Ankle

The first question after an ankle or foot injury might be: 'is it broken?'. If you are able to take four steps, it is likely that you ankle/foot is not broken.

However, the ankle and the foot is complex: there are multiple joints, ligaments, vessels, nerves, muscles and cartilages. Only the foot contains already 26 bones. So a diagnose of broken or not broken is not specific enough for good treatment. We want to know: what bone is broken? are ligaments torn? what if there is no prior injury?

Red Flags

Pins or needles in feet
Numbness
Incontinence
Numbness in groin region
Different shape of one foot or ankle in comparison with the other foot
Babinsky reflex

Cause

Injury
Insidious onset

Risk Factors

Back or leg pain
Hip or knee pain
Type of footwear (flats, sandals)
Foot problems in the past
Heavy loading (work, sports or hobbies)

Tests

Inspection: ligaments, bunions, claw toes, swelling, tenderness, color and temperature
Ottawa Ankle Rules (only applicable if you are over 18 years old): 6 cm of tenderness behind one of the two ankle sides, tenderness on the outside soul of your foot or on the inside soul of your foot, unable to set four steps. If you do the Ottawa Ankle Rules within 48 hours after injury and you have 0 items positive, the chance that you have a fracture is less than 1%.
Neurological if indicated: patella and achilles reflex, less feeling on the skin (dermatomes L1-S4), slump (if you have back pain as well)
Vascular if indicated: pulse behind the ankle
Posture: joint lines, foot arch (high arch, neutral foot or flat foot), leg length difference.
Navicular Drop
Gait assessment (including ankle, hip and knee functioning)
Calf examination (strength and flexibility)
Activity assessment: heal raise, standing up, squat, pistol squat, jump, standing on one foot, hop, running, active and passive range of motion test and strength test

Tests specifically for Lateral Ankle Sprain

A lateral (outside) ankle sprain is the most common sprain. A proper recovery is essential to avoid future recurrent ankle sprains and could even lead to chronic ankle instability.

Risk factors

Previous sprain
Being tall
Overweight
Limb dominance
Footwear (high heels)

Indications

Barely able to bare weight on affected ankle
Tenderness, swelling, bruising, higher temperature of the affected ankle
No tenderness of the bones (otherwise it might be broken instead of sprain, see Ottawa Ankle Rules)
Cold and/or numb foot indicates that Peroneal nerve could be involved in injury

Tests

Inversion of the foot is painful
Anterior Drawer
Talar Tilt
Squeeze
Kleiger (syndesmotic sprain)

Treatment

Inflammatory phase (0-3 days)

POLICE

Protect
Optimal Load
Ice
Compression
Elevation

Beginning exercises could be moving your feet in bed.

Proliferative phase (4-10 days)

Stability: Increase weight baring
Range of motion
Bracing

Early remodeling phase (11-21 days)

Strength
Dynamic stability
Range of motion
Functions (walking, walking up and down stairs etc.)
Education: avoiding recurrent sprains (footwear) and encouraging to trust ankle again and bracing
Quality of movement (symmetric walking)

Late remodeling phase

Work
Sports

Chronic instability

Stability
Strength

POSTERIOR TIBIAL TENDON DYSFUNCTION

Cause

Slow onset
Flatfeet (pes planus)
Repetitive loading
Hypertension
Insufficient vascularization in ankle region

Risk factors

Obesity
Diabetes
Previous injury
Steroid use
Middle aged women
Young athletes

Indications

Limited range of motion in ankle
Pain and/or swelling on medial side of the foot/ankle
Following activities are painful: standing on toes, walking stairs up and down and walking over uneven surfaces
Instability

Tests