Ankle joint examination

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Ankle Joint Examination

Sources: S Das Manual of Clinical Surgery 13th Ed, Bailey & Love's Short Practice of Surgery 28th Ed, Tintinalli's Emergency Medicine, Miller's Review of Orthopaedics 9th Ed, Campbell's Operative Orthopaedics 15th Ed 2026

Anatomy Recap

The ankle joint (talocrural joint) is a hinge joint formed by the tibia, fibula, and talus. The foot is divided into three regions:

Hindfoot: talus and calcaneus
Midfoot: navicular, cuboid, cuneiforms
Forefoot: metatarsals and phalanges

The lateral malleolus is less prominent, descends ~1 cm lower and lies slightly posterior to the medial malleolus. - S Das Manual on Clinical Surgery, p. 261

1. HISTORY

Key points to elicit:

Mechanism of injury: foot commonly anchored while the body drives forward - eversion, external rotation, or internal rotation injuries
Three injury types: (i) external rotation, (ii) internal rotation, (iii) vertical compression
In arthritis: gradual onset pain, swelling, stiffness - S Das Manual on Clinical Surgery, p. 214

2. GAIT

Observe the patient walking before formal examination:

Antalgic gait: painful ankle/foot joint
High-stepping gait: foot drop (common peroneal nerve injury)
Short propulsive phase: suggests forefoot pain
Examine footwear for abnormal wear patterns (normally posterolateral heel wear + ball of big toe) - Bailey & Love's Short Practice of Surgery 28th Ed, p. 518

3. INSPECTION (Look)

Standing Patient

From the front:

Overall alignment, foot shape, and any deformity
Assess pelvic obliquity, leg length discrepancy, valgus/varus at the knee

From the side:

Medial longitudinal arch (normal vs. pes planus or pes cavus)

From behind:

Heel alignment - normal heel valgus is 5-7°
"Too many toes" sign = increased forefoot abduction (pes planus / splayed forefoot)

Attitude

In arthritis of the ankle, the limb assumes a position of plantar flexion

Swelling

Joint effusion: fullness on either side of the tendo Achilles + a bulge across the front of the joint
Tendon sheath effusion: swelling extends along the long axis of the leg/foot far beyond joint level
In fractures: look for deformity (lateral, medial, forward, or backward displacement); excessive broadening of the ankle suggests inferior tibiofibular diastasis (talus wedged between tibia and fibula)

Skin

Ecchymosis, abrasions, blistering, skin color changes
Bunion, gouty tophi, corns, nail changes
Corns = callosities where toes rub shoes

Muscles

Wasting obvious in tuberculous ankle arthritis
Muscle wasting on the dorsum of the foot suggests neurological pathology - full neuro exam required

Foot Deformities

Deformity	MTP Joint	PIP Joint	DIP Joint
Claw toe	Hyperextension	Flexion	Flexion
Hammer toe	Normal	Flexion	Flexion
Mallet toe	Normal	Normal	Flexion
Hallux valgus/varus	Valgus/Varus	Normal	-

- Bailey & Love's Short Practice of Surgery 28th Ed

4. PALPATION (Feel)

Skin

Temperature: increased local warmth in arthritis/infection
Sensation: test light touch on dorsum (first web space) and lateral foot; inability to sense a Semmes-Weinstein 5.07 monofilament (10g) = neuropathy
Glove-and-stocking reduced sensation suggests diabetes

Vascular

Palpate posterior tibial pulse (behind medial malleolus)
Palpate dorsalis pedis pulse (dorsum of foot, first web space)

Palpation of posterior tibial and dorsalis pedis pulses

Palpation of (a) the posterior tibial pulse and (b) the dorsalis pedis pulse - Bailey & Love's

Soft Tissues

Tendo Achilles: palpate for gaps, tenderness, swelling along its full length; palpate attachment to os calcis
Peroneal tendons: lateral side (peroneus brevis is dorsal to longus at the peroneal tubercle)
Tibialis posterior tendon: medial side
Tibialis anterior tendon and long extensors: dorsum of foot
Sinus tarsi: soft-tissue depression anterior to the lateral malleolus - tenderness here with subjective hindfoot instability = sinus tarsi syndrome
Retrocalcaneal bursa and Haglund's posterolateral prominence of the calcaneus

Bones - Palpation Landmarks

Medial malleolus and lateral malleolus - palpate for bony tenderness, irregularity, crepitus
Dome of talus: palpate with deep pressure anteriorly just below the ankle
Calcaneum: posterior aspect; commonest cause of plantar heel pain = plantar fasciitis (most tender at plantar calcaneal origin)
Sustentaculum tali: one fingerbreadth below the medial malleolus - attachment for spring ligament
Syndesmosis (anterior ankle): tenderness suggests tibiofibular ligament injury
Palpate all tarsal bones, metatarsals, and phalanges along their lengths

Fluctuation Test for Effusion

With joint effusion, squeezing the swelling on either side of the tendo Achilles transmits a fluid impulse palpable in front of the joint - S Das Manual on Clinical Surgery

5. MOVEMENTS (Move)

The ankle is a hinge joint - primary movements are in one plane only.

Normal Ranges

Joint	Movement	Normal Range
Ankle (talocrural)	Dorsiflexion	25°
Ankle (talocrural)	Plantarflexion	35°
Subtalar	Inversion	~20°
Subtalar	Eversion	~20°
Midtarsal	Abduction	10°
Midtarsal	Adduction	20°
MTP (hallux)	Extension	70-90°
MTP (hallux)	Flexion	45°

Normal toe-off requires 35-40° of MTP dorsiflexion. - Bailey & Love's

Testing Ankle (Talocrural) Movement

Testing passive movements of the ankle joint. The leg is held in one hand; the foot is grasped to include the head of the talus - S Das Manual on Clinical Surgery

To test passive ankle movements: hold the leg with one hand and grasp the foot with the other hand including the head of the talus in the grip. This excludes movement at the subtalar and midtarsal joints, preventing a false impression of ankle motion in cases of ankle ankylosis.

Dorsiflexion: test with knee both flexed and extended
- Restriction greater with knee extended → contracture primarily in gastrocnemius
- Restriction equal in both positions → contracture primarily in soleus
Plantarflexion: weakness suggests Achilles tendon injury or S1 nerve root pathology

Subtalar Joint

Hold the talar neck (not the tibia - this isolates subtalar from ankle motion). Ask patient to move the heel side to side, or apply passive varus/valgus stress.

Inversion: foot moves inwards
Eversion: foot moves outwards
Normal: ~5° in each direction

Midtarsal Joint

Hold the heel; move the forefoot medially (adduction = 20°) and laterally (abduction = 10°).

6. SPECIAL TESTS

A. Thompson Test (Simmonds Squeeze Test) - Achilles Tendon Integrity

Indication: Suspected Achilles tendon rupture

Technique: Lie the patient prone with the foot free over the edge of the couch. Squeeze the calf belly and observe the ankle.

Positive test: Absence of plantar flexion = Achilles tendon rupture

Important: Do not be misled if the patient can stand on tiptoes - this can be achieved by long toe flexors even with a complete rupture.

Diagnosis of Achilles rupture requires 2 or more of:

Positive Thompson test
Decreased ankle plantarflexion strength
Palpable gap in the tendon
Increased passive dorsiflexion with gentle manipulation

Campbell's Operative Orthopaedics 15th Ed 2026

B. Anterior Drawer Test - ATFL (Anterior Talofibular Ligament)

Indication: Lateral ankle instability, suspected ATFL tear

Technique: Patient seated with the ankle in 10-15° of plantar flexion (places ATFL under tension). Cup the heel in one hand; apply counter-traction to the tibia with the other hand while drawing the heel forward.

Anterior drawer stress test of the ankle - Tintinalli's Emergency Medicine

Positive test: Increased anterior subluxation of ≥2 mm compared to the uninjured side, or visible dimpling of the anterior skin = significant ATFL injury (Grade III sprain)

Tintinalli's Emergency Medicine; Bailey & Love's

C. Talar Tilt Test (Inversion Stress Test) - CFL (Calcaneofibular Ligament)

Indication: CFL instability

Technique: Invert the ankle in dorsiflexion to stress the CFL. Inversion in plantar flexion may also assess the ATFL.

Positive test: Excessive and asymmetric talar tilt = CFL rupture/instability

D. Squeeze Test - Syndesmosis Injury

Technique: Squeeze the tibia and fibula together above the ankle joint (midcalf level)

Positive test: Pain at the ankle/syndesmosis = interosseous membrane or syndesmosis injury

Also: Springing the fibula - squeeze the upper ends of tibia and fibula; pain at the lower fibula suggests a fibular fracture (Maisonneuve pattern). - S Das Manual on Clinical Surgery

E. Crossed-Leg Test - Syndesmosis

Technique: Patient crosses the affected leg over the contralateral knee (fibula resting on the other knee); pressure is applied medially at the knee level.

Positive test: Pain in the syndesmosis = syndesmosis injury

F. Coleman Block Test - Subtalar Joint Flexibility (Pes Cavus)

Technique: Patient stands on a 2 cm block, great toe resting on the floor over the medial edge. Observe the hindfoot from behind.

Hindfoot varus corrects to valgus = subtalar joint is mobile (forefoot-driven deformity)
Hindfoot varus remains = subtalar joint is fixed

G. Windlass / Jack's Test - Flat Foot Flexibility

Technique: Ask patient to stand on tiptoes and observe the medial arch.

Arch forms as patient rises on tiptoes = flexible flat foot
Arch fails to form = fixed flat foot

Testing subtalar joint flexibility - Bailey & Love's

7. NEUROLOGICAL EXAMINATION

Test sensation in the first web space (deep peroneal nerve) and lateral border of the foot (sural nerve)
Deep peroneal nerve can be compressed at the anterior tarsal tunnel (anterior ankle / inferior extensor retinaculum)
Superficial peroneal, tibial, and sural nerves should be assessed in appropriate clinical context
Full upper and lower limb neurological exam if muscle wasting is present

8. MEASUREMENTS

When comparing to the contralateral side:

Distance from medial malleolus to head of 1st metatarsal and to heel
Distance from lateral malleolus to head of 5th metatarsal and to heel
In calcaneal fractures: these measurements are altered compared to the sound side

Summary - Ankle Examination Checklist

Step	Key Points
Gait	Antalgic, foot drop, propulsive phase
Inspect	Deformity, swelling, skin, alignment (front/side/behind)
Palpate	Temperature, pulses, malleoli, tendons, ligaments, effusion
Move	Dorsiflexion (25°), plantarflexion (35°), subtalar, midtarsal
Special Tests	Thompson, Anterior Drawer, Talar Tilt, Squeeze, Coleman Block
Neuro	Sensation, power, reflexes
Measure	Malleolus-to-metatarsal distances vs contralateral side

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