................................................................................. 47
APPENDICES .......................................................................................................................................... 48
Exercise Rehabilitation Strategies ......................................................................................................... 48
Exercises on a wobble board ................................................................................................................. 53
Return to Sport Dynamic Assessments ................................................................................................. 54
Four Single Leg Hop Tests ............................................................................................................. 54
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References ............................................................................................................................................ 54
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Assessment Process for the Ankle and Foot
Prepare for Case / Chart Review / Consent
S
Subjective Assessment (History)
Pause and Plan Objective (Clinical Reasoning - SSSSSNIPPPIRD)
Objective Assessment (Physical)
O
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A
T
P
Observation
*Safety Considerations (Contraindications/Red Flags e.g. vascular / neurological /
infection)
Active Assessment
Passive Assessment
*Special tests
Reassessment
Analysis - Diagnosis / Hypothesis
Pause and Plan Treatment
Treatment and Reassessment
Plan
Documentation
* As indicated depending upon the case
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Assessment Techniques for the Ankle & Foot
Presentation
Refer for Xray?
Instability
Syndesmosis Separation
Swelling
Gastro-Soleus mobility
Ankle Arthrokinematics
MMT
Balance Assessment
Gait
Vasculature
Tendon Pain
Tendon Rupture
Joint
Stiffness Talocrural Joint
Stiffness Subtalar Joint
Inferior Tib-Fibula Joint
Inter tarsals
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Assessment Technique
Ottawa Ankle Rules
ATFL Stress Test
Anterior Drawer Test
Posterior Drawer Test
Calcaneofibular (CFL) Test
Posterior talofibular (PTFL) Test
Eversion Stress Test
Palpation of Syndesmosis
External Rotation Stress Test
Syndesmosis Squeeze Test
Fig 8 Swelling Measure
Knee to wall test
Posterior talar glide test
Subtalar Joint Assessment
(as in FOPs)
(as in FOPs) Y Balance Test
(as in FOPs)
Dorsalis Pedis artery
Posterior Tibial Artery
Palpation : Head 5th MT & Achilles Tendon
Thompson of Simmon’s Test (Squeeze)
Self-Check √
Assessment & Treatment Techniques
Talocrural Joint Traction
Anterior-Posterior (A-P) glide
Posterior-Anterior (P-A) glide
Posterior-Anterior (P-A) glide (Alternate)
Talar Rock
Weight Bearing (MWM using a belt)
Subtalar Joint Medial Glide
Subtalar Joint Lateral Glide
Compression Talocrural and Subtalar Joint
Posterior-Superior glide
Distal Fibula Posterior Glide MWM in WB
Anterior Glide of Fibula for DF
Posterior Fibula glide taping technique
Inter tarsal, and metatarsal phalangeal and
tarsometatarsal mobilization
Self-Check √
Bond University Musculoskeletal Physiotherapy 1 PHTY71-402 2023
IMPORTANT TO KNOW AND BE ABLE TO PRESCRIBE – refer to Appendices of Manual
Therapeutic Exercise for the Ankle and Foot
Manual Therapy Ankle (PROM post surgery /
shoulder Ankle / pain relief )
Isometrics
TheraBand
Stretch
Tendinopathy
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Dorsi Flexion
Plantar flexion
Inversion
Eversion
Dorsi Flexion
Plantar flexion
Inversion
Eversion
Dorsi Flexion
Plantar flexion
Inversion
Eversion
Gastro
Soleus
Plantar fascia
Peroneals
Post Tib
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Isometrics
Isotonics
Return to Sport Criteria
Functional Assessment
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The Dorsi Flexion Lunge Test
The star Excursion Balance Test
Single Leg hop Tests (x4)
1. Fig of 8 Hope Test
2. Side Hop Test
3. 6-Meter Crossover Hop Test
4. Square Hop Test
Bond University Musculoskeletal Physiotherapy 1 PHTY71-402 2023
Ankle and Foot
The aim of this manual is to highlight key subjective, objective and treatment information
relating to common ankle presentations. It provides additional detail on objective tests to
aid practical learning and clinical practice. This manual is designed to be used in
conjunction with:
1. Assessment Lectures - assessment structure and reasoning processes
2. The Outpatient Musculoskeletal Assessment Manual - detailed general assessment
information
3. Foot & Ankle Lectures – detailed foot and ankle condition information
4. Your MSK 1 and 2 portfolios - a resource of additional learning in selected areas
Most Common Foot and Ankle Conditions Across the Lifespan
1.
2.
3.
4.
Foot and ankle pain due to osteoarthritis, inflammatory disorders resulting in
degenerative change
Soft tissue contusion
Inversion ankle sprain
Post-surgical pain, stiffness and decreased function
Common to Paediatric & Adolescent Populations
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Congenital talipes equinovarus (idiopathic club foot)
Talipes calcaneovalgus
Pes Cavus and planus
Kohler’s Disease (avascular necrosis of navicular)
Freiberg’s Disease (osteochondritis of lesser metatarsal heads)
Sever’s Disease (overuse injury of the calcaneal apophysis in growing child)
Haglund's deformity (calcaneous) a type of exostosis (a benign growth of new bone
on top of existing bone)
Retrocalcaneal heel bumps
Common to General Adult and Older Populations
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Rheumatoid arthritis
Gout
Diabetic foot
Overuse syndrome
Acute trauma
Stress fracture
Morton’s metatarsalgia
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Subjective Assessment (History)
Informed Consent
It is important that prior to any physiotherapy assessment or treatment intervention you
have gained informed consent from your patient. Different facilities will have guidelines
regarding this process and how to document it correctly. Please see the Australian
Physiotherapy Associations website for more information.
Subjective considerations to aid foot and ankle diagnosis and treatment:
Current History (any imaging available)
MAIN PROBLEM (predominantly what brings the patients to see you?)
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Acute (and mechanism of injury) versus gradual onset, sports information Sounds tear, pop, crack, swelling - instantly or later, could you continue to play or not
Progression since injury - better, same, worse
Past History
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Is this a common occurrence
How long since last episode
Previous Level of Function (PLOF) walk, stairs, inclines, uneven ground
Current work, sports, recreation participation as a contributor
24 hour Picture
• Am: initial weightbearing is painful (plantar fasciitis or achilles tendinopathy)
Stiffness and pain >15- 30mins inflammatory; < 15- 30 mins mechanical e.g. OA
• Am – Pm: consider activities occurring throughout day – is it movement or WB that
causes pain
Body Chart:
•
Be specific as the location of symptoms can help you distinguish foot and ankle
symptoms from other referred sources
Aggravating /Easing factors:
• Have questions ready for each condition that you suspect:
e.g. Lateral ankle sprain: pain, feeling of instability walking on uneven surfaces
• Have questions ready to differentiate structures:
e.g. Lumbar spine questions to indicate possible lumbar spine referral
Special / screening questions:
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Vasculature: Sweating, Temperature, Capillary refill, pulses (dorsalis pedis)
Consider peripheral vascular occlusion, diabetes (numbness or poor blood flow)
rheumatological (e.g. Polymyalgia rheumatica)
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Any strong psychological or social contributors that will affect the patient’s recovery
(fear of re-injury, hypervigilance, high threat value of injury, poor coping
mechanisms, medically aligned beliefs, secondary gain, income loss)
Social Issues
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Home: stairs, access, family, support
Public transport: can they access buses, trains
Shoe type mostly worn: Motion control / Orthotics (prescription, effective?)
Past Treatment:
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Consider injections, physical agents (ultrasound) exercises, medications
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Clinical Reasoning Tool
SSSSSNIPPPIRD Analysis – useful for interpreting the History assessment and deciding on the course
for objective assessment
Site
Clear definition of where pain & any associated symptoms are felt
Structures
List all probable and most possible structures that might be the source of
symptoms
Acute, Sub-acute, Persistent (Chronic), Acute on Persistent
Stage
Severity
VAS / NPRS / Faces Rating Scale for pain intensity@ best, worst and
average (select appropriate time i.e. last 24 hours / last week etc.)
Stability
Any suggestion of structural or functional instability?
Nature
Mechanical or chemical
Irritability
Mild, moderate or severe; what activities provoke symptoms, how long do
the symptoms last for and how long does it take for symptoms to diminish
once provoked
Pain
Nociceptive (Mechanical, Inflammatory, Ischemic, Thermal)
Peripheral/Central Neuropathic
Central Sensitization
Cognitive & Affective (thoughts, beliefs, mood)
Mixed Pain Presentation
Prognosis
What is the likely outcome for this patient? What is the natural history? If
change is expected, how long will it take? Factors a patient can control to
improve prognosis?
At time of assessment, is the patient's condition improving, deteriorating
or has it been relatively stable? If it has been changing, what has been the
rate of that change?
What factors are present for this patient that will be likely to influence their
treatment and or prognosis? (e.g. age, psycho-social influences, familywork support, hyper/hypomobility, pain beliefs, smoking, weakness etc.)
Progression and Rate
Influencing factors
Regular or Irregular pattern
Diagnosis (Provisional) /
Hypothesis
Does the patient's presentation make sense? Is there anything atypical
about it? Do the symptoms and signs add up to a logical diagnosis or are
there findings that are contradictory?
List 2 or 3 provisional diagnoses for this patient in order of most likely to
least likely.
Make these diagnoses as detailed and specific as possible.
For Workers Compensation refer to: Type of Occurrence Classification System
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Considerations of Findings before Physical Assessment
1. Are there any flag conditions (red, yellow, blue, black see Appendix 1) that warrant
referral? Does the nature of the signs and symptoms indicate caution and need to be
referred on?
2. If YES how will you manage these, be able to justify your response to your clinical
educator?
3. Are there any contra-indications to any part of your planned physical examination?
4. Is there possible involvement of the neural tissue? Specify: compression, irritation,
mobility/tension
5. Will you need to do a neurological exam (or neural tissue mobility test)? Which tests
would you select and why?
6. Are the symptoms local or are there referral patterns that need examining and is it
movement or activity that increases the symptoms and signs?
7. What is the influence of symptoms and pathology on the extent of your ability to
undertake a full examination and first treatment? Will you need to modify some aspects
of the assessment due to irritability and severity and nature symptoms e.g. suspected
fracture due to osteoporosis?
8. Is pain the main issue or are there other factors such as;
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Ineffectual neuromotor control, lack of active stability
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Ineffectual muscle endurance, power or strength
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Joint hypomobility, instability or hypermobility
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Proprioceptive deficit
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Postural issues
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Potential work, home or sporting ergonomic factors
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Any spinal deformity
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Any trauma
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Previous or existing pathology or associated comorbidities
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Pain behaviours elicited
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Any other conditions that you are considering that may be worth examining?
Bond University Musculoskeletal Physiotherapy 1 PHTY71-402 2023
Objective Assessment (Physical)
SCREEN for FRACTURE & Refer for Xray
Use Ottawa Ankle Rules (link to image and description of the rules)
Observation
Key observations to look for: symmetry, atrophy, girth, ability to bear weight, leg dominance
Starts from when patient comes into clinic, waiting room to treatment room
• WB status (full, partial [percentage] unable to bear weight, walking aide)
• Helpful or unhelpful movement patterns or compensations
Standing (if able)
Anterior View
• Lordotic, kyphotic, flattened lumbar spine
• Anterior posteriorly tilted pelvis
• Femoral (anteversion, retroversion) orientation
• Tibial orientation (varus, valgus)
• Patella orientation and position
• Muscle contour: extensor compartments lower limb, swelling*, bruising
• Foot position: pronation/ supination*, flat, high arch, forefoot, 1st toe position
• Swelling, bruising, scars, bunions
• Balance
Posterior View
• Lordotic, kyphotic, flattened lumbar spine
• Anterior posteriorly tilted pelvis
• Femoral (anteversion, retroversion) orientation
• Tibial orientation (varus, valgus)
• Knee crease alignment
• Muscle: hamstrings, soleus, gastrocnemius, peroneals (atrophy, tight, weak?)
• Angle of calcaneus varus / valgus (3-5 degrees= normal) *
• Achilles tendon appearance
• Foot position: Whole foot pronation/ supination*, flat/high arch, forefoot add/abd,
1st toe (hallux valgus)
• Swelling, bruising, scars, bunions
Lateral View
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Lordotic, kyphotic, flattened lumbar spine
Anterior posteriorly tilted pelvis
Genu recurvatum
Muscle: quads, hamstrings, soleus, gastrocnemius, peroneals (atrophy, tight, weak)
Foot position
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Supinated Foot
Figure 2 Magee p. 899
Pronated Foot
Figure 3 Magee p. 899
Functional Tests (if able or as indicated)
Note patient’s willingness to undertake the tests any adaptive or maladaptive postures
• Sit to stand, squat, single leg squat sequence
• Weightbearing with lateral shifts left and right
• Gait: components (HS, FF, midstance, HO, TO, swing). Analysis is complex, highly
subjective and moderately reliable (Video Analysis is a valuable clinical tool and can
establish base line performance)
• Walk backwards, sideways
• Knee to wall (functional DF measurement)
• Walk on toes (Checks WB PF, gastrocnemius & soleus strength)
• Walk on heels (checks WB DF)
• Walk on outside/ inside of feet (checks ligament stability & WB inversion & eversion)
• The 4-Stage Balance Test (link to simple balance assessment)
• Single Knee Bend (tests athlete’s lower limb control and stability during a functional
task)
• Jumping: land on both feet, land on injured foot
• Hopping (checks dynamic proprioception)
• Jogging, running, stairs up and down
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High level functional tests for Return to Sport (RTS) or return to work (Star Excursion
Balance Test, Single-limb hopping test, Figure-of-8 hop test, Side-hop test, 6 Meter
Cross Over Test
High level proprioception
Sports-specific
Figure 4: Foot Loading during Gait. Magee p. 924
Clear Nearby Joints
Knee, hip & lumbar spine
• If unable to squat, do knee (E & F) tests later in supine
• Lumbar spine quadrant
Physical Assessment in Supine
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Observation (skin condition, colour, ecchymosis, oedema, vasomotor changes)
Initial palpation
Measure Swelling
Figure 8 with tape measure using the following 4 bony landmarks
1. Medial malleolus
2. Lateral malleolus
3. Navicular tubercle
4. Base of 5th MT
Active Range of Motion (AROM) done bilaterally for quick comparison of left and right
Manual or dyno metric muscle testing can be done in conjunction with AROM testing
Passive Range of Motion (PROM) if AROM is painfree, appears to be full range or is limited
but painfree, passive overpressure can be applied without a need to go back and test PROM
through full range. Passive over pressure is contraindicated in presence of moderate to
severe pain at end of range. PROM can be applied to foot and ankle and more localized to
hind foot, mid foot and forefoot to localize regions of hyper or hypomobility
When appropriate measure specific deficits in AROM & PROM with goniometer.
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AROM and PROM Physiological Movements of foot and ankle include:
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Dorsiflexion with knee extended
Dorsiflexion with knee in 30° flexion (differentiates between talocrural joint (TCJ)
mobility and gastrocnemius length
Plantarflexion
Inversion
Toe flexion and extension
First metatarsal phalangeal joint flexion and extension
Passive Joint Assessment
1. Passive Physiological (DF, PF, Inversion, Eversion) as described above
2. Passive Accessory Supine /prone
Talocrural - AP ↑ glide, PA ↓glide talus, distraction, compression
Subtalar - Medial, Lateral. → glide, subtalar rock
Inferior tib / fib - AP↑, PA ↓
Inter tarsal accessory movements (Prone / supine)
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Each tarsal can be moved in an anteroposterior / posteroanterior (↑↓) direction
against its adjacent neighbor
Forefoot in supine
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TMT ↓, ↑
Intermetatarsal glides ↓, ↑
MTP and IP glides ↓, ↑,→,← ,med. & lat. Rotation
PALPATION of Foot and Ankle (be able to precisely palpate the following structures as part
of you objective assessment) Patient Supine or Sitting.
Medial aspect (distal to proximal)
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First toe
First MP joint (bunion, exostosis, callus, inflamed bursa “hallux valgus”)
First MT head (plantar surface 2 sesamoid bones prox to head)
First cuneiform (move laterally from 1st to 2nd & 3rd cuneiform)
Navicular tubercle
Head of talus
Medial malleolus
Sustentaculum tali
Bond University Musculoskeletal Physiotherapy 1 PHTY71-402 2023
Medial tubercle of the talus
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Lateral aspect
Fifth MP joint
Fifth metatarsal bone (prominent base of the 5th)
Cuboid
Calcaneus
Peroneal tubercle
Lateral malleolus
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Sinus tarsi area
Dome of Talus
Inferior Tibiofibular joint
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Area of the Hindfoot
Dome of Calcaneus
Medial tubercle
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Planter surface
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Sesamoid bone & Metatarsal heads
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Clinical Objective Assessment of the Ankle & Foot
TESTS Lateral and Medial Ankle Ligaments
Test unaffected side first for comparison. Show caution when applying test by applying light
pressure initially. Ensure you monitor patient’s response throughout the following tests.
ATFL Stress Test.
Assesses: Anterior talofibular ligament (ATFL)
Position: Knee joint in flexion and ankle in 10-20°plantar flexion
Action: The examiner stabilizes the tibia while simultaneously inverting the foot while grasping
behind the heel
Interpretation: A significant difference from the unaffected side (>2 mm) or dimpling of the anterior
skin (suction or dimple sign) is considered positive. These findings need to be considered in relation
to mechanism of injury, functional capacity, pain and apprehension exhibited by the patient.
Anterior Drawer Test (alternate assessment technique to ATFL Stress Test)
Assesses: Anterior talofibular ligament (ATFL)
Position: Knee joint in flexion and ankle in 10-20°plantar flexion
Action: The examiner stabilizes the tibia & fibula while simultaneously drawing the foot in an
anterior direction while grasping behind the heel
Interpretation: A significant difference from the unaffected side (>2 mm) or dimpling of the anterior
skin (suction or dimple sign) is considered positive. These findings need to be considered in relation
to mechanism of injury, functional capacity, pain and apprehension exhibited by the patient.
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Posterior Drawer Test (alternate assessment technique to ATFL Stress Test)
Assesses: Anterior talofibular ligament (ATFL)
Position: Knee joint in flexion and ankle in 10-20°plantar flexion
Action: The examiner stabilizes the foot and ankle while simultaneously drawing the foot in a
posterior direction
Interpretation: A significant difference from the unaffected side (>2 mm) or dimpling of the anterior
skin (suction or dimple sign) is considered positive. These findings need to be considered in relation
to mechanism of injury, functional capacity, pain and apprehension exhibited by the patient.
Calcaneofibular (CFL) Test
Assesses: Calcaneofibular Ligament
Position: Knee joint in flexion and ankle in an anatomical neutral position
Action: The examiner stabilizes the tibia & fibula while simultaneously inverting the foot
Interpretation: A significant difference from the unaffected side (>2 mm) or if patient complains of
familiar pain or if you feel excessive gapping in the joint when compared to the unaffected
side. These findings need to be considered in relation to mechanism of injury, functional capacity,
pain and apprehension exhibited by the patient.
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Posterior Talofibular Ligament (PTFL) Test
Assesses: Posterior Talofibular Ligament (PTFL)
Position: Knee joint in flexion and ankle in a maximal DF
Action: The examiner stabilizes the tibia & fibula while simultaneously inverting the foot with the DF
position maintained
Interpretation: A significant difference from the unaffected side (>2 mm) or if patient complains of
familiar pain or if you feel excessive gapping in the joint when compared to the unaffected
side. These findings need to be considered in relation to mechanism of injury, functional capacity,
pain and apprehension exhibited by the patient.
Talar Tilt (Eversion stress test)
Superficial layer of deltoid ligament. 1. Tibionavicular ligament. 2. Tibiospring ligament. 3.
Tibiocalcaneal ligament. 4. Deep posterior tibiotalar ligament (deep layer). 5. Superior
calcaneonavicular ligament (component of spring ligament). 6. Posterior tibial tendon. 7. Plantar
calcaneonavicular ligament (component of spring ligament)
Ref: https://link.springer.com/article/10.1007/s00167-012-2159-3#Fig4
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The talar tilt test described above can also be used to assess the medial deltoid ligament by
applying an eversion stress with the foot in anatomical neutral
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Deltoid ligament complex
Tibionavicular (superficial layer)
Tibiocalcaneal
Posterior tibiotalar (deep layer)
Assesses: Deltoid Ligament
Position: Ankle in anatomical neutral
Action: The examiner stabilizes the tibia & fibula while simultaneously everting the foot
Interpretation: A significant difference from the unaffected side (>2 mm) or if patient complains of
familiar pain or if you feel excessive gapping in the joint when compared to the unaffected side.
These findings need to be considered in relation to mechanism of injury, functional capacity, pain
and apprehension exhibited by the patient.
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Syndesmosis Separation
Rotational strains
Forced rotation of the leg on a fixed foot causes the talus to rotate within the ankle mortice.
This can cause the tibia and fibula to separate and damage the anterior or posterior inferior
tibo-fibular ligaments and syndesmosis Often called a high ankle sprain. This injury may be
accompanied by a spiral fibular fracture.
As a test, forced rotation of the foot within the mortice may reproduce pain over the
inferior tib-fib ligament. Similarly, forced dorsiflexion can reproduce pain as the wide
anterior aspect of the talus separates this joint.
Inferior Tibiofibular Ligaments. A) Lateral view; B) Cross-sectional view; C) Posterior view; and D) Anterior view
of the main ligamentous structures that support the tibiofibular syndesmosis. 1) Posterior inferior tibiofibular
ligament (PITFL); 2) Anterior inferior tibiofibular ligament (AITFL); 3) Interosseus membrane (IOM); 4) Inferior
transverse tibiofibular ligament (ITTFL)
Ref: Syndesmosis Ligament Anatomy Mulligan 2011
‘Numerous clinical tests have been described for syndesmotic injuries yet relatively little is
known regarding their clinical utility. Their diagnostic accuracy, prognostic potential, ability
to distinguish severity of injury, or capability to correlate with the degree of instability
present has yet to be well established. It is unlikely that any one test can consistently gauge
the degree of tibiofibular displacement and it would only be speculative to associate the
degree of pain with the extent of laxity.’ Mullligan 2011
Best Cluster of Tests for ROTATIONAL STRAINS
Ref: Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle
syndesmosis injury. Br J Sports Med 2015;49:323–9.
• Tenderness of the syndesmosis ligament
• External Rotation Stress Test
• The Syndesmosis Squeeze Test
• Inability to walk
• Inability to hop
• Pain out of proportion to the apparent injury
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Palpation of Syndesmosis
Assesses: Anterior tibiofibular ligament and syndesmosis joint
Position: Ankle 10-20 PF
Action: The examiner stabilizes the foot while simultaneously palpating the Anterior tibiofibular
ligament and Syndesmosis joint from distal to proximal
Interpretation Localised tenderness on palpation of the syndesmosis ligaments is the most sensitive
clinical assessment test. Replication of the patient’s presenting symptoms, and lower limb withdrawl
signifies disruption of this complex. These findings need to be considered in relation to mechanism
of injury, functional capacity, pain and apprehension exhibited by the patient.
Ref: Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle
syndesmosis injury. Br J Sports Med 2015;49:323–9.
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External Rotation Stress Test
Assesses: Anterior & /or Posterior inferior tib-fib ligaments & interosseous membrane
Position: Supine or Sitting knee at 90° flexion
Action: Therapist passively maximally dorsiflexes the ankle & externally rotate foot in the
horizontal plane
Interpretation: Reproduction of anterolateral pain over the syndesmosis area. These findings need to
be considered in relation to mechanism of injury, functional capacity, pain and apprehension exhibited
by the patient.
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Syndesmosis Squeeze Test
Assesses: Distal separation of the tibia and fibula
Position: Supine
Action: Place heels of hands opposite each other on tibia and fibula proximally above
midpoint of the calf and squeezes bones together.
Repeat at different levels along the shaft of the bones moving distally.
Interpretation: the more proximal the pain is felt the more severe the injury
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Swelling Assessment
Image: https://www.foothealthclinic.com.au/foot-ankle-pain/
Assesses: Swelling surround the ankle joint. There may be a combination of edema, effusion
combined with hemarthrosis
Position: Supine leg out straight off edge of plinth
Action: Once the patient has assumed their position on the plinth, the following standardized
landmarks were marked with a pen prior to measurement:
a) the point midway over the anterior ankle between the tibialis anterior tendon and lateral
malleolus,
b) the navicular tuberosity,
c) the base of the fifth metatarsal, and
d) the inferior tip of the medial malleolus
Then run the tape over these landmarks and measure to the closest mm.
Interpretation: Compare bilaterally. An increase in measurement indicates swelling.
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Gastro-Soleus Mobility
Knee to Wall Test (Weightbearing Lunge Test)
Initial participant position for the weight-bearing lunge. The great toe is 10 cm from the wall and the
knee is in line with the second toe. The participant is allowed to maintain contact with the wall using
two fingers from each hand to maintain balance.
Assesses: Weightbearing ankle dorsiflexion
Position: Step stance with affected leg forward & feet flat on the floor
Action: Patient tries to maintain a flat foot with the heel in contact with the floor
Patient bends their forward knee and attempts to touch the wall with the knee cap whilst
maintaining a foot flat position. Balance was maintained by allowing contact with the wall using two
fingers from each hand.
The foot is then progressed away from the wall 1 cm at a time and the subject repeats the lunge
until they were unable to touch the wall with their knee without lifting the heel from the ground.
Maximal dorsiflexion ROM was defined as the maximum distance of the great toe from the wall
while maintaining contact between the wall and knee without lifting the heel.
Various Measurement Techniques can be used to measure ankle DF:
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Method 1. Inclinometer placement at the tibial tuberosity along the anterior tibial crest.
Method 2. Goniometer aligned with floor (stable arm) and through the shaft of the fibula (mobile arm) by
visually bisecting the lateral malleolus and the fibular head.
Method 3. The distance from the wall to the great toe in mm while the foot remains flat
Images from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362988/
Ref: Konor, M.M., Morton, S., Eckerson, J.M. and Grindstaff, T.L., 2012. Reliability of three measures of ankle
dorsiflexion range of motion. International journal of sports physical therapy, 7(3), p.279.
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Ankle Arthrokinematics
Posterior Talar Glide Test
Image from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780668/
Assesses: Mobility of the talus with the talocrural joint.
Position: Knee joint in slight flexion and ankle in neutral position hanging over the edge of the plinth
Action: The examiner stabilizes the foot at the distal tib-fib joint and simultaneously cups the head
of the talus and draws the foot into a posterior direction
Interpretation: Hypermobility or hypomobility are noted and compared to the opposite side.
Impairment of the talocrural joint arthrokinematics is often associated with chronic ankle instability.
These findings need to be considered in relation to mechanism of injury, functional capacity, pain
and apprehension exhibited by the patient.
Subtalar Joint Arthrokinematics
Assesses: Mobility of the subtalar joint (STJ).
Position: Patient side lying, sandbag or small bolster in line proximal aspect of the STJ
Action: The examiner stabilizes the distal tib-fib joint and simultaneously cups the heel of the
calcaneus and draws the foot in a lateral direction for medial joint assessment and a medial direction
for a lateral joint assessment.
Interpretation: Hypermobility or hypomobility are noted and compared to the opposite side.
Impairment of the STJ arthrokinematics is often associated with chronic ankle instability.
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Balance Assessment
Balance Error Scoring System (BESS) Click link for details related to testing and outcomes
Image and Ref: Docherty CL, McLeod TC, Shultz SJ. Postural control deficits in participants with functional
ankle instability as measured by the balance error scoring system. Clinical journal of sport medicine. 2006 May
1;16(3):203-8.
Protocol
For each condition, participants are instructed to close their eyes, place their hands on their hips and
remain as motionless as possible for 20 seconds. If they lost their balance they are instructed to try
to get back into the test position as quickly as possible.
During each trial recorded one error for each time we observed any of the following:
1.
2.
3.
4.
5.
6.
lifting hands off iliac crests;
opening eyes;
stepping, stumbling, or falling;
moving the hip into more than 30 degrees of flexion or abduction;
lifting the forefoot or heel;
remaining out of the testing position for more than five seconds.
The total number of errors were calculated for each individual condition and then summed to
produce a total BESS score.
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Y- Balance Test
For details related the Y balance test please access
https://academic.oup.com/milmed/article/178/11/1264/4356822?login=true
Video demonstrating the Y balance test (click on link to access video)
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Distal Pulses of Importance
Examination of pedal pulses is a required clinical skill when evaluating peripheral circulation
in the musculoskeletal outpatient and inpatient setting. Comorbidities such as diabetes
and peripheral vascular disease interfere with the peripheral circulation.
Dorsalis Pedis Pulse
Image and Ref: https://pmj.bmj.com/content/78/926/746
Posterior Tibial Artery
Use two fingers, index and middle of the dominant hand.
Locate the medial malleolus and palpate slightly posterior to this land mark as illustrated in the
photo above. You should compare bilaterally and comment on pulse rhythm, rate & force.
Image and Ref: https://www.medistudents.com/osce-skills/peripheral-vascular-examination
https://ecampusontario.pressbooks.pub/vitalsign/chapter/what-pulse-qualities-are-assessed/
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Achilles Tendinopathy
The clinical diagnosis of tendinopathy is commonly determined via both patient history and clinical
tests. However, with no consensus on gold standard clinical tests with which to diagnose tendinopathy.
many research studies utilise a variety of measures to diagnose Achilles tendinopathy.
The most commonly identified clinical test for Achilles tendinopathy are;
•
•
•
Tendon palpation (including pain on palpation, localised tendon thickening or
localised swelling)
Morning stiffness with initial loading
Crepitus felt in the tendon
Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264655/
Achilles Tendon Tear
Clinical Signs
• An abnormal resting posture of the ankle particularly on knee flexion
• Almost always a palpable gap in the tendon
• Unwillingness to weight bear through affected limb
Thompson or Simmons Test (calf Squeeze Test)
Tests: Achilles tendon.
Patient Position: prone, leg straight.
Operator Position: Squeeze calf muscle belly: foot should plantarflex.
No plantarflexion movement observed = Achilles tendon rupture
Of Note: “Sometimes the plantar flexion weakness that one suspects with a tendon
rupture can be masked by the posterior tibial, plantar, and peroneus muscles. It is
important to note that patients with a totally ruptured Achilles tendon can still walk on the
injured foot, something that may be confusing to the attending clinician. The tendon gap
can be difficult to palpate due to swelling and hematoma.”
Ref and quote from: https://link.springer.com/chapter/10.1007/978-3-662-58704-1_33
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Manual Assessment/Treatment Techniques for the Ankle and Foot
Passive Accessory Movements (view this video as an adjunct to the resource session’s
demonstration)
Talocrural Joint (TCJ)
1.Traction TCJ
Assessment & Treatment for a stiff or painful TCJ post ankle fracture and immobilization OA, RA,
general hypomobility. Can help to improve DF and PF ROM restrictions as well as reduce pain. The
number of repetitions will vary upon symptoms but typically 6-10 repetitions in a set 3-5 sets per
treatment session.
Patient Position: Prone, knee flexed or patient supine as
illustrated.
Therapist position: Web of hand around anterior talus &
web of other hand around calcaneus. If needed stabilize
patients limb with your leg over their hamstrings
Action: Distract talus & calcaneus
Can also be done with seatbelt
2. Anterior-Posterior - AP glide MWM to improve Dorsiflexion
Assessment & Treatment for a stiff or painful TCJ post ankle fracture and immobilization, OA, RA,
general hypomobility will improve DF ROM. The number of repetitions will vary upon symptoms but
typically 6-10 repetitions in a set 3-5 sets per treatment session.
•
•
•
•
Patient supine just over the edge of the plinth
Distal leg supported and knee slightly bent on a rolled towel
One of the therapist’s hands holds the calcaneus while the web space of the other
hand contacts the ventral talus both hands contribute to the AP glide of the talus
While maintaining the AP glide the patient can perform active dorsi flexion or the
therapist can initiate passive dorsiflexion of the ankle
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•
3. Posterior-Anterior - PA glide to Improve Plantar Flexion
Assessment & Treatment for a stiff or painful TCJ post ankle fracture and immobilization, OA, RA,
general hypomobility will improve PF ROM. The number of repetitions will vary upon symptoms but
typically 6-10 repetitions in a set 3-5 sets per treatment session.
Patient Position: Supine, leg straight (may need towel under tibia).
Therapist position: Cup one hand over tarsal and midtarsal region (can use a towel or light
foam to improve grip), stabilize the distal tib-fib region, apply an anterior drawer over the
surface of the tarsal and midtarsal region in relation to tib-fib.
Alterante Hand Position: The motive hand can be placed under the posterior aspect of the
calcaneus, and a drawer motion can be applied in an anterior direction
PA Glide in Supine
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PA Glide in Supine (Alternate Position)
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4. Posterior-Anterior - PA glide to improve Plantar Flexion
Alternative Handling
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5.Talar Rock
Assessment & Treatment for a stiff or painful TCJ post ankle fracture and immobilization, OA, RA,
general hypomobility can help to improve both DF and PF at the TCJ. The number of repetitions will
vary upon symptoms but typically 6-10 repetitions in a set 3-5 sets per treatment session.
Anterior and posterior rock of Os calcis on talus
Patient Position: Prone (can be done in side-lying also) with
knee flexed to 90 degrees
Therapist Position: Clasp calcaneus with left hand by
cupping the calcaneus posteriorly. Cup the right hand
around the anterior aspect of the talus.
Action: The left hand ‘rocks’ the calcaneus over the fixed or
counter moving talus. You may feel a ‘clunk’ with this
motion
MWM in standing to Improve DF
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Subtalar Joint (STJ)
1. Medial & Lateral Glide
Assessment & Treatment for a stiff or painful STJ post ankle fracture and immobilization, OA, RA,
general hypomobility can help to improve pronation and supination restrictions at STJ. The number of
repetitions will vary upon symptoms but typically 6-10 repetitions in a set 3-5 sets per session.
Patient Position: Side lying, hip & knee flexed, lower leg flat on plinth, foot over edge of
plinth.
Therapist Position: Stand at side of plinth, stabilize tib/fib & talus with one hand, cup
calcaneus with the other.
Action: Glide the calcaneus against talus towards the floor in either a medial or lateral
direction depending on which side the patient is lying. (medial glide illustrated)
(Application – assessment & mobilization of subtalar joint)
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Compression TCJ and STJ
Treatment for improving weight acceptance after fracture immobilization can help reduce fear
around moving in kinesophobia. The number of repetitions will vary upon symptoms but typically 610 repetitions in a set 3-5 sets per session.
Patient Position: Prone, knee at 90⁰ F
Therapist position: Stand by side of patient, your knee on
couch to support patients shin. Both hands grasp hind foot
Action: Apply compression, move into DF & PF
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Inferior Tibiofibular Joint
Direction of glide describes movement of the fibula on the larger more stable tibia.
Posterior-Superior Glide
Treatment for improving weight acceptance after fracture immobilization can help reduce fear
around moving in kinesophobia. The number of repetitions will vary upon symptoms but typically
6-10 Repetitions in a set 3-5 sets per session.
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Distal Fibula Posterior Glide MWM in Weight-bearing
Anterior Glide of Fibula MWM for Dorsi-flexion
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Posterior Fibula Glide Taping Technique
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Joints of the Foot
Inter tarsal accessory movements
Each Phalange can be moved in an anteroposterior / posteroanterior (↑↓) direction against
its adjacent neighbor as well as distracted (tractioned)
Key Principle: Stabilize proximally mobilize distally
Assessment & Treatment for a stiff or painful hind and midfoot post ankle fracture and
immobilization, OA, RA, general hypomobility. The number of repetitions will vary upon symptoms
but typically 6-10 repetitions in a set 3-5 sets per session
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MTP and IP gliding
Each proximal phalanx can be moved in an anteroposterior / posteroanterior (↑↓), medial
and lateral, compression & distraction and rotary direction against its articulating MT (MTP)
and more distal phalanx (IP joint).
(Application – decrease pain & increase mobility of affected joints)
Tarsal Bone Gliding
Each Tarsal bone can moved in an anteroposterior / posteroanterior (↑↓), medial and
lateral, compression & distraction and rotary direction against its articulating partner.
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Myotherapy Sequence
Leg Massage
x10 Long effleurage full leg
x5 Gastro local effleurage
Lift and Squeeze
Dividing (lateral, central, medial [thumb, fingers or elbow])
Cross overs
Rolling (heel of hand)
Friction (cross fibre, longitudinal)
Repeat on opposite side, can move to other
side of plinth.
Cross overs
Raise plinth, bend knee, foot on shoulder, towel separation
Rolling (heel of hand)
Friction (deep or needed)
•
Posterior tibilas | lateral gastro-soleus
Move foot to chest, towel separation
•
Knuckle petrissage
Flatten leg out
Effleurage x3 (light surface skim local to gastro)
Tapotement
•
•
•
•
•
•
Cupping
Hacking
Flicking
Beating (beat-flick technique)
Finger tipping
Pick ups
Effleurage x5 (light surface skim local to gastro & foot)
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APPENDICES
Exercise Rehabilitation Strategies
Normalize Gait first with crutches (appropriate walking aide) progressively load the ankle
while maintaining gait sequence normally
Control swelling & provide appropriate support to ankle
•
•
Tubigrip stocking, eversion or inversion bandage or taping to support injured
ligament
Advice about swelling control, elevation and initial exercise
Hydrotherapy
If available us the pool as an excellent medium to get patients walking again post ankle
injury
http://www.orthop.washington.edu
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Passive ROM Exercises: dorsi-plantar flexion, inversion eversion at talocrural and subtalar joint
Accessed 23/05/2019 optimalmotion-pt.com
Active Assisted Exercises; Use a towel to assist the ankle into DF PF Inv-Eversion
Accessed 23/05/109 https://genesisortho.com
AROM Ankle Exercises (can be done without gravity or against gravity)
How would you position the patient to achieve gravity eliminated and assisted exercises?
Accessed 23/05/2019 https://www.ruperthealth.com
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All Illustrations from AAOS https://orthoinfo.org
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Exercises on a wobble board
Start wobble board exercises in sitting if patient is
not FWB
Exercises on a wobble board in standing. (Patient can perform these between parallel bars
for safety.)
a) Standing balance b) inversion & eversion movement c) dorsi flexion & plantar
flexion emphasis d) circular movement
Patient walking between parallel bars on a large spring
based board
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Return to Sport Dynamic Assessments
Four Single Leg Hop Tests
4 Single Leg Hop tests to determine functional deficits below (Caffrey et al., 2006)
References
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•
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•
•
•
•
Magee D. J. Orthopaedic Physical Assessment 6th ed. Saunders – Elsevier Hengeveld E (ed.)
2014.
Caffrey, E., Docherty, C. L., Schrader, J., & Klossner, J. (2009). The ability of 4 single-limb hopping
tests to detect functional performance deficits in individuals with functional ankle instability.
Journal of orthopaedic & sports physical therapy, 39(11), 799-806.
Foot and Ankle Image on Cover (2018). Retrieved from https://kneerover.com/pages/broken-ankle
Hertel, J., Braham, R. A., Hale, S. A., & Olmsted-Kramer, L. C. (2006). Simplifying the star
excursion balance test: analyses of subjects with and without chronic ankle instability. Journal of
Orthopaedic & Sports Physical Therapy, 36(3), 131-137
Konor, M. M., Morton, S., Eckerson, J. M., & Grindstaff, T. L. (2012). Reliability of three measures
of ankle dorsiflexion range of motion. International journal of sports physical therapy, 7(3), 279.
Measurement of Calcaneal Angle Image (2012). Retrieved from
http://teamdoctorsblog.com/2012/05/stress-fracture-mid-shaft2nd-metatarsal-is-it-healed/
Supination, Pronation Image (2013). Retrieved from
https://walkwellstaywell.wordpress.com/tag/supination/
Pronation Image (2014). Retrieved from http://athletewithstent.com/pronating-on-purpose/
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Supination Image (2018). Retrieved from http://boneandspine.com/supination-of-foot-and-
oversupination/
Ankle and Ligaments Image (2017). Retrieved from
http://pennstatehershey.adam.com/content.aspx?productId=112&pid=3&gid=100209
Eversion Sprain Image (2018). Retrieved from http://www.newhealthadvisor.com/Eversion-AnkleSprain.html
Squeeze Test 2 Image (2008). Retrieved from Achillestendon.com
MT5 Palpation Image (2004). Retrieved from http://kylekranz.com/peroneal-tendonitis/
Peroneal Tendon Subluxation image (2017). Retrieved from
http://www.summitortho.net/page/view-article.html?articleid=585036c5a2c9a38b0cae361379adb83f
Calf squeeze test image (2016). Retrieved from http://achillestendon.com/types-of-injuries/
Talocural joint Passive Movement Image (2017). Retrieved from
http://www.cyberpt.com/anklejointmobilization.asp
Anterior/Posterior Glide Movement Image 1 (2014). Retrieved from Anterior/Posterior glide
movement picture 2 (2017
Anterior/Posterior Glide Movement Image 2 (2017). Retrieved from
http://www.cyberpt.com/anklejointmobilization.asp
Posterior/Anterior Glide Movement Image (2017). Retrieved from
http://www.cyberpt.com/anklejointmobilization.asp
Inferior tib/fib Joint Images (2009). Retrieved from http://www.cyberpt.com/anklejointmobilization.asp
Intertarsal Accessory Movements Image (2017). Retrieved from https://safeshoes.com/safety-shoenews/metatarsal-work-boots/
Medial / lateral glide of the subtalar joint (2019) Image retrieved from
https://www.google.com/search?q=medial+glide+of+the+subtalar+joint&rlz=1C1GCEA_enAU832AU832&
source=lnms&tbm=isch&sa=X&ved=0ahUKEwi9noCMpOXiAhWx4XMBHe4WD1oQ_AUIECgB&biw=1637&
bih=892#imgrc=Zo_J4L66zBvczM:
Figure 8 with Tape Measure Image (2018). Retrieved from http://morphopedics.wikidot.com/ankle-joint
Lateral view of Ankle Image (2018). Retrieved from http://boneandspine.com/ankle-joint-anatomy/
Medial views of ankle Image (2017). Retrieved from https://emedicalhealth.net/deltoidligament/#.WwNMUoWFOUk
Ligament of the Ankle Image (2017). Retrieved from http://morphopedics.wikidot.com/highankle-sprain-syndesmotic-injury
Spring Ligament Complex Image (2018). Retrieved from
http://www.southfloridasportsmedicine.com/spring-ligament.html
Spring Ligament Complex Plantar View Image (2018). Retrieved from
http://www.mplsortho.com/conditionstreatments/ecategory/46/etopic/5340498006403406826ed7c4b4051950/
Long Plantar Ligament Image (2018). Retrieved from
https://academic.amc.edu/martino/grossanatomy/site/Medical/CASES/Lower%20limb/POP_UPS/flat%20f
oot%20anspop_up5.htm
Exercises on a wobble board. Four common exercises recommended (2019) Retrieved from
https://www.google.com/search?q=wobble+board+for+ankle+sprain&rlz=1C1GCEA_enAU832A
U832&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi91tvUgN7iAhU_8HMBHTRiC3UQ_AUIESgC
&biw=1637&bih=892#imgrc=SAdC8EBOy9eAbM:
Wobble board exercises in sitting. (2019) Retrieved from
https://www.google.com/search?q=wobble+board+for+ankle+sprain&rlz=1C1GCEA_enAU832AU832&sou
rce=lnms&tbm=isch&sa=X&ved=0ahUKEwi91tvUgN7iAhU_8HMBHTRiC3UQ_AUIESgC&biw=1637&bih=89
2#imgrc=GWzq_IrbFtNumM:
Ankle proprioception training on foam (2019) retrieved from
https://www.google.com/search?q=wobble+board+for+ankle+sprain&rlz=1C1GCEA_enAU832A
U832&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi91tvUgN7iAhU_8HMBHTRiC3UQ_AUIESgC
&biw=1637&bih=892#imgrc=vqO3JjkikRmgvM:
Patient walking between parallel bars
https://www.google.com/search?q=patient+on+a+wobble+board+between+parallel+bars&rlz=1
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C1GCEA_enAU832AU832&source=lnms&tbm=isch&sa=X&ved=0ahUKEwikmsTNh97iAhUZ73MB
HYy3BEwQ_AUIECgB&biw=1637&bih=892#imgrc=niUAFngVpvlB3M:
Illustration of subtalar joint
https://erikdalton.com/blog/subtalar-joint-the-bodys-steering-wheel/
Mulligan, E. P. (2011). Evaluation and management of ankle syndesmosis injuries. Physical
Therapy in Sport, 12(2), 57-69
Sman, A. D., Hiller, C. E., & Refshauge, K. M. (2013). Diagnostic accuracy of clinical tests for
diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med, 47(10), 620-628.
Ankle Bones https://geekymedics.com/bones-of-the-foot/
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