Foot and Ankle Assessment-Investigations and Tests

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Introduction[edit | edit source]

Taking a patient's history and completing an objective assessment is a gold standard for the foot and ankle assessment. The purpose of using special investigations and tests is to confirm the clinical diagnosis.

"We can't treat the patient just on x-rays or just on MRI findings. These things have to come together (with the objective assessment)". Helene Simpson

Techniques[edit | edit source]

Investigations[edit | edit source]

X-Rays[edit | edit source]

An X-ray can help to investigate bone, air and soft tissue injury:

  • Assists with the diagnosis of the Achilles tendon rupture based on the presence of five radiological X-ray signs[1]. Lateral ankle X-ray is reliable to support diagnosis of the Achilles tendon rupture. [1]
  • May not be sufficient to identify malleolar fractures. [2]
  • Syndesmosis injury is often overlooked on X-ray. [2]
  • Assists with a diagnosis of the ankle fracture. AP, lateral and mortise views are recommended. Mortise view refers to the AP view with 15° internal rotation. If possible, the X-ray should be done with the patient in a standing position. When ankle fracture was ruled out, but there is no progress in patient's rehabilitation and the patient continues to complain of pain: X-ray should be repeated within 6 weeks to rule out osteochondral lesion or hairline fracture.
  • Malalignment of the second tarsometatarsal joint is a common feature in Lisfranc fracture-dislocations. The X-ray's AP view shows lateral displacement of the second metatarsal base and diastasis over 2 mm between the first and second metatarsal bases. It is recommended that the x-ray of both feet is taken in a weight-bearing position on one foot and compared with the contralateral side. [3]
  • Hindfoot malalignment causes foot and ankle disability and the assessment of X-ray results of hindfoot alignment is important. The recommendation for a clinical and research purpose is to use the long axial hindfoot view in a bilateral stance. [4]
  • The fracture of the sesamoid bone is shown on the X-ray image as a rough space between the bone pieces. A smooth separation of two bones visible on the X-ray is a normal sign in about 10 % of the population.
  • The ligament injuries were confirmed on the first X-ray diagnosis in only 50% of patients. This number increased to 66% of patients during the second X-ray when the diagnosis was confirmed. [5]

Diagnostic Ultrasound[edit | edit source]

Diagnostic ultrasound allows for dynamic examination of the foot and ankle pathology. It is a non-invasive, economical and readily available tool that is recommended as a first-line diagnostic modality to rule out torn ligaments, tendonitis, tenosynovitis, plantar fascia, soft tissue masses or Morton's neuroma. [6] [7]

Diagnostic ultrasound was found to be an effective diagnostic tool for the following foot and ankle injuries:

  • Fifth metatarsal, lateral and medial malleolus fractures in patients with foot and/or ankle sprains. Note: sensitivity for navicular fractures is low.[8]
  • To rule out torn vs sprained anterior talofibular ligament and calcaneofibular ligament.[9][10][11]
  • Ankle pain related to lateral ligament pathologies, tendinous pathologies, and joint effusion. Note: limited use in a suspected posterior talofibular ligament injury.[12]
  • Achilles tendon injuries.[13]
  • Statistically significant for diagnosing a syndesmosis injury at ≥6.0 mm of tibiofibular clear space widening. [14]
  • For foot and ankle fractures should be considered as a primary modality.[15]

MRI[edit | edit source]

MRI is the investigation of choice in chronic foot pain. Based on the available research MRI is a modality used in various foot and ankle soft tissue disorders due to its high resolution and contrast, but the interpretation of the results is key in proper diagnosis. MRI is:

  • A gold standard for the diagnosis of Achilles tendon rupture.[1]
  • Recommended in patients with ongoing pain at rest following ankle sprains as the clinical examination is insufficient when syndesmotic injury is suspected.[16]
  • A preoperative decisional tool for ATFL repair in case of chronic lateral ankle instability.[17][18]
  • A routine inspection method of the ankle ligament in the case of the ankle ligament injury. A weight-bearing MRI is recommended because the transverse position and the coronal position can show the full length of the ligament.[5]
  • A valuable tool in the diagnosis of the post-traumatic ankle pain as it has 96% accuracy in detecting tendon injury. [19]
  • Advantageous for assessing tendons, ligaments, nerves, and fascia and for recognising occult bone injuries. [19]
  • An investigation of choice for metatarsalgia due to its high resolution demonstrating sesamoid anatomy, plantar glenosesamoid apparatus, and the adjoining flexor, abductor, and adductor tendons. [20]

CT Scan[edit | edit source]

In the foot and ankle injury the use of CT scan is a proposed modality to assess passive subsystem. It is a quick tool and it can be used during the surgery. The recommendations for using a CT scan are for:

  • Assessing fractures in the ankle joint area. [2]
  • Evaluation of syndesmostic reduction. A weight-bearing CT scan is proven to be more reliable.[21]

Special Tests[edit | edit source]

Ottawa Foot and Ankle Rules[edit | edit source]

Ottawa Ankle Rule is 99% sensitive to detect ankle fractures, but the test has some limitations:

  • High accuracy is true for the first 10 days post injury
  • High sensitivity is detected for patients younger than 55- years- old

Detailed information can be found in Ottawa Ankle Rule page.

Knee To Wall Test[edit | edit source]

Always perfumed in ankle and foot injury

Anterior Drawer Test[edit | edit source]

Always perfumed in ankle and foot injury

Squeeze Test[edit | edit source]

Syndesmosis injury

External Rotation Test[edit | edit source]

Syndesmosic injury

Cotton Test[edit | edit source]

Coleman Block Test[edit | edit source]

Other special tests include:

Balance tests[edit | edit source]

BESS test[edit | edit source]

Star Excursion Balance Test (SEBT)[edit | edit source]

Return to Sport Tests[edit | edit source]

Jump test

Jump to stability test

Jump high test

Shuttle run

Questionnaires[edit | edit source]

FAAM

FADI

Visa-A

CRPS

Additional details can be found on the Foot and Ankle Assessment page.

The following video demonstrates the application and interpretation of special tests for foot and ankle assessment:

[22]


References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Bowen L, Evans R, Bodger O, Howard J, Anne-Marie H. Investigating the Validity of Soft Tissue Signs on Lateral Ankle X-Ray to Aid Diagnosis of Achilles Tendon Rupture in the Emergency Department. Int J Foot Ankle. 2019;3:033.
  2. ↑ 2.0 2.1 2.2 Szymański T, Zdanowicz U. Comparison of routine computed tomography and plain X-ray imaging for malleolar fractures—How much do we miss?. Foot and Ankle Surgery. 2021 Apr 1.
  3. ↑ Stavlas P, Roberts CS, Xypnitos FN, Giannoudis PV. The role of reduction and internal fixation of Lisfranc fracture-dislocations: a systematic review of the literature. Int Orthop. 2010 Dec;34(8):1083-91.
  4. ↑ ML Reilingh, L Beimers, GJM Tuijthof, SAS Stufkens, M Maas, et al. Measuring hindfoot alignment radiographically: the long axial view is more reliable than the hindfoot alignment view. Skeletal radiology 2010;39 (11): 1103-1108.
  5. ↑ 5.0 5.1 Qi H, Feng Y. Analysis of the clinical value of weight-bearing magnetic resonance diagnosis of ankle ligament sports injury. IEEE Access. 2020 Mar 30;8:62725-37.
  6. ↑ Khoury V, Guillin R, Dhanju J, Cardinal É. Ultrasound of ankle and foot: overuse and sports injuries. Seminars in musculoskeletal radiology 2007 Jun; 11(02): 149-161.
  7. ↑ Rawool NM, Nazarian LN. Ultrasound of the ankle and foot. In: Seminars in Ultrasound, CT and MRI 2000 Jun; 21(3): 275-284.
  8. ↑ Atilla OD, Yesilaras M, Kilic TY, Tur FC, Reisoglu A, Sever M, Aksay E. The accuracy of bedside ultrasonography as a diagnostic tool for fractures in the ankle and foot. Academic Emergency Medicine. 2014 Sep;21(9):1058-61.
  9. ↑ Hosseinian SH, Aminzadeh B, Rezaeian A, Jarahi L, Naeini AK, Jangjui P. Diagnostic Value of Ultrasound in Ankle Sprain. The Journal of Foot and Ankle Surgery. 2021 Aug 20.
  10. ↑ Esmailian M, Ataie M, Ahmadi O, Rastegar S, Adibi A. Sensitivity and specificity of ultrasound in the diagnosis of a traumatic ankle injury. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences. 2021;26.
  11. ↑ Gribble PA. Evaluating and differentiating ankle instability. Journal of athletic training. 2019 Jun;54(6):617-27.
  12. ↑ Singh K, Thukral CL, Gupta K, Singh A. Comparison of high-resolution ultrasonography with clinical findings in patients with ankle pain. J Ultrason. 2018;18:316–24.
  13. ↑ Lee SH, Yun SJ. The feasibility of point-of-care ankle ultrasound examination in patients with a recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging. Injury. 2017;48:2323–8.
  14. ↑ Fisher CL, Rabbani T, Johnson K, Reeves R, Wood A. Diagnostic capability of dynamic ultrasound evaluation of supination-external rotation ankle injuries: a cadaveric study. BMC musculoskeletal disorders. 2019 Dec;20(1):1-7.
  15. ↑ Wu J, Wang Y, Wang Z. The diagnostic accuracy of ultrasound in the detection of foot and ankle fractures: a systematic review and meta-analysis. Medical Ultrasonography. 2021 May 20;23(2):203-12.
  16. ↑ Grossterlinden LG, Hartel M, Yamamura J, Schoennagel B, Burger N, Krause M, et al. Isolated syndesmotic injuries in acute ankle sprains: diagnostic significance of clinical examination and MRI. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1180–6.
  17. ↑ Morvan A, Klouche S, Thes A, Hardy P, Bauer T. Reliability and validity of preoperative MRI for surgical decision making in chronic lateral ankle instability. European Journal of Orthopaedic Surgery & Traumatology. 2018 May;28(4):713-9.
  18. ↑ Cao S, Wang C, Ma X, Wang X, Huang J, Zhang C, Wang K. Reliability and validity of different ankle MRI scanning planes for the anterior talofibular ligament injury diagnosis: a cadaveric study. Journal of orthopaedic surgery and research. 2019 Dec;14(1):1-8.
  19. ↑ 19.0 19.1 Elgohary MM, Abdul Rahim SA, Ibrahim TA. Role of MRI in Evaluation of Traumatic Ankle Injuries. The Egyptian Journal of Hospital Medicine. 2017 Oct 1;69(3):2016-24.
  20. ↑ Batta NS, Gupta A, Batra V. Imaging Findings of Bilateral Medial Hallucal Sesamoid Insufficiency in a Marathon Runner. Indian J Musculoskelet Radiol 2019;1(1):57-60.
  21. ↑ Abdelaziz ME, Hagemeijer N, Guss D, El-Hawary A, El-Mowafi H, DiGiovanni CW. Evaluation of syndesmosis reduction on CT scan. Foot & ankle international. 2019 Sep;40(9):1087-93.
  22. ↑ Kris Porter DPT. Movement Screen of the Lower Quarter. Available from: https://www.youtube.com/watch?v=l6gkHR02rIM [last accessed 30/6/2021]


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