Inspection (1): Look for (A) deformity of shape, Tenderness (2): After inversion sprains, tenderness is

suggesting recent or old fracture; (B) sinus scars, often diffuse. Swelling to begin with lies in the line of
suggesting old infection, particularly tuberculosis. the fasciculi of the lateral ligament.

Inspection (2): Look for deformity of posture (e.g. Lateral ligament (1): complete lateral ligament tear:
plantarflexion owing to short tendo calcaneus, talipes Swelling is rapid, and if seen within 2 hours of injury is
deformity, ruptured tendo calcaneus or drop foot). eggshaped and placed over the lateral malleolus
(McKenzie’s sign).

Inspection (3): Look for bruising, swelling or oedema.

If there is any swelling, note whether it is diffuse or Lateral ligament (2): stress testing for complete
localised. Note also whether oedema is bilateral, lateral ligament tears (1): Grasp the heel and forcibly
suggesting a systemic rather than a local cause. invert the foot, feeling for any opening-up of the lateral
side of the ankle between the tibia and the talus.
Tenderness (1): When there is tenderness localised
over the malleoli following injury, radiographic
examination is necessary to exclude fracture.

Lateral ligament (3): stress testing for complete
lateral ligament tears (2): If in doubt, have a
radiograph taken while the foot is forcibly inverted.
Lateral ligament (4): stress testing for complete
lateral ligament tears (3): If tilting of the talus in the
ankle mortice is demonstrated, repeat the examination
on the other side and compare the films.
Lateral ligament (5): stress testing for complete
lateral ligament tears (4): If the injury is fresh and
painful, the examination may be more readily permitted
after the injection of 15–20 mL of 0.5% lidocaine
widely in the region of the lateral ligament.
Lateral ligament (6): stress testing of the anterior
talofibular component of the lateral ligament (1):
Instability may sometimes follow tears of the anterior
talofibular portion only of the lateral ligament. With the
patient prone, press downwards on the heel, looking for
anterior displacement of the talus, which is often
accompanied by dimpling of the skin on either side of
the tendo calcaneus.
Lateral ligament (6): Stress testing of the anterior
tibiofibular ligament (2): Anterior displacement may
be confirmed by radiographs taken in the prone
position; alternatively, with the patient supine (and
preferably with local anaesthesia), support the heel on a
sandbag (1) and press firmly downwards on the tibia (2)
for 30 seconds up to exposure. A gap on the radiograph
between the talus and tibia of more than 6 mm is
regarded as pathological (3).
Inferior tibiofibular ligament (1): In tears of this
ligament (which has anterior and posterior components)
tenderness is present over the ligament just above the
line of the ankle joint.
Inferior tibiofibular ligament (2): In tears of the
inferior tibiofibular ligament pain is produced by
dorsiflexion of the foot, which displaces the fibula
laterally.
Inferior tibiofibular ligament (3): Grasp the heel and
try to move the talus directly laterally in the ankle
mortice. Lateral displacement indicates a tear of the
ligament.
Ankle joint movements (1): First confirm that the
ankle is mobile, and that any apparent movement is not
arising in the midtarsal or more distal joints. Firmly
grasp the foot proximal to the midtarsal joint; try to
produce dorsiflexion and plantarflexion.
Ankle joint movements (2): Measure plantarflexion
from the zero position. This reference lies at right angles
to the line of the leg. Normal range = 55°.
Ankle joint movements (3): Measure the range of
dorsiflexion. Always compare the sides. Normal range
= 15
Ankle joint movements (4): If dorsiflexion is
restricted, bend the knee. If this restores a normal range,
the Achilles tendon is tight. If it makes no difference,
joint pathology (such as osteoarthritis, rheumatoid
arthritis or infection) is the likely cause.
Ankle joint movements (5): If there is loss of active
dorsiflexion (drop foot) a full neurological examination
is required. The commonest causes are stroke, old
poliomyelitis, prolapsed lumbar intervertebral discs,
and local lesions of the common peroneal (lateral
popliteal) nerve
Suspected tendinopathy (3): If tenderness is found,
note whether the site of maximum tenderness changes
with dorsiflexion and plantarflexion of the foot. If the
pain is secondary to paratendinitis the site of maximum
tenderness will remain fixed (a). If it is due to
tendinosus alone, it will move with the tendon (b). Note
also any weakness of plantarflexion.

Tendo calcaneus (Achilles tendon): suspected

tendinopathy (1): The patient should be prone, with the Suspected tendon rupture (1): Again the patient
feet over the edge of the couch. Inspect and compare the should be examined with the feet over the end of the
sides. Note any local (a) or diffuse swelling, redness of couch. Defects in the contour of the tendon may be
the skin, or the presence of a Hagland deformity (b): this obvious.
is an exostosis affecting the posterosuperior aspect of
the heel on its lateral aspect. It is commonly associated
with an Achilles insertional tendinitis, although it does
not directly involve the tendon.

Tendo calcaneus (2): Test the power of plantarflexion

by asking the patient to press the foot against your hand.
Compare one side with the other, and note the shape of
each contracting calf and the prominence of each
Suspected tendinopathy (2): Now look for tenderness, tendon.
which in the case of a tendinopathy is normally situated
3–5 cm proximal to the tendon insertion. Check for any
increase in local heat. Palpate the tendon, noting any
localised or fusiform swelling, and any nodularity.
Gently squeeze the tendon (illus.); marked pain is a
feature of tendinosis with an associated paratendinitis.
Tendo calcaneus (3): Palpate the tendon while the
patient continues resisted plantarflexion. Compare the
sides. Any gap in the tendon (ruptured tendo calcaneus)
should be obvious. The integrity of the tendon may also
be tested by inserting a needle vertically into the middle
of the calf. Normally the needle should tilt when the
ankle is passively dorsiflexed and plantarflexed.
Tendo calcaneus (4): Thomson test: Normally when
the calf is squeezed the foot moves as the ankle
plantarflexes. Loss of this movement is pathognomonic
of an acute rupture of the tendo calcaneus.
Tenosynovitis (1): medial (1): Look for tenderness
along the line of the long flexor tendons. Tenderness is
usually diffuse and linear in pattern. Note the site and
extent of any local thickening.
Tenosynovitis (2): medial (2): Look for synovitis in
relation to the flexor tendons. There may be obvious
swelling. Demonstrate the presence of any excess
synovial fluid by milking the tendon sheaths in a
proximal direction.
Tenosynovitis (3): medial (3): Plantarflex and evert the
foot. This may produce pain where tenosynovitis
involves the tendon of tibialis posterior.
Tenosynovitis (4): medial (4): With the foot held in the
plantarflexed and everted position, look for tenderness
or gaps in the line of the tendon of tibialis posterior.
Spontaneous rupture is seen most frequently in
association with flat foot and rheumatoid arthritis.
Tenosynovitis (5): lateral (1): Examine the peroneal
tendons for tenderness and the presence of excess
synovial fluid in their sheaths.
Tenosynovitis (6): lateral (2): Force the foot into
plantarflexion and inversion. This will give rise to pain
and increased tenderness along the line of the peroneal
tendons if tenosynovitis of the peroneal tendons is
present.
Tenosynovitis (7): lateral (3): Feel for crepitus along
the line of the tendon sheaths behind both malleoli as
the foot is swung backwards and forwards between
inversion and eversion. Confirm by auscultation.
Peroneal tendons: Lightly palpate the peroneal
tendons with the fingers; look and feel for displacement
of the tendons as the patient everts the foot against light
resistance. Displacement occurs in the condition known
as ‘snapping peroneal tendons’.
Articular surfaces (1): Forcibly plantarflex the foot to
allow palpation of the anterior part of the superior
articular surface of the talus. Tenderness occurs in
arthritic conditions, and in osteochondritis of the talus.
A tender exostosis may be palpable in cases of
footballer’s ankle.
Articular surfaces (2): Place a hand across the front of
the ankle and passively dorsiflex and plantarflex the
foot. Crepitus, which may be confirmed by auscultation,
suggests articular surface damage.