Special Test (Ankle & Foot)

Front 1

Tests for Neutral Position of the Talus

Back 1

The neutral position of the talus is often referred to as the neutral or balanced position of the foot. This so-called neutral position is an ideal position that, in reality, is not commonly found in people in normal weight bearing. For most patients, the subtalar joint is normally in slight valgus, with the forefoot in slight varus and the calcaneus in slight valgus. The tibia is in slight varus, so each joint slightly compensates for the adjacent one. The neutral position is used as a starting position to determine foot and leg deviations. Functional asymmetry may occur in the lower limb in normal standing; the examiner should then put the talus in tlle neutral position to see whether the asymmetry remains. If it does, there is anatomical
or structural asymmetry as well as functional
asymmetry. If the asymmetry disappears, there is only
functional asymmetry, which is often easier to treat.

Front 2

Neutral Position of the TaIus (Weight-Bearing
Position)

Back 2

The patient stands with the feet in a relaxed standing position so that the base width and Pick angle are normal for the patient. Usually, only one foot is tested
at a time. The examiner palpates the head of the talus on the dorsal aspect of the foot With the thumb and forefinger of one hand. The patient slowly rotates the trunk to the right and then to the left, which causes the tibia to medially and laterally rotate so that the talus supinates and pronates. If the foot is positioned so that the talar head does not appear to bulge to either side, then the subtalar joint will be in its neutral position in weight bearing. Mueller, described a progression
of the neutral talus position in standing called the
navicular drop test to quantify midfoot mobility and
its effect on other parts of the kinetic chain. Using a
small rigid ruler, the examiner first measures the height
of the navicular from the floor in the neutral talus position using the most prominent part of the navicular
tuberosity and then measures the height of the navicular in normal relaxed standing. The difference is called the navicular drop and indicates the amount of foot pronation or flattening of the medial longitudinal arch during standing. Any measurement greater
than 10mm is considered abnormal. Experience in measuring is necessary to ensure reliable measures.

Front 3

Neutral Position of the TaIus (Supine)

Back 3

The patient lies supine with the feet extending over the end of the examining table. The examiner grasps the
patient's foot over the fourth and fifth metatarsal
heads, using the thumb and index finger of one hand.
The examiner palpates both sides of the head of the
talus on the dorsum of the foot with the thumb and
index finger of the other hand. The examiner then gently, passively dorsiflexes the foot until resistance is felt. While the examiner maintains the dorsiflexion, the foot is passively moved through an arc of supination (talar head bulges laterally) and pronation (talar head bulges medially). If the foo is positioned so that the talar head does not appear to bulge to either side, the subtalar joint will be in its neutral non-weight-bearing position. This supine test position is best for determining the relation of the forefoot to the hindfoot.

Front 4

Neutral Position of the Talus (Prone)

Back 4

The patient lies prone with the foot extended over the end of the examining table. The examiner grasps
the patient's foot over the fourth and fifth metatarsal
heads with the index finger and thumb of one hand. The examiner palpates both sides of the talus on the dorsum of the foot, using the thumb and index finger of the other hand. The examiner then passively and gently dorsiflexes the foot until resistance is felt.
While maintaining the dorsiflexed position, the examiner moves the foot back and forth through an arc of supination (talar head bulges laterally) and pronation
(talar head bulges medially). As the arc of movement is
performed, there is a point in the arc at which the foot
appears to fall off to one side or the other more easily.
This point is the neutral, non-weight-bearing position of
tl1e subtalar joint. This prone test position is best
for determining the relation of the hindfoot to the leg.

Front 5

Leg-Heel Alignment

Back 5

The patient lies in the prone position with tl1e foot extending over the end of the examining table. The examiner places a mark over the midline of the calcaneus at the insertion of tl1e Achilles tendon.
The examiner makes a second mark approximately 1 cm
distal to the first mark and as close to the midline of the
calcaneus as possible. A calcaneal line is then made to
join the two marks. Next, the examiner makes two markson the lower third of the leg in the midline. These two marks are joined, forming the tibial line, which represents the longitudinal axis of the tibia. The examiner then places the subtalar joint in the prone neutral position. While the subtalar joint is held in neutral, the examiner looks at the two lines. If the lines are parallel or in slight varus (20 to 80), the leg-to-heel alignment is considered normal.78 If the heel is inverted, the patient has hindfoot varus; if the heel is everted, the patient has hindfoot valgus.

Front 6

Test for TIbial Torsion (General)

Back 6

When testing for tibial torsion, the examiner must realize
that some lateral tibial torsion (13° to 18° in adults, less in
children) is normally present.SI If tibial torsion is more than
18°, it is referred to as a toe-out position. If tibial torsion is
less than 13°, it is referred to as a toe-in position. Excessive toeing-in is sometimes referred to as pigeon toes and may be caused by medial tibial torsion, medial femoral torsion, or excessive femoral anteversion.

Front 7

Tibial Torsion (Sitting)

Back 7

Tibial torsion is measured by having the patient sit with the knees flexed to 90° over the edge of the examining table. The examiner places the thumb of one hand over the apex of one malleolus and the index finger of the same hand over the apex of the other malleolus. Next, the examiner visualizes the axes of the knee and of the ankle. The lines are not normally parallel but instead form an angle of 12° to 18° owing to lateral rotation of the tibia.

Front 8

Tibial Torsion (Supine)

Back 8

The patient lies supine. The examiner ensures that the femoral condyle lies in the frontal plane (patella facing straight up). The examiner palpates the apex of both malleoli with one hand and draws a line on the heel representing a line joining the two apices. A second line is drawn on the heel parallel to the floor. The angle formed by the intersection of the two lines indicates the amount of lateral tibial torsion.

Front 9

Tibial Torsion (Prone)

Back 9

The patient lies prone with the knee flexed to 90°. The examiner views from above the angle formed by the foot and thigh after the subtalar joint has been placed in the neutral position, noting the angle the foot makes with the tibia. This method is most often used in children because it is easier to observe the feet from above.

Front 10

Too many Toes sign

Back 10

The patient stands in a normal relaxed position while the examiner views the patient from behind. If the heel is in valgus, the forefoot abducted, or the tibia laterally rotated more than normal (tibial torsion), the examiner can see more toes on the affected side than on the normal side. Similarly, lateral femoral torsion could cause the "too many toes" test to be positive. If the talus is positioned in neutral and the calcaneus is in neutral, the "too many toes" sign means the forefoot is adducted on the rearfoot and may be seen with excessive pronation (hyperpronation). Hyperpronation is often associated with metatarsalgia, plantar fasciitis, hallux valgus, and posterior tibial tendon pathology.

Front 11

Anterior Drawer Test of the Ankle. This test is designed primarily to test for injuries to the anterior talofibular ligament, the most frequently injured ligament in the ankle. The patient lies supine with the foot relaxed. The examiner stabilizes the tibia and fibula, holds the patient's foot in 20° of plantar flexion, and draws the talus forward in the ankle mortise. Sometimes, a dimple appears over the area of the anterior talofibular ligament on anterior translation (dimple or suction sign) if pain and muscle spasm are mininlal. In the plantar-flexed position, the anterior talofibular ligament is perpendicular to the long axis of the tibia. By adding inversion, which gives an anterolateral stress, the examiner can increase the stress on the anterior talofibular ligament and the calcaneofibular ligament.

Back 11

A positive anterior drawer test may be obtained with a
tear of only the anterior talofibular ligament, but anterior translation is greater if both ligaments are torn, especially if the foot is tested in dorsiflexion. If straight anterior movement or translation occurs,
the test indicates both medial and lateral ligament insufficiencies. This bilateral finding, which is often more evident in dorsiflexion, means that the superficial and deep deltoid ligaments, as well as the anterior talofibular ligament and anterolateral capsule, have been torn. If the tear is on only one side, only that side would translate forward. For example, with a lateral tear, the lateral side would translate forward, causing medial rotation of the talus and resulting in anterolateral rotary instability which is increasingly evident with growing plantar flexion of the foot.
Ideally, the knee should be placed in 90° of flexion to
alleviate tension on the Achilles tendon. The test should
be performed in plantar flexion and in dorsiflexion to test for straight and rotational instabilities.
The test may also be performed by stabilizing the foot
and talus and pushing the tibia and fibula posteriorly on
the talus. In this case, excessive posterior movement of the tibia and fibula on the talus indicates a positive test.

Front 12

Prone Anterior Drawer Test

Back 12

The patient lies prone with the feet extending over the end of the examining table. With one hand, the examiner pushes the heel steadily forward. Excessive anterior movement and a sucking in of the skin on both sides of the Achilles tendon indicate a positive sign. The test, like the previous one, indicates ligamentous instability primarily the anterior talofibular ligament.

Front 13

Talar Tilt

Back 13

The patient lies in the supine or side lying position with the foot relaxed. The patient's gastrocnemius muscle may be relaxed by flexion of the knee. This test is to determine whether the calcaneofibular ligament is torn. The normal side is tested first for comparison. The foot is held in the anatomical (90°) position, which brings the calcaneofibular ligament perpendicular to the long axis of the talus. If the foot is plantar flexed, the anterior talofibular ligament is more likely to be tested (inversion stress test). The talus is then tilted from side to side into adduction and abduction. Adduction tests the calcaneofibular ligament and, to some degree, the anterior talofibular ligament by increasing the stress on the ligament. Abduction stresses the deltoid ligament, primarily the tibionavicular, tibiocalcaneal, and posterior tibiotalar ligaments. On radiograph, the talar tilt may be measured by obtaining the angle between the distal aspect of the tibia and the proximal surface of the talus.

Front 14

Squeeze Test of the Leg

Back 14

The patient lies supine. The examiner grasps the lower leg at midcalf and squeezes the tibia and fibula together. The examiner then applies the same load at more distallocations moving toward the ankle. Pain in the lower leg may indicate a syndesmosis injury, provided that fracture, contusion, and compartment
syndrome have been ruled out. Borosky and associates
called this test the distal tibiofibular compression test and applied the compression over the malleoli rather
than the shaft of the tibia and fibula. Nussbaum et al. reported that the "length of tenderness" above the lateral malleolus indicates severity.

Front 15

Cotton Test

Back 15

This test is also used to assess for syndesmosis instability caused by separation of the tibia and fibula (diastasis). The two bones are normally held together by four ligaments (the tibiofibular interosseous ligament, anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, and transverse tibiofibular ligament), The examiner stabilizes the distal tibia and fibula with one hand and applies a medial and lateral translation force (not an inversion/eversion force) with the other hand to the foot. Any lateral translation (>3 to 5mm) or clunk indicates syndesmotic instability.

Front 16

External Rotation Stress Test (Kleiger Test)

Back 16

The patient is seated with the leg hanging over the examining table with the knee at 90°. The examiner
stabilizes the leg with one hand. With the other hand, the examiner holds the foot in plantigrade (90°) and applies a passive lateral rotation stress to the foot and ankle. The test is positive for a syndesmosis ("high ankle") injury if pain is produced over the anterior or posterior tibiofibular ligaments and the interosseous membrane. If the patient has pain medially and the examiner feels the talus displace from the medial malleolus, it may indicate a tear of the deltoid ligament. On a stress radiograph, if the medial clear space is increased, it suggests rupture of the ligament (see the discussion presented later in the chapter) if the lateral malleolus is intact.

Front 17

Thompson's (Simmonds') Test (Sign for Achilles
Tendon Rupture)

Back 17

The patient lies prone or kneels on a chair with the feet over the edge of the table or chair. While the patient is relaxed, the examiner squeezes the calf muscles. The absence of plantar flexion when the muscle is squeezed indicates a positive test and a ruptured Achilles tendon (third-degree strain) One should be careful not to assume that the Achilles tendon is not ruptured if the patient is able to plantar flex the foot while not bearing weight. The long flexor muscles can perform this function in the non-weight-bearing stance even with a rupture of the Achilles tendon.

Front 18

Figure-8 Ankle Measurement for Swelling

Back 18

The patient is positioned in long sitting with the ankle
and lower leg beyond the end of the examining table with the ankle in plantigrade (90°). Using a 6mm (one-quarter- inch) wide plastic tape measure, the examiner places the end of the tape measure midway between the tibialis anterior tendon and the lateral malleolus, drawing the tape medially across the instep just distal to the navicular tuberosity. The tape is then pulled across the arch of the foot just proximal to the base of the fifth metatarsal, across the tibialis anterior tendon, and then arow1d the ankle joint just distal to the tip of the medial malleolus, across the Achilles tendon, and just distal to the lateral malleolus, returning to the starting position. The measurement is repeated three times and an average taken.

Front 19

Patla Tibialis Posterior Length Test

Back 19

The patient is in prone lying with the knee flexed to 90° and the calcaneus held in eversion and the anlde in dorsiflexion with one hand. With the other hand, the examiner's thumb contacts the plantar surface of the
bases of the second, third, and fourth metatarsals while
the index and middle fingers contact the plantar surface
of the navicular. The examiner then determines the end
feel by pushing dorsally on the navicular and metatarsal
heads. The end feel is compared with the normal side.
A reproduction of the patient's symptoms indicates a
positive test.

Front 20

Feiss Line

Back 20

The examiner marks the apex of the medial malleolus and the plantar aspect of the first metatarsophalangeal
joint while the patient is not bearing weight. The examiner then palpates the navicular tuberosity on the
medial aspect of the foot, noting where it lies relative to a line joining the two previously made points. The patient then stands with the feet 8 to 15 cm (3 to 6 inches) apart. The two points are checked to ensure that they still represent the apex of the medial malleolus and the plantar aspect of the metatarsophalangeal joint. The navicular tubercle is
again palpated. The navicular tubercle normally lies on or close to the line joining the two points. If the tubercle falls one third of the distance to the floor, it represents a first-degree flatfoot; if it falls two thirds of the distance, it represents a second-degree flatfoot; if it
rests on the floor, it represents a third-degree flatfoot.

Front 21

Hoffa's Test

Back 21

The patient lies prone with the feet extended over the edge of the examining table. The examiner palpates the Achilles tendon while the patient plantar flexes and dorsiflexes the foot. If one Achilles tendon (the injured one) feels less taut than the other one, the test is considered positive for a calcaneal fracture. Passive dorsiflexion on the affected side is also greater.

Front 22

Tinel's Sign at the Ankle (Percussion Sign)

Back 22

Tinel's sign may be elicited in two places around the ankle. The anterior tibial branch of the deep peroneal nerve may be percussed in front of the ankle. The
posterior tibial nerve may be percussed as it passes behind the medial malleolus. In both cases,
tingling or paresthesia felt distally is a positive sign.

Front 23

Duchenne Test

Back 23

The patient lies supine with the legs straight. The examiner pushes up on the head of the first metatarsal through the sole, pushing the foot into dorsiflexion. The test is positive for a lesion of the superficial peroneal nerve or a lesion of L4, L5, or SI nerve root if, when the patient is asked to plantar flex the foot, the medial border dorsiflexes and offers no resistance while the lateral border plantar flexes.

Front 24

Morton's Test

Back 24

The patient lies supine. The examiner grasps the foot around the metatarsal heads and squeezes the heads together. Pain is a positive sign for stress fracture or neuroma.

Front 25

Romans' Sign

Back 25

The patient's foot is passively dorsiflexed with the knee extended. Pain in the calf indicates a positive Romans' sign for deep vein dlrombopWebitis. Tenderness is also elicited on palpation of the calf. In addition to these findings, the examiner may find pallor and swelling in the leg and a loss of the dorsalis pedis pulse.

Front 26

Buerger's Test

Back 26

This test is designed to test the arterial blood supply to the lower limb.28 The patient lies supine while the examiner elevates the patient's leg to 45° for at least 3 minutes. If the foot blanches or the prominent veins collapse shortly after elevation, the test is positive for poor arterial blood circulation. Then sit the patient up and ask them to hang their legs down over the side of the bed at an angle of 90 degrees. Gravity aids blood flow and colour returns in the ischaemic leg. The skin at first becomes blue, as blood is deoxygenated in its passage through the ischaemic tissue, and then red, due to reactive hyperaemia from post-hypoxic vasodilatation. Both legs are examined simultaneously as the changes are most obvious when one leg has a normal circulation.