++
Observation of the lower extremity is extensive. It is extremely important to observe the entire kinetic chain when assessing the leg, foot, and ankle. Weight-bearing and non–weight-bearing postures of the foot are compared.
++
Observing the patient while they move from sitting to standing and walk to the treatment area gives the clinician a sense of the patient's functional ability in weight-bearing and provides the first opportunity for gait analysis.
101An important part of the examination of the foot and ankle is the gait assessment (see
Chap. 6). During gait, the transverse and longitudinal arches can be grossly assessed—the lateral longitudinal arch bears the body weight in the early stance, whereas the medial longitudinal arch provides support in the mid- and late-stance phase of gait.
136The foot should touch the ground, the heel first and the heel should begin to rise at approximately 35% of the gait cycle.
136Early heel rise may occur due to tightness of the gastrocnemius–soleus complex, whereas late heel rise may be secondary to weakness of the calf musculature.
136Normally, the foot pronates during the early stance phase, but the foot should not remain pronated during heel rise and toe off.
136
++
Clinical
Pearl
++
Patients with an ankle injury usually avoid the normal heel-to-toe progression to decrease weight-bearing and painful ankle dorsiflexion.
137Instead, the patient is likely to adopt a toe-to-heel progression, with varying amounts of hip circumduction and external rotation of the lower leg, or steppage gait, to further unload the ankle.
138
++
The following are assessed with the patient standing:
++
- Shoulder and pelvic heights (see
Chaps. 16and
29).
- Spinal curvature (see
Chap. 27).
- Pelvic rotation (see
Chap. 29).
- The degree of hip rotation.In the femur, anteversion and retroversion angles should be noted (refer to
Chap. 19). Excessive internal rotation of the hip toward the opposite hip (anteversion) may result in a flattening of the medial longitudinal arch and toeing-in/internal torsion of the tibia (pigeon toes). Excessive external rotation of the hip away from the opposite hip (retroversion) may result in an elevation of the medial longitudinal arch.
- The degree of knee flexion or hyperextension.A genu recurvatum (hyperextension) places the talocrural joint in more plantar flexion than normal and can often be a compensatory mechanism in the longer limb of individuals who have a leg-length inequality; see
Chap. 29.
139An increase in knee flexion accomplishes the same compensation for a leg-length inequality.
139
- The degree of varus and valgus of the knee and tibia.Excessive tibia varum, genu varus, or forefoot varus can increase the frontal angle of the talocrural joint, which promotes excessive weight-bearing on the lateral aspect of the foot unless compensatory pronation is available within the foot to bring the medial aspect of the foot to the support surface.
139Tibia varum refers to the frontal plane position of the distal one-third of the leg, as it relates to the supporting surface.
107
- Rotational components of the tibia.Tibial torsion is assessed with the patient in sitting, with their feet hanging over the end of the bed so that their knees are in approximately 90 degrees of flexion.
101The thumb of one hand is placed over the apex of one malleolus, and the index finger of the same hand is placed over the apex of the other malleolus. A qualitative estimate of the direction and magnitude of tibial torsion can be made by envisioning a line that passes through the malleoli and estimating its orientation to the frontal plane of the proximal tibia.
139Alternatively, tibial torsion can be measured with the patient in prone with the knee flexed to 90 degrees and the subtalar joint positioned and stabilized in subtalar neutral.*
++
Clinical
Pearl
++
The neutral subtalar position is calculated based on a normal 2:1 ratio of inversion to eversion. To locate subtalar neutral, the patient is positioned in prone with the opposite hip flexed, abducted, and externally rotated. If evaluating the right ankle, the clinician uses the thumb and forefinger of the left hand to palpate the hollows over the neck of the talus on either side of the anterior portion of the ankle. Using the thumb and forefinger of the other hand, the clinician grasps the head of the fourth and fifth metatarsals and rocks the foot back and forth. As the foot is inverted, a bulge can be felt on the lateral aspect of the foot. With eversion, the bulge can be felt to bulge medially. The point at which the talar head is felt to bulge equally on the medial and lateral sides is the subtalar neutral position.
++
Once the subtalar neutral position has been established, a line is drawn on the sole of the foot parallel to the length of the femur. A second line is drawn in line with the foot. The angle between these lines is the tibial torsion angle.
64There is normally an angle of 12–18 degrees to the frontal plane.
140Tibial torsion is generally less in children. A position of relative internal rotation of the tibia produces an increase in rigidity to the subtalar joint prior to midstance, due to premature stabilization of the longitudinal arch of the foot.
141Excessive external rotation of the tibia places an increased strain along the longitudinal arch, as well as the first MTP joint.
141
++
- Rearfoot to leg orientation.This can be an indicator of weight-bearing subtalar position. It is assessed by measuring the acute angle formed between a line representing the posterior aspect of the distal third of the leg, and a line approximately 1-cm distal to the first mark, representing the midline of the posterior aspect of the calcaneus (see
Fig. 21-13).
139The angle is assessed as the patient shifts weight on the lower extremity to simulate single-limb support. If the lines are parallel or in slight varus (2–8 degrees), the leg–rearfoot orientation is considered normal.
142Movement of the rearfoot into eversion (rearfoot valgus) during this maneuver is indicative of subtalar pronation.
94Pronation of the foot is manifested by eversion of the heel, abduction of the forefoot, a decrease in the medial longitudinal arch, internal rotation of the leg in relation to the foot, and dorsiflexion of the subtalar and midtarsal joints. If the heel is in too much valgus, the forefoot is excessively abducted, or there is excessive external rotation of the tibia, more toes can be seen on the affected side than the normal side when viewing the leg from behind (“too-many-toes sign”).
42If the patient is asked to raise up on the toes, the calcaneus should be observed to move into a position of inversion. An inability of the calcaneus to invert with this maneuver could indicate the presence of an abnormality within the subtalar joint mechanism or a weakness of the posterior tibialis.
42,
141
- The weight-bearing foot.The following are major components of the normal weight-bearing foot:
119,
143
- Both planar condyles of the calcaneus are on the floor surface. An imaginary plane representing the ground surface is applied to the anterior (plantar) surface of the calcaneus. The metatarsal heads should rest upon this plane. If the plane of the metatarsal heads is perpendicular to the bisection of the calcaneus, the forefoot-to-rearfoot relationship is normal, or neutral.
- The “normal” foot should demonstrate 6–8 degrees of calcaneal eversion during gait. The foot should pronate initially, just after initial contact (see
Chap. 6).
- All of the metatarsal heads lie in one plane, which is in the same plane as the anterior (plantar) condyles of the calcaneus
94
- The ball of the foot is level with the plantar surface of the heel.
- A normal forefoot-to-rearfoot relationship (see later).
- The orientation of the distal third of the lower leg should be vertical, to position the foot properly for the stance phase.
- The midtarsal joint is maximally pronated, while the subtalar joint, MTP, and IP joints are in neutral.
- The presence of a well-formed static medial arch should be noted, as well as its dynamic formation with heel raising.
- Forefoot-to-rearfoot relationship.Goniometric measurement of forefoot position relative to the rearfoot is a routine procedure used by rehabilitation specialists. This measurement is also frequently made by visual estimation. Neutral alignment of the forefoot relative to the rearfoot is present when a line representing the anterior (plantar) aspect of the metatarsal heads is perpendicular to the line bisecting the rearfoot. The forefoot-to-rearfoot angle is approximately 10–12 degrees.
119,
143Forefoot varus is the term used to describe inversion of the forefoot away from this neutral position, while forefoot valgus describes an everted forefoot position.
139The relationship can be assessed with the patient positioned in prone with their knee extended and their feet over the end of the table. The subtalar neutral position is located using the method described previously. Slight pressure is applied to the metatarsal heads while maintaining subtalar neutral. This will determine the relationship of the forefoot to rearfoot, and both of these to the bisection of the lower leg. A varus or valgus tilt of the forefoot in relation to the hindfoot becomes significant when the first metatarsal is in a plantar flexed position, as this positions the hindfoot into an inverted position during weight-bearing.
141Somers et al. examined the reliability of goniometric and visual estimation of forefoot position measurements when experienced and inexperienced testers performed the evaluation. Two clinicians (≥ 10 years' experience) and two physical therapy students were recruited as testers. Ten subjects (20–31 years old), free from pathology, were measured. Each foot was evaluated twice with the goniometer and twice with visual estimation by each tester. Intraclass correlation coefficient (ICC) and coefficients of variation method error were used as estimates of reliability. There was no dramatic difference in the intratester or intertester reliability between experienced and inexperienced testers, regardless of the evaluation used. Estimates of intratester reliability (ICC 2,1), when using the goniometer, ranged from 0.08 to 0.78 for the experienced clinicians and from 0.16 to 0.65 for the inexperienced clinicians. When using visual estimation, ICC (2,1) values ranged from 0.51 to 0.76 for the experienced clinicians and 0.53 to 0.57 for the inexperienced clinicians. The estimate of intertester reliability [ICC (2,2)] for the goniometer was 0.38 for the experienced clinicians and 0.42 for the inexperienced clinicians. When using visual estimation, ICC (2,2) values were 0.81 for the experienced clinicians and 0.72 for the inexperienced clinicians. Although experience does not appear to influence forefoot position measurements, of the two evaluation techniques, visual estimation may be the more reliable.
- Foot deviations in weight-bearing.These include pes planus (low inclined subtalar joint axis), pes cavus (high inclined subtalar joint axis), talipes equinus (plantar flexed foot), talipes equinovarus (supinated foot), and hallux valgus.
101
- Degree of foot pronation or supination in non–weight-bearing.The patient lies in the prone position, with the foot over the edge of the table. The clinician holds the foot over the fourth and fifth metatarsal heads with one hand. Both sides of the talus are palpated on the posterior aspect of the foot using the thumb and index finger of the other hand. The clinician then passively dorsiflexes the foot until a resistance is felt. At this point, and while maintaining the dorsiflexed position, the clinician moves the foot back and forth through the arc of supination and pronation. During supination, the talus should be felt to bulge laterally, while during pronation, the talus should be felt to bulge medially. Supination at the subtalar joint occurs in association with 20 degrees of calcaneal inversion, while pronation occurs in association with 10 degrees of calcaneal inversion.
- Degree of toe-out.The normal foot in relaxed standing adopts a slight toe-out position of approximately 12–18 degrees from the sagittal axis of the body (Fick angle).
134
- Forefoot equinus.To assess for forefoot equinus, the clinician stabilizes the rearfoot with one hand and applies pressure on the entire forefoot via pressure across the metatarsal heads, into dorsiflexion. If the plantar declination of the lateral structures cannot be reduced so that the plantar flexed attitude is no longer visible, a positive identification of forefoot equinus can be made.
143
- Presence of a talar bulge.The patient is positioned in standing, and the clinician observes to see whether the talar head bulges excessively on the medial side of the midfoot, indicating excessive subtalar joint pronation in weight-bearing. Adaptive shortening of the gastrocnemius/soleus group is indicated with a prominence of the soleus, particularly on the medial side of the teno-calcaneum.
++
Other areas that should be examined include the following:
++
- Condition of the nails.When examining the nails a systematic approach is used, involving an inspection of the shape, contour, and color of the nails. The clinician should observe for the presence of subungual hematomas, subungual exostosis, onychocryptosis, onychia, onychauxis, onychomycosis, paronychia, tinea pedis, or blisters.
- Toe deformities.Contractions of the capsule of the IP or MTP joints of the toes in association with tendon shortening may produce a series of deformities, ranging from hammer toe to mallet toe to claw toe.
Hammer toeusually involves a flexion contracture of the anterior (plantar) surface of the PIP, with a mild associated extension contracture of the MTP joint.
Mallet toeresults from a flexion deformity of the distal interphalangeal joint (DIP) with plantar contracture. Often a corn or callus is present on the posterior aspect of the affected joint. Corns are similar to calluses but have a central nidus.
Claw toedeformity is a more advanced contracture of capsules and intrinsic musculature, which may also be associated with pes cavus and neurologic or primary muscle pathology to the lumbrical and interosseous muscles. The claw toe results in hyperextension of the MTP joints and flexion of the PIP and DIP joints.
- Functional hallux limitus.Clinically, the presence of functional hallux limitus, an inability of the first MTP joint to extend, can be determined by assessing the ROM available at the first MTP joint, while the first ray is prevented from plantar flexing. The patient is positioned in standing, the feet shoulder-width apart. The patient is asked to actively raise the great toe off the floor, while keeping the remaining toes and foot on the ground. The amount of hallux extension is measured; less than 10 degrees is considered limited.
144This test has been found to have a sensitivity of 0.72 and a specificity of 0.66.
144
- The leg, foot, and ankle are examined for the presence of bruising, swelling, or unusual angulation.Ecchymosis may be present, but the blood usually settles along the medial or lateral aspects of the heel.
16,
125The appearance of bluish-black plaques on the posterior and posterolateral aspect of one or both heels in a young distance runner is found in a condition called
black-dot heel, which results from a shearing stress or a pinching of the heel between the counter and the sole of the shoe at initial contact during running.
++
++
Extracellular fluid pools on the posterior aspect of the foot and around the malleoli after injury or surgery.
101Shortly after a lateral ligament sprain, the swelling is limited to the lateral ankle. Subsequently, the swelling is diffuse, and the localization of tenderness may be difficult. An objective measure of the amount of swelling present can be made using the figure-of-eight method (see
“Special Tests”section).
++
- Callus formation.Calluses provide the clinician with an index as to the degree of shear stresses applied to the foot and clearly outline abnormal weight-bearing areas.
145In adequate amounts calluses provide protection, but in excess they may cause pain. Callus formation under the second and third metatarsal heads could indicate excessive pronation in a flexible foot, or Morton's (interdigital) neuroma (see
Chap. 5) if under the second through fourth. A callus under the fifth and sometimes the fourth metatarsal head may indicate an abnormally rigid foot.
- Any evidence of circulatory impairment or vasomotor changes.Brick-red coloring or cyanosis when the leg is dependent is an indication of vascular impairment, especially if the color changes when the leg is elevated. Vasomotor changes include toenail changes, changes in skin texture, abnormal skin moisture or dryness, and loss of hair on the foot. Vasomotor changes may be associated with complex regional pain syndrome (see
Chap. 5).
- The type of shoes.High-heeled shoes have been associated with adaptive shortening of the gastrocnemius soleus complex, knee pain, and low-back pain.
50,
146They have also been associated with an increased potential for ankle sprains, hallux valgus, bunions, metatarsalgia, interdigital neuromas, peripheral nerve compression, and stress fractures.
50,
146Shoes with a negative heel may result in hyperextension of the knees.
- The weight-bearing and wear patterns of the shoe.The greatest amount of wear on the sole of the shoe should occur beneath the ball of the foot, in the area corresponding to the first, second, and third MTP joints and slight wear to the lateral side of the heel. Old running shoes belonging to patients who excessively pronate tend to display overcompression of the medial arch of the midsole and extensive wear of the lateral regions of the heel counter and medial forefoot. The upper portion of the shoe should demonstrate a transverse crease at the level of the MTP joints. A stiff first MTP joint can produce a crease line that runs obliquely, from forward and medial to backward and lateral.
147The cup at the rear of the shoe, which is formed by the heel counter (
Fig. 21-34), should be vertical and symmetrical with respect to the shoe and should be of a durable enough material to hold the heel in place.
148A medial inclination of the cup, with bulging of the lateral lip of the counter, indicates a pronated foot.
147A lateral bulge of the heel counter indicates a supinated foot. Scuffing of the shoe might indicate tibialis anterior weakness.
80The shape of the last influences the amount of motion that the shoe permits.
149As the degree of curvature in the last increases, more foot mobility is available.
++
The non–weight-bearing component of the examination is initiated by having the patient seated on the edge of the bed, feet dangling. The feet should adopt an inverted and plantar flexed position. A mobile or nonstructural flatfoot will take on a more normal configuration in non–weight-bearing, whereas a fixed or structural flatfoot will maintain its planus state. By placing one hand on the patella and the other hand on the tips of the malleoli, the clinician should note approximately 20–30 degrees of external rotation of the ankle in relation to the knee.
141
++
*The subtalar neutral position refers to the position in which all bones of the subtalar joints and the talocrural joints line up optimally in their open-packed positions—a position of neither pronation nor supination.
++
Careful palpation should be performed around the leg, foot, and ankle to differentiate tenderness of specific ligaments and other structures. Areas of localized swelling and ecchymosis over the ligaments on the medial or lateral aspects of the foot and ankle should be noted.
+++
Posterior Aspect of Foot and Ankle
++
The Achilles tendon is inspected for contour changes such as swelling, erythema, and thickening. Any gaps or nodules in the tendon and specific sites of pain should be carefully examined. Palpable gaps in the tendon accompanied by an inability to rise up on the toes could indicate a rupture of the tendon.
++
At the distal end of the Achilles tendon is the calcaneal tuberosity. The posterior aspect of the calcaneus and surrounding soft tissue is palpated for evidence of exostosis (“pump bump” or Haglund's deformity) and associated swelling (retrocalcaneal bursitis). The inferior medial process of the calcaneus, just distal to the weight-bearing portion of the calcaneus, serves as the attachment of the plantar fascia and is often tender with plantar heel pain.
+++
Anterior and Anteromedial Aspects of the Foot and Ankle
++
While reading the next section, the reader may find it helpful to remove a shoe and sock and self-palpate.
+++
Great Toe and the Phalanges
++
Beginning medially, the clinician locates and palpates the great toe and its two phalanges. The first metatarsal bone is more proximal, the head of which should be palpated for tenderness on the lateral aspect (bunion) and inferior aspect (sesamoiditis).
++
Moving laterally from the phalanges of the great toe, the clinician palpates the phalanges and metatarsal heads of the other four toes.
++
Tenderness of the second metatarsal head could indicate the presence of Freiberg's disease, an osteochondritis of the second metatarsal head (see
Chap. 5). A callus under the second and the third metatarsal head may indicate a fallen metatarsal arch. Palpable tenderness in the region of the third and fourth metatarsal heads could indicate a Morton's neuroma, especially if the characteristic sharp pain between the toes of this condition is relieved by walking barefoot. Tenderness on the lateral aspect of the fifth metatarsal head could indicate the presence of a tailor's bunion.
++
The first cuneiform is located at the proximal end of the first metatarsal (see
Fig. 21-1) and is palpated for tenderness.
++
The navicular is the most prominent bone on the medial aspect of the foot. The navicular tuberosity can be located by moving proximally from the medial aspect of the first cuneiform (see
Fig. 21-1). The talonavicular joint line lies directly proximal to the navicular tuberosity. In addition, the posterior tibialis, which can be made more prominent with resisted plantar flexion, adduction, and supination, can be used as a reference as it inserts on the plantar surface of the navicular (see later). Tenderness of the navicular could indicate the presence of a fracture or osteochondritis of the navicular (Köhler's disease).
+++
Second and Third Cuneiforms
++
These two bones can be palpated by moving laterally from the first cuneiform (see
Fig. 21-1). Tenderness of these bones may indicate a cuneiform fracture.
+++
Posterior (Dorsal) Pedis Pulse
++
The pulse of the posterior (dorsal) pedis artery, a branch of the anterior tibial artery, can be palpated over the talus, cuneiform bones (
Fig. 21-14), between the first and second cuneiforms, or between the first and second metatarsal bones.
++
++
The medial malleolus is palpated for swelling or tenderness. Moving proximally from the anterior aspect of the medial malleolus, the distal aspect of the tibia is palpated. Distal to that is the talus bone. Moving distal from the tibia, the clinician palpates the long extensor tendons, the tibialis anterior, and the superior and inferior extensor retinaculum. The tendon of the tibialis anterior is visible at the level of the medial cuneiform and the base of the first metatarsal bone, especially if the foot is positioned in dorsiflexion and supination.
++
The talus can be located by moving from the distal aspect of the medial malleolus along a line joining the navicular tuberosity. It can be more easily located by everting and inverting the foot. Eversion causes the talar head to become more prominent, while inversion causes the head to be less visible.
++
Distal and inferior to the medial malleolus, a shelf-like bony prominence of the calcaneus, the sustentaculum tali, can be palpated. At the posterior aspect of the sustentaculum tali, the talocalcaneal joint line can be palpated.
+++
Posterior Tibialis Tendon
++
This tendon is palpable at the level of the medial malleolus, especially with the foot held in plantar flexion and supination. Distal and medial to this tendon, the crossing of the flexor digitorum longus and flexor hallucis tendons can be felt.
+++
Posterior Tibial Artery
++
The posterior tibial artery (
Fig. 21-9) can be located posterior to the medial malleolus and anterior to the Achilles tendon.
+++
Medial (Deltoid) Ligament of the Ankle
++
The medial (deltoid) ligament of the ankles is very difficult to differentiate, so they are usually palpated as a group on the medial aspect of the ankle (see
Fig. 21-4).
+++
Anterior and Anterolateral Aspects of the Foot and Ankle
++
The tibial crest is palpated for tenderness, which may indicate the presence of shin splints. Swelling in this area may indicate the presence of anterior compartment syndrome. The muscles of the lateral (peronei) and anterior compartments (tibialis anterior and the long extensors) are palpated here for swelling or tenderness. Swelling or tenderness of these structures usually indicates inflammation.
++
The lateral malleolus is located at the distal aspect of the fibula. Distal to the lateral malleolus is the calcaneus.
+++
Fibularis (Peroneus) Longus
++
The tendon of the fibularis (peroneus) longus runs superficially behind the lateral malleolus. Resisted pronation and plantar flexion of the foot make the tendon more prominent.
+++
Fibularis (Peroneus) Brevis
++
The origin for the fibularis (peroneus) brevis is more distal to the fibularis (peroneus) longus and lies deeper. It becomes superficial on the lateral aspect of the foot, at its insertion at the tuberosity of the fifth metatarsal.
+++
Anterior Talofibular Ligament
++
The ATFL can be palpated two to three finger-breadths anteroinferior to the lateral malleolus (see
Fig. 21-5).
129This is usually the area of most extreme tenderness following an inversion sprain. The anterior aspect of the distal tibiofibular syndesmosis may also be tender following this type of sprain.
+++
Calcaneofibular Ligament
++
The CFL can be palpated one to two finger-breadths inferior to the lateral malleolus (see
Fig. 21-5).
129
+++
Posterior Talofibular Ligament
++
The PTFL can be palpated posteroinferior to the posterior edge of the lateral malleolus (see
Fig. 21-5).
129
++
The sinus tarsi is visible as a concave space between the lateral tendon of the extensor digitorum longus muscle and the anterior aspect of the lateral malleolus. The origin of the EDB is at the level of this tunnel.
++
The cuboid bone can be palpated by moving distally approximately one finger-breadth from the sinus tarsi.
+++
Active and Passive Range of Motion
++
ROM testing is divided into active range of motion (AROM) and passive range of motion (PROM), with overpressure being superimposed at the end of available range to assess the end-feel. AROM tests are used to assess the patient's willingness to move and the presence of movement restriction patterns such as a capsular or noncapsular pattern. The end-feel may provide the clinician with information as to the cause of a motion restriction. The normal ranges of motion and end-feels for the lower leg, ankle, and foot are outlined in
Table 21-7. The open- and close-packed positions and capsular patterns for the ankle and foot are outlined in
Table 21-1.
++
++
General AROM of the foot and ankle in the non–weight-bearing position is assessed first, with painful movements being performed last. The hip and knee joints may also be examined as appropriate. Weight-bearing tests are usually performed after the non–weight-bearing tests.
++
If the symptoms are experienced during the general tests, then passive, active, and resisted tests of specific structures must be performed. If the general tests are negative, there is probably no immediate need to proceed with a more detailed examination, although this may have to be done if no other region appears to be the cause of the problem.
++
Although specific motions at the distal tibiofibular joint cannot be produced voluntarily, the function of this joint can be assessed indirectly by asking the patient to twist around both feet in each direction while bearing weight.
++
The patient lies in the supine position, with the knee slightly flexed and supported by a pillow, while the clinician stands at the foot at the table, facing the patient
.
++
++
++
Active dorsiflexion is initially performed with the knee flexed (
Fig. 21-15). Care must be taken to prevent pronation at the subtalar and oblique midtarsal joint during dorsiflexion. The foot is slightly inverted to lock the longitudinal arch.
141Passive overpressure is applied. With the knee flexed to approximately 90 degrees, the length of the soleus muscle is examined. Passive overpressure into dorsiflexion when the knee is flexed assesses the joint motion, as well as the soleus length. The soleus is implicated if pain is produced in this test, especially if resisted plantar flexion is painful or more painful with the knee flexed than with the knee extended. With the knee flexed, 20 degrees of dorsiflexion past the anatomic position (the foot at 90 degrees to the bones of the leg) is found in the normally flexible person.
150The flexibility of the soleus muscle may also be assessed in standing in able-bodied individuals by asking the patient to perform a deep squat or a lunge.
++
- Squat. If the muscle length is normal, the patient should be able to place the whole foot on the floor, including the heel, while in the full squat position (
Fig. 21-16). If the soleus is short, the heel will not touch the floor.
- Lunge. A standard goniometer is aligned along the lateral aspect of the leg and the floor. The subject steadies themselves and then performs a weight-bearing lunge maneuver (
Fig. 21-17). The angle recorded on the goniometer indicates the range of dorsiflexion under load. If the goniometer is set so that vertical is zero, the arm of the goniometer always aligns to the vertical and the scale rotates to indicate the inclination from the vertical. This angle is then recorded as the ankle dorsiflexion range. This method is considered the most appropriate method of measuring ankle dorsiflexion range, as it reflects the functionally available range for the individual. Bennell et al.
151evaluated the interrater and intrarater reliability of a weight-bearing dorsiflexion lunge using a gravity goniometer in 13 healthy subjects. Two methods were used to assess the dorsiflexion lunge: (1) the distance from the great toe to the wall and (2) the angle between the tibial shaft and the vertical using an inclinometer. The average of three trials was used in data analysis. Intrarater ICCs ranged from 0.97 to 0.98. Interrater ICC values were 0.97 (angle) and 0.99 (distance), indicating excellent reliability for both methods of assessing a DF lunge.
151
++
++
++
++
++
Clinical
Pearl
++
Chronic adaptive shortening of the soleus muscle can be caused by excessive running, a weak posterior tibialis, or a weak quadriceps. Adaptive shortening of the soleus can result in forefoot pronation and a valgus stress at the knee.
++
To assess the length of the gastrocnemius, the patient is placed in the supine position with the knee extended, and the ankle positioned in subtalar neutral. The patient is then asked to dorsiflex the ankle (
Fig. 21-18). Passive overpressure into dorsiflexion is applied. The normal range is 20 degrees. If the gastrocnemius is shortened, dorsiflexion of the ankle will be reduced as the knee is extended, and increased as the knee is flexed. A muscular end-feel should be felt with the knee extended, and a capsular end-feel should be felt with the knee flexed.
++
++
Clinical
Pearl
++
A decrease in the flexibility of the gastrocnemius can result from a number of dysfunctions, including dysfunction of the subtalar joint or transtarsal joint, an ankle sprain, high-heeled footwear, or poor gait/running mechanics.
++
The patient is placed in the supine position, while the clinician stands at the foot of the table, facing the patient
. The patient is asked to plantar flex the ankle (
Fig. 21-19). Plantar flexion of the ankle is approximately 30–50 degrees.
94When tested in weight-bearing with the unilateral heel raise, heel inversion should be seen to occur. Failure of the foot to invert may indicate instability of the foot/ankle, posterior tibialis dysfunction, or adaptive shortening.
152
++
++
+++
Hindfoot Inversion (Supination) and Hindfoot Eversion (Pronation)
++
Both hindfoot inversion (
Fig. 21-20) and hindfoot eversion (
Fig. 21-21) are tested by lining up the longitudinal axis of the leg and vertical axis of the calcaneus. Passive motion of hindfoot inversion (supination) is normally 20 degrees.
94The amount of hindfoot eversion (pronation) is normally 10 degrees.
94
++
++
++
++
The patient is positioned in supine, with the leg being supported by a pillow, while the clinician stands at the foot at the table, facing the patient. Active extension of the great toe is performed and assisted passively without dorsiflexing the first ray. The amount of posterior (dorsal) mobility is usually classified as normal, hypomobile, or hypermobile. Although this method of assessment is common, its reliability and validity have been shown to be poor.
122Extension of the great toe occurs primarily at the MTP joint. Passive extension of the great toe at the MTP joint should demonstrate elevation of the medial longitudinal arch (windlass effect), and external rotation of the tibia.
153Passive MTP joint extension of between 55 and 90 degrees is necessary at terminal stance,
154depending on length of stride, shoe flexibility, and toe-in/toe-out foot placement angle.
139Forty-five degrees of first MTP flexion and 90 degrees of IP joint flexion are considered normal.
141
++
+++
Gastrocnemius and Plantaris Muscles
++
Plantar flexion strength can be tested initially in non–weight-bearing (
Fig. 21-22). If no plantar flexion weakness is apparent in non–weight-bearing, a heel raise test is performed in the functional position, standing with the knee extended and the opposite foot off the floor
. Technically, one heel raise through full ROM, while standing with support on one leg, scores a 3/5 (fair) with manual muscle testing, with five single-limb heel raises scoring a 4/5 (good) and 10 single-limb heel raises scoring a 5/5 (normal). From a functional viewpoint, a wider range of scoring can sometimes prove more useful.
Table 21-8outlines an alternative scoring method.
++
++
++
++
The soleus muscle produces plantar flexion of the ankle joint, regardless of the position of the knee. To determine the individual functioning of the soleus as a plantar flexor, the knee is flexed to minimize the effect of the gastrocnemius muscle. The soleus is tested in a similar manner to that of the gastrocnemius, except that the patient performs the unilateral heel raise with some degree of knee flexion. Ability to perform 10–15 raises in this fashion is considered normal, five to nine raises graded as fair, one to four raises graded as poor, and zero repetitions graded as nonfunctional. Alternatively, the strength of the soleus can be tested with the patient in prone
.
++
+++
Tibialis Anterior Muscle
++
The tibialis anterior muscle produces the motion of dorsiflexion and inversion. The knee must remain flexed during the test to allow complete dorsiflexion. The patient's foot is positioned in dorsiflexion and inversion. The leg is stabilized, and resistance is applied to the medial posterior aspect of the forefoot into plantar flexion and eversion (
Fig. 21-23)
.
++
++
+++
Tibialis Posterior Muscle
++
The tibialis posterior muscle produces the motion of inversion in a plantar flexed position. The leg is stabilized in the anatomic position, with the ankle in slight plantar flexion. Resistance is applied to the medial border of the forefoot into eversion and dorsiflexion (
Fig. 21-24)
.
++
++
+++
Fibularis (Peroneus) Longus, Fibularis (Peroneus) Brevis, and Fibularis (Peroneus) Tertius Muscles
++
The lateral compartment muscles and the fibularis (peroneus) tertius muscle
produce the motion of eversion. The patient is positioned in supine, with the foot over the edge of the table and the ankle in the anatomic position. Resistance is applied to the lateral border of the forefoot (
Fig. 21-25).
++
++
++
++
Grades for the toes differ from the standard format because gravity is not considered a factor.
++
- 0: No contraction.
- Trace or 1: Muscle contraction is palpated, but no movement occurs.
- Poor or 2: Subject can partially complete the ROM.
- Fair or 3: Subject can complete the test range.
- Good or 4: Subject can complete the test range but is able to take less resistance on the test side than on the opposite side.
- N or 5: Subject can complete the test range and take maximal resistance on the test side as compared with the normal side.
+++
Flexor Hallucis Brevis and Longus Muscles
++
The flexor hallucis brevis
and FHL muscles
produce MTP joint flexion and IP joint flexion. The foot is maintained in midposition. The first metatarsal is stabilized, and resistance is applied beneath the proximal and distal phalanx of the great toe into toe extension.
+++
Flexor Digitorum Brevis and Longus Muscles
++
The flexor digitorum longus and brevis muscles produce IP joint flexion. The motion is tested with the foot in the anatomic position. If the gastrocnemius muscle is shortened, preventing the ankle from assuming the anatomic position, the knee is flexed. The toes may be tested simultaneously.
++
The foot is held in the midposition and the metatarsals are stabilized. Resistance is applied beneath the distal and proximal phalanges
.
+++
Extensor Hallucis Longus and Brevis Muscles
++
The extensor hallucis longus and the EHB muscles produce the motion of extension of the IP and MTP joints. The foot is maintained in midposition. Resistance is applied to the posterior aspect of both phalanges of the first digit into toe flexion.
++
++
+++
Extensor Digitorum Longus and Brevis Muscles
++
The extensor digitorum longus and the EDB muscles produce the motion of extension at the MTP and IP joints of the lateral four digits from a flexed position
. Resistance is applied to the posterior (dorsal) surface of the proximal and distal phalanges into toe flexion.
+++
Intrinsic Muscles of the Foot
++
The intrinsic muscles of the foot are tested with the patient in either the supine or the sitting position. Most subjects are unable to voluntarily contract the intrinsic muscles of the foot individually.
+++
Abductor Hallucis Muscle
++
The metatarsals are stabilized, and resistance is applied medially to the distal end of the first phalanx
.
++
++
+++
Adductor Hallucis Muscle
++
The metatarsals are stabilized, and resistance is applied to the lateral side of the proximal phalanx of the first digit
.
++
The lateral four metatarsals are stabilized, and resistance is applied to the middle and distal phalanges of the lateral four digits.
+++
Plantar Interossei Muscles
++
The lateral three metatarsals are stabilized, and resistance is applied to the middle and distal phalanges.
+++
Posterior (Dorsal) Interossei and Abductor Digiti Minimi Muscles
++
The metatarsals are stabilized and resistance is applied:
++
- Posterior (Dorsal) interossei.Applied to the middle and distal phalanges.
- Abductor digiti minimi.Applied to the lateral side of the proximal phalanx of the fifth digit.
+++
The Ankle Joint Functional Assessment Tool
++
The Ankle Joint Functional Assessment Tool (AJFAT)
155is composed of 12 questions rating the ankle's functional ability (
Table 21-9). The AJFAT questions are based on assessment tools previously used for evaluating the functional level of the knee.
156–
158
++
+++
The Foot Function Index
++
The Foot Function Index (FFI)
159is a functional outcome measure that consists of three subsections: pain, disability (
Table 21-9), and activity. A study by Budiman-Mak et al.
159examined test–retest reliability (intraclass correlation coefficient, ICC = 0.87), internal consistency (0.96), and construct and criterion validity of the questionnaire.
++
In weight-bearing, with the feet fixed, the patient should be asked to perform the following while the clinician notes any reproduction of pain or abnormal motion:
++
- Weight-bearing on the foot borders.The patient is asked to bear weight on the medial borders of the feet while keeping the knees extended. The patient is then asked to bear weight on the lateral borders of the feet while maintaining the knee extension.
- Heel raising.In addition to being a general screening test, heel raising also assesses the ability of the medial arch to increase and produce a supinated/inverted arch. Under normal conditions, the tibialis posterior tendon inverts the hind foot as the patient raises their heel. With poor or absent tibialis posterior function, the patient just rolls on the outside of the foot and demonstrates a decreased ability to unilaterally raise the heel.
- Twisting of the lower leg.Twisting tests the ability of the foot to supinate on the ipsilateral side, and its ability to pronate on the contralateral side.
++
The results of these tests may not be helpful in forming an actionable diagnosis, but they may be the only way to reproduce the patient's symptoms and will therefore be of use in the formation of a diagnosis.
+++
Single-Leg Stance Test
++
Chronic ankle instability is a frequent consequence after lateral ankle sprain. The inability to maintain quiet stance during single standing has consistently been shown to be associated with ankle instability.
160
+++
Star Excursion Balance Test
++
The star excursion balance test (SEBT) is a clinical test purported to detect functional performance deficits associated with lower extremity pathology in otherwise healthy individuals.
160The SEBT consists of a series of lower extremity reaching tasks in directions that challenge subjects' postural control, strength, ROM, and proprioceptive abilities. The farther a subject can reach with one leg while balancing on the opposite leg, the better the functional performance they are deemed to have. The subject stands barefoot at the center of the grid with eight lines extending in a star pattern at 45-degree increments from the center of the grid.
161Subjects are asked to maintain a single-leg stance while reaching with the contralateral leg to touch as far as possible along the chosen line, and then to return to a bilateral stance while maintaining their equilibrium.
161The test is then repeated using the other leg.
+++
Passive Articular Mobility
++
Passive articular mobility tests assess the accessory motions available between the joint surfaces. These same techniques can be used to increase joint play using the varying grades of mobilization (see “Joint Mobilizations” in
Techniques to Increase Joint Mobility). As with any other joint complex, the quality and quantity of joint motion must be assessed to determine the level of joint involvement. The joint play movement tests must be performed on both sides so that comparisons can be made. The patient is positioned in lying.
+++
Distal Tibiofibular Joint
++
Although the glide at this joint would appear to be negligible, Mulligan has proposed that some ankle inversion injuries may be the result of a distal fibular positional fault. One study
162examined the distal tibiofibular posterior glide of the ankles of 25 subjects for joint excursion. Of the 50 ankles, six had been diagnosed with an acute ankle sprain. Two ankles exhibited an increase in excursion, both of which of had been sprained suggesting that in approximately one-third of diagnosed ankle sprains, the true cause might be an anterior positional fault of the distal fibular on the tibia.
++
To perform the mobility tests of this joint, the patient is placed in supine and the clinician grips the tibia and fibula using one hand for each (
Fig. 21-26). While one hand prevents downward motion of the medial malleolus, the other hand glides the fibula anteriorly and posteriorly in relation to the tibia. To assess the motion of the tibial component, one hand stabilizes the fibula and lateral malleolus, while the other hand glides the tibia anteriorly and posteriorly in relation to the fibula. Theoretically, a superior and inferior glide can be assessed at this joint, but it is unclear whether information provided by such testing would help the clinician in making a diagnosis or designing a plan of care.
++
+++
Long-Axis Distraction of Ankle and Foot
++
The clinician stabilizes the proximal segment and applies traction to the distal segment. This test is performed at the talocrural joint (
Fig. 21-27), the subtalar joint (
Fig. 21-28), the MTP joints (
Fig 21-29), and the IP joints (
Fig 21-30).
++
++
++
++
+++
Anterior–Posterior Glide
++
To test the anterior glide of the talocrural joint, the clinician stabilizes the tibia and fibula and draws the talus and foot forward together (
Fig. 21-31). Pushing the talus and foot together in a posterior direction on the tibia and fibula (
Fig. 21-32) tests the posterior movement. The anterior glide of the talus assesses the joint's ability to move into plantar flexion, whereas the posterior glide of the talus assesses the joint's ability to move into dorsiflexion.
++
++
++
The anterior–posterior glides can also be applied to the midtarsal (
Fig. 21-33), intertarsal (
Figs. 21-34and
21-35), MTP (
Fig. 21-36), and IP (
Fig. 21-37) joints.
++
++
++
++
++
+++
Calcaneal Inversion–Eversion (Subtalar)
++
Subtalar joint motion is extremely important to normal foot function. A loss of eversion causes weight-bearing to occur along the lateral side of the ankle joint. The patient lies in the prone position with the knee slightly flexed and supported by a pillow, while the clinician stands at the foot of the table, facing the patient. The clinician grasps the calcaneus in one hand, while the other hand locks the talus. The calcaneus is passively inverted (varus) and everted (valgus) on the talus (
Fig. 21-38). The amount and quality of the motions as compared with the other foot are noted. Although some differences exist, generally calcaneal eversion will measure 5–10 degrees, while calcaneal inversion will measure approximately 20–30 degrees.
20,
94,
141A similar technique can be used to assess medial and lateral gapping at this joint. Medial gapping is associated with subtalar joint eversion, whereas lateral gapping is associated with subtalar joint inversion.
++
+++
Midtarsal Joint Motion
++
The rotational movements of the midtarsal joint, which allow the forefoot to twist on the rearfoot, can be observed in the non–weight-bearing position. The clinician stabilizes the calcaneus with one hand, while inverting and everting the foot at the midtarsal joint with the other hand (
Fig. 21-39).
85
++
+++
First MTP Joint (First Ray) Motion
++
The patient lies in supine position, with the clinician at the foot of the table facing away from the patient. The clinician grasps and locks the first MTP joint, before grasping the great toe and moving it into extension and flexion (posteriorly (dorsally) and anteriorly (ventrally), respectively) (
Fig. 21-40). Long-axis distraction and compression can also be applied (
Fig. 21-41) to assess capsular and articular integrity, respectively.
++
++
++
Limited range may result from a combination of biomechanical factors such as excessive pronation or joint glide restriction.
163To examine the conjunct rotation of the metatarsals, the clinician locks the second metatarsal to evaluate the first and locks the third to evaluate the second. The quantity and quality of motion is noted and compared with the other side.
++
Special tests are merely confirmatory tests and should not be used alone to form a diagnosis. Selection for their use is at the discretion of the clinician and is based on a complete patient history. The results from these tests are used in conjunction with the other clinical findings. To assure accuracy with these tests, both sides should be tested for comparison.
+++
Assessing Ankle Girth
++
Physical therapists need a reliable method by which to measure ankle girth following injury so that there can be clinical quantification of the volume of edema. Two methods are described:
++
- Figure-of-eight tape method.The patient lies in the supine position or seated. The clinician places a tape measure midway between the tibialis anterior tendon and lateral malleolus. The tape is then drawn medially and is placed just distal to the navicular tuberosity. The tape is then pulled across the arch and just proximal to the fifth metatarsal. The tape is then pulled across the tibialis anterior tendon and around the ankle to a point just distal to the medial malleolus, before being finally pulled across the Achilles tendon and placed just distal to the lateral malleolus and across the start of the tape. Tatro-Adams et al.
164reported the ankle figure-of-eight method to be a reliable tool for measuring ankle girth. (
Fig. 21-42)
- Volumetry method.A volumeter is filled with water, and the patient's foot is placed into the volumeter with toe tips touching the front wall. The amount of water displaced is measured.
++
++
Petersen et al. performed a study to determine the interrater and intrarater reliability of water volumetry and the figure-of-eight method on subjects with ankle joint swelling and found high interrater reliability for both the water volumetry (ICC = 0.99) and the figure-of-eight methods (ICC = 0.98). In addition, intrarater reliability was high for both (ICCs = 0.98–0.99). The authors concluded that both methods are reliable measures of ankle swelling, although they recommended the figure-of-eight method because of its ease of use, time efficiency, and cost effectiveness. However, water volumetry may be more appropriate when measuring diffuse lower extremity swelling.
+++
Ligamentous Stress Tests
++
The examination of the ligamentous structures in the ankle and foot is essential, not only because of their vast array but also because of the amount of stability that they provide. Positive results for the ligamentous stability tests include excessive movement, as compared with the same test on the uninvolved extremity, pain (depending on the severity), or apprehension.
++
The patient lies in supine position with their foot over the end of the bed. One hand is used to stabilize the distal leg on the bed, while the clinician uses the other hand to grasp the heel and move the calcaneus laterally (see
Fig. 21-43).
165A clunk can be felt as the talus hits the tibia and fibula, if there has been significant mortise widening.
129Beumer et al.
166found this test to have a sensitivity of 46%.
++
+++
Kleiger (External Rotation) Test
++
The Kleiger (external rotation) test
17,
137,
167is a general test to implicate the syndesmosis if pain is produced over the anterior or posterior tibiofibular ligaments and the interosseous membrane, but can also be used to assess the integrity of the medial (deltoid) ligament of the ankle complex.
168,
169If this test is positive, further testing is necessary to determine the source of the symptoms.
++
The patient sits with their legs dangling over the end of the bed, the knee flexed to approximately 90 degrees, and the foot relaxed. The clinician stabilizes the lower leg with one hand and, using the other hand, grasps the foot and externally rotates it (
Fig. 21-44). Pain experienced at the anterolateral aspect of the distal tibiofibular syndesmosis is a positive sign for syndesmosis injury,
170whereas pain on the medial aspect of the ankle and/or displacement of the talus from the medial malleolus (depending on severity) with the ankle positioned in plantar flexion may indicate a tear of the medial (deltoid) ligament of the ankle. Alonso et al.
170reported data that indicate that the external rotation stress test is more reliable than the squeeze test and the dorsiflexion–compression test for diagnosing syndesmosis injuries.
++
+++
The Point Test
170,
171
++
The point test, also referred to as the palpation test, is used to impose pressure on the anterior distal tibiofibular syndesmosis. The patient can be positioned in supine or sitting. The clinician applies pressure directly over the anterior aspect of the distal tibiofibular syndesmosis (
Fig. 21-45). Pressure is applied gradually, and a positive test involves a report of pain by the patient.
++
+++
The Dorsiflexion Maneuver
171,
172
++
The dorsiflexion maneuver is performed to force the wider anterior portion of the talar dome into the ankle mortise, thereby inducing separation of the distal fibula and tibia. The patient sits at the edge of the examination table, and the clinician stabilizes the patient's leg with one hand, while the clinician's other hand passively moves the foot into dorsiflexion (
Fig. 21-46). Pain experienced at the distal tibiofibular syndesmosis is a positive test result. A variation of the dorsiflexion maneuver exists, known as the dorsiflexion compression test,
170which involves patients moving their ankle joints into extreme dorsiflexion in bilateral weight-bearing. Patients are asked to note the pain they experience in this position and the position of the tibia is noted with an inclinometer. The patient then assumes an upright position, and the clinician applies medial–lateral compression with two hands on the malleoli of the injured leg. The clinician maintains the medial–lateral compression, as the patient is asked to move the ankles into dorsiflexion again and to report if the end-range pain has changed compared with the previous movement. A positive test result is either a reported reduction in the end-range pain or an increase in dorsiflexion ROM.
++
+++
Fibula Translation Test
++
The patient is placed in the side-lying position with the tested leg uppermost. The clinician applies an anterior and posterior force on the fibula at the level of the syndesmosis (
Fig. 21-47). A positive test is pain during translation and more displacement of the fibula than the compared side. Although a cadaver study by Beumer et al.
166found this test to have a sensitivity of 82% and specificity of 88% (LR+ 6.8; LR− 0.2), the study only found increased translation when all ligaments were removed in the cadavers.
++
+++
The One-Legged Hop Test
171,
173
++
The one-legged hop test is performed by having the patient stand on the injured leg and hop continuously. Nussbaum et al.
173reported that patients with syndesmosis injuries could not complete 10 repetitions of unilateral hopping without significant pain. However, the one-legged hop test should be used with caution, and perhaps only if the other special tests are negative, because performing this test may impose further separation of the distal tibiofibular syndesmosis.
171
+++
The Crossed-Leg Test
171,
174
++
The crossed-leg test mimics the squeeze test (see later) and attempts to induce separation of the distal syndesmosis. The patient sits in a chair, with the injured leg resting across the knee of the uninjured leg. The resting point should be at approximately mid-calf. The clinician then applies a gentle force on the medial aspect of the knee of the test leg (
Fig. 21-48). Pain experienced in the area of the distal syndesmosis suggests the presence of injury. This test may not be useful for patients with knee or hip pathology because it may be difficult for them to assume the test position. Reliability and validity data for this test are not yet available.
++
+++
The Heel-Thump Test
171,
175
++
The heel-thump test is performed to force the talus into the mortise, in an attempt to impose separation of the distal syndesmosis. The patient lies at the edge of the examination table, with the ankle resting in plantar flexion. The clinician holds the patient's leg with one hand and with the other hand applies a gentle but firm thump on the heel with their fist (
Fig. 21-49). This force is applied at the center of the heel and in line with the long axis of the tibia. Pain experienced at the distal tibiofibular syndesmosis suggests the presence of injury. Although the heel thump test has been recommended to help differentiate between a syndesmotic sprain and a lateral ankle sprain, this test may not be specific for a syndesmotic sprain as the test has also been recommended to assess the possible presence of tibial stress fractures.
176Reliability and validity data for this test are not yet available.
++
+++
Posterior Drawer Test
++
The posterior drawer test can also be used to test for the presence of instability at the distal tibiofibular joint. The patient is supine. The hip and knee are flexed to provide as much dorsiflexion of the ankle as possible. This drives the wide anterior part of the talus back into the mortise. An anterior stabilizing force is then applied to the cruris, and the foot and talus are translated posteriorly (
Fig. 21-50). If the distal tibiofibular joint is stable, there will be no drawer available, but if there is instability, there will be a drawer.
++
+++
Squeeze (Distal Tibiofibular Compression) Test
++
In the squeeze test, the patient lies in supine or side-lying position and the clinician squeezes the upper to middle third of the leg at a point approximately 6–8 inches below the knee (
Fig. 21-51).
137Pain felt in the distal third of the leg may indicate a compromised syndesmosis, if the presence of a tibia and/or fibula fracture, calf contusion, or compartment syndrome has been ruled out.
126,
168
++
++
The lateral collateral ligaments of the ankle resist inversion. An additional function is to prevent excessive varus movement, especially during plantar flexion. In extreme plantar flexion, the mortise no longer stabilizes the broader anterior part of the talus, and varus movement of the ankle is then possible.
++
The patient lies in the supine position. The lower leg is stabilized using a lumbrical grip, while the other hand grasps the foot and calcaneus. The clinician applies a medially directed force in an attempt to adduct the calcaneus, thereby gapping the lateral side of the ankle (
Fig. 21-52). Pain on the lateral aspect of the ankle with this test, and/or displacement (depending on severity), may indicate a sprain of the ligament. Hertel et al.
177found this test to have a sensitivity of 78% and a specificity of 75% (LR+ 3.1; LR− 0.29).
++
++
This test is used to determine whether the CFL is torn. The patient lies in a supine or side-lying position with the foot relaxed and the knee flexed. The clinician places the foot in the anatomical (90 degrees) position to bring the CFL perpendicular to the long axis of the talar. The talus is then tilted from side to side into adduction and abduction (
Fig. 21-53). Adduction tests the CFL and, to some degree, the ATFL, whereas abduction stresses the deltoid ligament. No diagnostic accuracy studies have been performed to determine the sensitivity and specificity of this test.