Welcome to Leg Day #5 of the SplintER Series. The focused history and physical ankle exam of the patient with an acute ankle injury is a crucial tool often overlooked in the Emergency Department (ED). Our hope is that after enough practice, you will be able to complete your ankle exam within 2 minutes! The key is to practice, practice, and practice some more.
Why the Ankle Exam Matters
Acute ankle injuries are frequently encountered in the Emergency Department. The majority of acute ankle pain can be diagnosed with a good history and physical examination. Plain film imaging and, occasionally, a computed tomography (CT) scan can help with diagnosis and management.
Key Questions for Your History
- What was the mechanism of injury and what symptoms occurred afterwards? Subsequent symptoms include swelling, inability to bear weight, fevers/chills, and erythema
- What is the location of pain?
- Was there a previous injury or surgery to the affected ankle?
- Has the patient experienced similar pain previously?
Key Points for the Ankle Exam
Develop a structured approach to your ankle exam and you won’t miss an injury. Here’s our suggestion:
- Visually inspect the ankle and ask the patient to take at least 4 steps.
- Evaluate the medial and lateral malleolus, lateral 5th toe, and 1st dorsal web space for sensation.
- Palpate for a posterior tibial (PT) and dorsalis pedis (DP) pulse.
- Evaluate for effusion and reduced range of motion.
- Evaluate for focal tenderness especially at the proximal tibia/fibula, posterior edge of lateral/medial malleolus, base of 5th metatarsal (MT), navicular.
- Test ankle dorsi/plantar-flexion, eversion, and inversion strength.
- Test ankle stability by performing the anterior drawer and talar tilt.
- Test syndesmotic stability by performing the squeeze test.
- Test achilles tendon injury by performing the Thompson test.
We recommend performing these steps in the sequence described as it allows quick triage and prioritizes the neurovascular exam. The 9 step exam can be broken down into 3 critical questions:
- Is the patient neurovascularly intact?
- Is the ankle stable?
- Is there a fracture?
We review these 3 components in more detail.
An Example Case
An 18-year-old high school basketball player presents to the emergency department complaining of ankle pain. He was in practice last night when he came down from a rebound and landed on another players foot, inverting the ankle.
Utilizing our 3 critical questions an ankle exam is performed:
Neurovascular status: Sensation and pulses are intact.
Ankle stability: The anterior drawer, talar tilt, and Thompson are normal. The squeeze test is positive; there is concern for tibio-fibular sprain/rupture.
Fracture: There is no significant deformity, but there is significant swelling of the lateral ankle. The patient reports tenderness over the posterior aspect of the distal fibula. He is not able to bear weight; there is concern for a fracture.
Per the OAR, ankle radiographs are warranted given his inability to bear weight and tenderness over the lateral malleolus. There is no acute fracture noted on a 3-view ankle radiograph.
The athlete likely has a syndesmotic injury or a “high ankle sprain”. A splint or walking boot may be used to immobilize the joint and the athlete should be advised to use crutches and be non-weight bearing until follow up.