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atient’s Name

DOBMRNDate 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 spontaneousonset

- Pop or tear with injury

- Location of pain- Swelling (Y/N)

- Ability to ambulate immediately after i

- Ability to ambulate at time of evaluatio- Provoking/alleviating factors

PMH/PSH

rior ankle/foot injury or surgery

Other orthopedic history (surgeries, arthritis, trauma, injuries etc…)

Physical exam

nspection

Limping gait Y N NE

Weight bearing Y N NE

Swelling Y N NE

Ecchymosis Y N NE

Atrophy Y N NE

ROM

Plantarflexion Full LimitedDorsiflexion Full Limited

trength

Dorsiflexion Full Weak Painful

Plantarflexion Full Weak Painful

Inversion Full Weak Painful

Eversion Full Weak Painful

pecial Tests

 Effusion Y N NE

Special testing

Thompson’s squeeze Y N NE

Anterior Drawer Y N NE

Talar Tilt Y N NE

Proprioception Y N NETinel’s test (medial ankle) Y N NE

Squeeze test Y N NE

Passive external rotation test Y N NE

Lunge test (anterior impingement) Y N NE

Palpation

Achilles tendon Y N 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 NEDeltoid 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 m

of the following:

- Inability to weight bear 4 steps immediately Y

- Inability to weight bear 4 steps at evaluation Y

- Tender on posterior half of medial malleolus Y - Tender on posterior half of lateral malleolus Y

- Tender on posterior half of distal tibia or fibula Y

- Tender at the base of the 5th

 metatarsal Y

- Tender on cuboid Y

 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 syndromePeroneal tendinopathy

Tibialis posterior tendinopathy

Tibialis anterior tendinopathy

Flexor hallicus longus

tendinopathy

Tarsal tunnel syndrome

Sinus tarsi syndrome

Complex regional painsyndrome

Achilles tendon rupture

Achilles tendinopathy

Retrocalcaneal bursitis

Haglund’s deformity

Stress Fracture:

 ______________________

Other: ______________________

Plan:) Treatment (Circle all employed)

RICE (Rest, Ice, Compression, Elevation)

Exercises: (specify)_____________________________________

Crutches/reduced weight bearing

Ankle brace/Immobilizer

Aspiration/Injection

Casting

) Medications

 NSAIDs Y N Specify:________________________ Other:______________________________

) Imaging

X-rays Y N MRI Y N If yes, specify test ordered:_____________________

) Referral Sports Med   Y N Orthopedics  Y N Physical Therapy Y N

) Follow up: ______ wks

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Palpation, continued

@ Ashwin Rao and Jonathan Drezner,

8/12/2019 Exam de Tobillo

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Ankle exam- Anatomy and Demonstra tion

Images obtained via Google Images; Captions adapted from Brukner & Khan, “Clinical Sports Medicine, revised ed.

Figure 1- Bones of the foot and ankle Figure 2- Ligaments of the Ankle

gures 5: Ottowa Ankle rules, demonstrating zones for palpating the foot and ankle to assess forotential bony disturbance/fracture. 

Figure 3- Demonstration of the anterior drawer and talar tilt tests to assess for stablility of ankleligaments. The anterior drawer test (left), in which the ankle is grasped in the neutral positionand translocated forward, assesses for ATFL injury. The talar tilt test tests the Calcaneofibularligament’s integrity. Both exams are assessed by comparing the injured and uninjured ankles.

Figure 4- Thompson’s squeeze test to assess for Achilles trupture. Squeezing the leg at the level of the gastrocnemiusshould cause the foot to plantarflex. Lack of foot motion suan Achilles tendon rupture

Grading Ankle sprainsrade I sprain: Strain, no ligamentous laxity, when comparing ankles 

rade II sprain: Partial tear, some degree of laxity, however with a stable endpoint, when

ompared to uninjured ankle 

rade III sprain: Complete tear, gross laxity, when compared to the uninjured ankle, with noscernable endpoint

Anterior drawer test Talar tilt test

Abbreviation KeyATFL: Anterior Talofibular ligament

PTFL: Posterior Talofibular ligament

CFL: Calcaneofibular ligament

Figure 6: Squeeze test. This test, designed to evaluate for hankle sprains, is performed when squeezing the tibia and fitogether at the proximal leg causes pain at the ankle tibiofib

 joint. A positive test suggests syndesmotic injury.