Patient’s Name DOB MRN Date of Visit Ankle Pain H & P HPI KEY: Y = Yes(positive) N = No(negative) NE= Not Examined History elements to ask: - Mechanism of injury - Acute traumatic, overuse, or spontaneous onset - Pop or tear with injury - Location of pain - Swelling (Y/N) - Ability to ambulate immediately after injury - Ability to ambulate at time of evaluation - Provoking/alleviating factors PMH/PSH Prior ankle/foot injury or surgery Other orthopedic history (surgeries, arthritis, trauma, injuries etc…) --------------------------------------------------------------------------------------------------------------------------------------------------Physical exam Inspection Limping gait Y N Weight bearing Y N Swelling Y N Ecchymosis Y N Atrophy Y N ROM Plantarflexion Full Dorsiflexion Full Strength Dorsiflexion Full Plantarflexion Full Inversion Full Eversion Full Special Tests Effusion Y Special testing Thompson’s squeeze Y Anterior Drawer Y Talar Tilt Y Proprioception Y Tinel’s test (medial ankle) Y Squeeze test Y Passive external rotation test Lunge test (anterior impingement) Palpation Achilles tendon Y Palpation, continued NE NE NE NE NE Limited Limited Weak Weak Weak Weak Painful Painful Painful Painful N NE N N N N N N NE NE NE NE NE NE Y Y N N N NE NE NE Medial Malleolus Y N NE Lateral Malleolus Y N NE Peroneal tendons Y N NE Base of the 5th metatarsal Y N NE ATFL Y N NE PTFL Y N NE CFL Y N NE Deltoid ligament Y N NE Talus Y N NE Navicular Y N NE Cuboid Y N NE Tibiofibular syndesmosis Y N NE Neurovasc Exam Sensation Y N NE Pulses (DP & PT) Y N NE OTTOWA ANKLE RULES - Consider X RAY if any one ore more of the following: - Inability to weight bear 4 steps immediately Y N - Inability to weight bear 4 steps at evaluation Y N - Tender on posterior half of medial malleolus Y N - Tender on posterior half of lateral malleolus Y N - Tender on posterior half of distal tibia or fibula Y N - Tender at the base of the 5th metatarsal Y N - Tender on cuboid Y N EXCLUDE CHILDREN, PREGNANT WOMEN, THOSE NOT CAPABLE OF PERFORMING EXAM FOR 2o REASONS ---------------------------------------------------------------------------------------------------------------------------------------------Asssessment (circle suspected diagnosis - all that apply) Ankle sprain (grade I-III_____) -- ATFL injury -- Deltoid ligament injury -- CFL injury -- PTFL injury --Syndesmotic injury (“high ankle sprain”) Ankle fracture Osteoarthritis Medial malleolar fx Lateral malleolar fx Maisonneuve fracture Ankle impingement syndrome Peroneal tendinopathy Tibialis posterior tendinopathy Tibialis anterior tendinopathy Flexor hallicus longus tendinopathy Tarsal tunnel syndrome Sinus tarsi syndrome Complex regional pain syndrome Achilles tendon rupture Achilles tendinopathy Retrocalcaneal bursitis Haglund’s deformity Stress Fracture: ______________________ Other: ______________________ Plan: 1) Treatment (Circle all employed) RICE (Rest, Ice, Compression, Elevation) Ankle brace/Immobilizer Exercises: (specify)_____________________________________ Aspiration/Injection Crutches/reduced weight bearing Casting 2) Medications NSAIDs Y N Specify:________________________ Other:______________________________ 3) Imaging X-rays Y N MRI Y N If yes, specify test ordered:_____________________ 4) Referral Sports Med Y N Orthopedics Y N Physical Therapy Y N 5) Follow up: ______ wks @ Ashwin Rao and Jonathan Drezner, 2007 Ankle exam- Anatomy and Demonstration Figure 1- Bones of the foot and ankle Anterior drawer test Figure 2- Ligaments of the Ankle Talar tilt test Figure 3- Demonstration of the anterior drawer and talar tilt tests to assess for stablility of ankle ligaments. The anterior drawer test (left), in which the ankle is grasped in the neutral position and translocated forward, assesses for ATFL injury. The talar tilt test tests the Calcaneofibular ligament’s integrity. Both exams are assessed by comparing the injured and uninjured ankles. Figures 5: Ottowa Ankle rules, demonstrating zones for palpating the foot and ankle to assess for potential bony disturbance/fracture. Figure 4- Thompson’s squeeze test to assess for Achilles tendon rupture. Squeezing the leg at the level of the gastrocnemius should cause the foot to plantarflex. Lack of foot motion suggests an Achilles tendon rupture Figure 6: Squeeze test. This test, designed to evaluate for high ankle sprains, is performed when squeezing the tibia and fibula together at the proximal leg causes pain at the ankle tibiofibular joint. A positive test suggests syndesmotic injury. Grading Ankle sprains Abbreviation Key Grade I sprain: Strain, no ligamentous laxity, when comparing ankles ATFL: Anterior Talofibular ligament Grade II sprain: Partial tear, some degree of laxity, however with a stable endpoint, when compared to uninjured ankle PTFL: Posterior Talofibular ligament CFL: Calcaneofibular ligament Grade III sprain: Complete tear, gross laxity, when compared to the uninjured ankle, with no discernable endpoint Images obtained via Google Images; Captions adapted from Brukner & Khan, “Clinical Sports Medicine, revised ed. 2”