Foot and Ankle Assessment-Investigations and Tests
Original Editor - Ewa Jaraczewska
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Introduction[edit | edit source]
Taking a patient's history and completing an objective assessment is the 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
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. A lateral ankle X-ray is reliable to support the diagnosis of the Achilles tendon rupture.
- May not be sufficient to identify malleolar fractures.
- Syndesmosis injury is often overlooked on X-rays.
- Assists with a diagnosis of an 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. The patient is advised to stand even with little weight (even 99 % on the un-injured foot). There are exceptions when there is an obvious dislocation / open fracture. When ankle fracture is ruled out, but there is no progress in patient's rehabilitation and the patient continues to complain of pain, an 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 an X-ray is taken of each foot in a weight-bearing position, so that the injured side can be compared to the contralateral side.
- Hindfoot malalignment causes foot and ankle disability. 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. 
- The fracture of the sesamoid bone is shown on X-ray as a rough space between the bone pieces. A smooth separation of two bones visible on X-ray is a normal sign in about 10 % of the population.
- Ligament injuries were confirmed on a first diagnostic X-ray in only 50% of patients. This number increased to 66% of patients during the second X-ray when the diagnosis was confirmed.
Diagnostic Ultrasound[edit | edit source]
Diagnostic ultrasound allows for dynamic examination of 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.  
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.
- To rule out torn vs sprained anterior talofibular ligament and calcaneofibular ligament.
- Ankle pain related to lateral ligament pathologies, tendinous pathologies, and joint effusion. Note: limited use in a suspected posterior talofibular ligament injury.
- Achilles tendon injuries.
- Statistically significant for diagnosing a syndesmosis injury at ≥6.0 mm of tibiofibular clear space widening.
- Should be considered as a primary modality for foot and ankle fractures. 
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 modality is expensive and not always easily accessible in many countries and it should be the orthopaedic surgeon who requests this particular investigation.
"It's fantastic to have a look at your soft tissue. If we're looking for cartilage injuries, it's sensitive, but it might overestimate the extent of the injury". Helene Simpson
- A gold standard for the diagnosis of Achilles tendon rupture.
- Recommended in patients with ongoing pain at rest following ankle sprains as the clinical examination is insufficient when a syndesmotic injury is suspected.
- A preoperative decisional tool for the anterior talofibular ligament repair in case of chronic lateral ankle instability.
- 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.
- A valuable tool in the diagnosis of post-traumatic ankle pain as it has 96% accuracy in detecting tendon injury.
- Advantageous for assessing tendons, ligaments, nerves, and fascia and for recognising occult bone injuries.
- 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.
CT Scan[edit | edit source]
In the foot and ankle injury, the use of CT scan is proposed as a modality to assess the passive subsystem. It is a quick tool and it can be used during surgery. A weight-bearing computed tomography (WBCT) allows for the measurement and analysis of foot and ankle bone position and its deformities. The recommendations for using a CT scan and WBCT are:
- To assess fractures in the ankle joint area.
- To evaluate a syndesmotic reduction. A weight-bearing CT (WBCT) scan is proven to be more reliable.
- To predict syndesmotic injuries in ankle fractures.
- To characterise hindfoot alignment in order to determine the amount of translation needed for a neutral alignment during a calcaneal osteotomy.
- To diagnose subtle Lisfranc instability.
Special Tests[edit | edit source]
Ottawa Foot and Ankle Rules[edit | edit source]
Ottawa Ankle Rule determine the need for radiographs in acute ankle sprains. It is an accurate instrument for excluding fractures of the ankle and mid-foot, 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 on the Ottawa Ankle Rule page.
Knee To Wall Test[edit | edit source]
- Provides a means of assessing gastrocnemius length
- Recommended for a foot dorsiflexion range of motion assessment when conditions such as foot overpronation or plantar fasciitis are being examined
- Starting position for testing: toes against the wall and gradually moving away. The distance between the toes and the wall is measured with the ruler and is recorded for comparison and future reassessment.
Detailed information can be found on the Knee To Wall Test page.
Anterior Drawer Test[edit | edit source]
- Always performed in when assessing an ankle and foot injury
- Always compare with the "normal" side
- During the test remember to "hug" the calcaneus, because it moves the talus.
- See more here Anterior Drawer of the Ankle
Squeeze Test[edit | edit source]
- Performed to detect syndesmotic injury
- Attempting to reproduce pain symptoms
Detailed information can be found on the Squeeze Test page.
External Rotation Test[edit | edit source]
- Performed to detect a syndesmotic injury
- Attempting to reproduce a mechanism of the injury
Detailed information can be found on the External Rotation Test page.
Cotton Test[edit | edit source]
- Performed to detect syndesmotic instability
- It is a manual stress test
- It identifies the amount of the lateral translation of the talus within the ankle mortise
Coleman Block Test[edit | edit source]
- Performed to evaluate hindfoot flexibility and pronation of forefoot
- Completed by supporting the lateral forefoot on a woodblock that is 2.5-4 cm thick
- Determines if an inverted heel is due to a forefoot issue
Other Tests[edit | edit source]
Other special tests include:
- Ankle ligament stress tests
- Talar tilt test
- Eversion stress test
- Silfverskiöld test
- Windlass test
- Impingement sign ankle
- Navicular drop test
For detailed information on these tests, please refer to the relevant pages with links provided.
Balance Tests[edit | edit source]
BESS Test[edit | edit source]
- Assessment tool for postural stability
- Requires two testing surfaces, stopwatch and scoring sheet
Detailed information can be found on the Balance Error Scoring System page.
Star Excursion Balance Test (SEBT)[edit | edit source]
- Assesses anterior movements
- Record the movements and compare results
- Used to show progress
- Y balance test is a short version of the Star test
- see more here Star Excursion Balance Test
Return to Sports Tests[edit | edit source]
The purpose of administering a return to sport test is to determine an individual's readiness to participate in high-level activities.
Return to Sports Tests:
- Help to determine the timing for a return to unrestricted activity.
- Aim to decrease the risk of re-injury.
- They test an athlete's ability to return to sport. They should mimic the athlete's activity. Example: single-leg hop or double-leg jump test for a long jumper with a history of a sprained ankle. Other examples include a jump to stability test or shuttle run.
- They are not standardised. No data is available to support the use of one test versus a series of testing.
- It is important to utilise a wide range of assessments: patient self-report questionnaires and assessment of psychological factors as examples. 
- See also Return to Play in Sports
Outcome Measures[edit | edit source]
Foot and ankle injuries are fairly common and the patient's progress and satisfaction with outcomes are the focus of all physiotherapy providers. Outcome measures used in different stages of rehabilitation help to monitor improvement in function and determine if there are further limitations preventing the patient from returning to sports or activities of daily living. The most commonly used self-reported outcome measures for foot and ankle injuries are as follows:
- Foot and Ankle Ability Measure (FAAM)
- Oxford Ankle Foot Questionnaire
- Foot and Ankle Disability Index (FADI)
- Lower‐Limb Tasks Questionnaire (LLTQ)
- Foot Function Index (FFI)
- American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Score/Foot and Ankle Module
- Ankle Joint Functional Assessment Tool (AJFAT)
- VISA-A Scale
Conclusion[edit | edit source]
Please watch the following video demonstrating the application and interpretation of special tests for the foot and ankle assessment:
References[edit | edit source]
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- The Weight Bearing Lunge Test. 2017. Available from: https://www.youtube.com/watch?v=wV9tITMsbDs [last accessed 12/01/2022]
- Kleiger's Test or External Rotation Test. 2013 Available from: https://www.youtube.com/watch?v=LnB1fta_rQA [last accessed 12/01/2022]
- UWECATEP. Cotton Test. 2013. Available from: https://www.youtube.com/watch?v=qX68KET3dls [last accessed 12/01/2022]
- Assessing Foot Flexibility: Part 05 (Modified Coleman Block Test). Available from: https://www.youtube.com/watch?v=TCp25F0l7hc [last accessed 6/6/2009]
- Star Excursion Balance Test (SEBT).2017. Available from: https://www.youtube.com/watch?v=GBT9V78d6E0[last accessed 12/01/2022]
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