Subjective Interview

Description of present condition:

At the initial assessment, the patient will be asked what their main complaint is and
what has brought them to see a physiotherapist.

 Pain, stiffness, or symptoms of giving way are common symptoms often

described by patients with ankle pathology.
 Symptoms such as pin’s and needles and numbness around the ankle region
may indicate neural pathology.
 The type of symptoms felt around the ankle region can be variable depending
on which structure is at fault.
 Aggravating/easing factors need to be clearly established, such as the
activities or postures that either provoke or reduce the presenting symptoms
 Level of function must be established and the effect that the symptoms have
on activities of daily living needs to be clearly identified.

Obtaining this knowledge will provide evidence towards the provisional diagnosis,
and therefore guide management decisions.

Area of pain:
The area of pain provides a clue as to the structure that may be involved.

 Pain in the ankle is often fairly localised.

o Localised pain on the lateral aspect could be indicative of a lateral

ligament sprain or fracture of the malleolus.
o Localised pain over the navicular tuberosity could be indicative of a
stress fracture of the navicular.

History of present complaint:

 Presence/absence of trauma:

o With a traumatic event the mechanism of injury needs to be carefully

analysed to determine what structure may have been injured.
Therefore it is helpful if the patient is able to provide a precise
description of the mechanism of injury (where possible) and
subsequent symptoms.
o If there has been no trauma the therapist needs to consider
pathologies of gradual onset and intrinsic or extrinsic factors that may
have contributed to the development of the presenting symptoms.
 Intrinsic factors that might affect the ankle/foot region of the lower limb
include pronated foot type or reduced ankle ROM (such as
dorsiflexion), whereas extrinsic factors include the type of training
undertaken, footwear, or biomechanics of the movement undertaken.

Mechanism of injury:
The lateral ankle ligaments are the most common structures to be injured acutely in
sports and recreational activities. A large number of ankle injuries result from trauma
to the lateral ligaments associated with excessive ankle inversion combined with
plantar flexion. When a patient’s symptoms occur insidiously the patient often cannot
recall a specific time or event that caused them. Achilles tendinopathy is an example
of a chronic pathology that presents in the lower leg region.

Example of acute ankle injuries:

Inversion Ankle Sprains
The most common acute injury affecting the ankle is the lateral ankle sprain. A
plantar flexion/inversion ankle injury may involve damage to any of the three
ligaments:

 Anterior talofibular (ATF)

 Posterior talofibular (PTF)
 Calcaneofibular (CF)

The ATF is the most common ligament injured if the ankle injury involves plantar
flexion. The CF ligament is usually involved if a dorsiflexion force is associated with
the inversion. The PTF ligament is most likely damaged if the ankle is dorsiflexed,
and is often torn in conjunction with the other lateral ligaments. If this ligament has
been torn the trauma has probably been quite severe causing significant damage to
other structures such as a fracture/dislocation to the TCJ.
Inversion ankle sprains may also occur in combination with a fractured fibula and/or
base of the 5th metatarsal (refer below for details regarding requesting an ankle x-
ray).

Analysing the mechanism of injury and identifying the site

of pain will provide information regarding the structure(s)
most likely injured.
Eversion ankle sprains:
Forced ankle eversion can damage the medial deltoid ligaments of the ankle
although this is not a common injury because of the strong deltoid ligament fibres.
The lateral malleoli also serves as a bony block to the eversion movement as it sits
lower than the medial malleoli, thus reducing the amount of tensile load that can go
through the ligaments on the medial side of the ankle joint.

Rotational ankle sprains:

The distal tibiofibular joint is a very stable joint due to dense connective tissue
around the joint including the interosseous ligament and the anterior and posterior
tibiofibular ligaments.

 Forced rotation of the leg on a fixed foot will cause the talus to rotate within
the ankle mortise. This can cause the tibia and fibula to separate damaging
the inferior tibofibular ligaments.
 Another mechanism of injury affecting the inferior tibofibular ligaments is
forced ankle dorsiflexion i.e. when landing from a fall. End range dorsiflexion
is the closed pack position of the TCJ therefore this end range position under
load also contributes to separation of the distal tibiofibular joint damaging the
inferior tibofibular ligaments.
 In the event of an injury to the distal tibiofibular joint, damaged ligaments can
also be accompanied by a spiral fibular fracture. Injury to the distal tibiofibular
joint is known as a syndesmosis injury or a high- ankle sprain. Location of
pain with this type of injury is more proximal compared to a lateral ankle
ligament injury. Due to the importance of the distal tibiofibular joint providing
stability to the ankle joint, rehabilitation can be a lengthy process compared to
lateral ankle ligament sprain.

Behaviour of symptoms:
Understanding the behaviour of symptoms with respect to movements and postures
will also provide information that may support or rule out a provisional diagnosis. The
load and mechanics of aggravating and easing movements and how they might
influence the structures around the ankle region need to be considered.

 Aggravating activities typical of ankle pathology:

o Squatting, walking/running and stairs – movements that involve weight
bearing and end ranges of movement are generally provocative due to
the increased loading and demands of the movements that require joint
stability.
o The stage of injury will also influence what activities may cause pain. A
patient with an acute ankle injury will have an antalgic gait pattern
 during the acute and sub acute phase of recovery. As the tissues begin
to heal the gait pattern will begin to normalise.
o Kneeling with the ankle in end range plantar flexion- this position will be
extremely uncomfortable for a patient with injured lateral ankle
ligaments as plantar flexion puts the ligaments on stretch.
 Easing activities:

o Positions that reduced the load through injured structures are often
adopted e.g. a patient with injured lateral ligaments are often pain free
with straight line walking as the demand on the lateral ligaments is
minimal (as opposed to more dynamic side to side tasks which are
provocative).
o Positions that are non-weight bearing are often less provocative (due to
minimal compressive forces going through the ankle joint).
o Positions where the ankle joint is in the resting position are also less
provocative.
o Resting position of the ankle is approximately 10° plantar flexion.
 24 Hour Behaviour
With any assessment it is important to establish how the patient’s symptoms
change over the course of the day (refer to the chapter on Subjective
Interview and Objective Examination for more detail).
o Night pain- pain at night needs to be distinguished between pain that is
aggravated due to a particular resting position in bed that can be
reduced by changing the position of the ankle, compared to unremitting
night pain that cannot be altered biomechanically. In this instance the
pain could be linked to a more sinister pathology.
o Morning-morning stiffness associated with pain > 60 minutes may
indicate the presence of an inflammatory condition.
o Daytime-The behaviour of symptoms throughout the day can be
established when enquiring about aggravating, and easing factors.

It is important that the patient rates the severity of

aggravating activities using the visual analogue scale
(VAS) or numerical rating scale (NRS) throughout the
course of the day including rating their symptoms at rest.

Limitation of function:
Determine what activity(s) the patient normally undertakes and how these activities
have been affected by the presence of the current dysfunction, so that the
appropriate rehabilitation strategies can be implemented.
Referral for X-ray
There are a variety of fractures that may occur around the ankle region particularly
with respect to a traumatic mechanism of injury.
Clues in the history that might indicate a fracture is present:

Observation
Observation of joint deformity would be a fairly obvious clue that bony injury had
occurred.

Degree of disability
 Inability to weight bear, sleep disturbances, and severe pain could also
indicate the presence of a fracture.
 Giving way may suggest joint instability.

Mechanism of injury
As described previously a plantar flexion/inversion ankle injury could damage the
lateral ankle ligaments. However if there was an element of compression at the time
of injury (e.g. the ankle was injured whilst landing from a jump) an osteochondral
injury of the talus may be present.
The common lateral ankle sprain can occur in combination with:

 Fracture to distal fibula

 Fracture base of 5th metatarsal
 Osteochondral lesion of talus.

The simple ankle sprain is not always simple

Location of pain
Location of tenderness and site of swelling over bony regions may indicate
significant damage to a bone therefore careful palpation of structures around the
ankle/foot region is essential regarding potential provisional diagnosis and
management.
Ottawa ankle rules
The Ottawa ankle rules were established to aid therapists’ in their clinical reasoning
process with respect to requesting an x-ray to rule in a fracture. Very localised
tenderness over the following bony areas could indicate a fracture.

The following are the Ottawa ankle rules:

I. Pain on the posterior 6cm of distal lateral malleolus or
II. Pain on the posterior 6cm of distal medial malleolus or
III. Inability to weight-bear four steps both immediately and in the emergency
room (Steill et al, 1993).

Previous history and treatment:

If a patient has received physiotherapy treatment for a similar problem it is necessary
for the patient to describe the specifics of what treatment they have had as this might
provide information pertaining to a potential provisional diagnosis, and guide the
development of rehabilitation strategies. An onwards referral to another medical
specialist may need to be considered if the patients symptoms have not been altered
with appropriate physiotherapy management.

 A patient who presents with an ankle injury may in fact have had several
previous episodes of ankle sprains receiving treatment on previous occasions.
If the patient’s problem still persists despite receiving treatment then it needs
to be clearly established what treatment was received. This information may
guide the rehabilitation strategies selected i.e. different strategies may need to
be selected than those received previously, or an onwards referral may be
necessary to gather more information (particularly if the symptoms have not
been altered with treatment to date).

Social history:
An important part of the subjective interview is to gain an understanding of
psychosocial factors including mood disorders (e.g. depression and anxiety), sleep,
social support, ability to cope, social wellbeing as well as the patient’s participation in
leisure activities, community, and employment. All these factors will impact selection
& implementation of the rehabilitation strategies.
Past medical history:
 Being informed of any previous surgery/injury or trauma to the ankle region
may also help in establishing a provisional diagnosis. The patient may have
already had previous investigations (such as x-ray, MRI) due to previous
issues; therefore the findings of these are worth reviewing in light of the
current presenting condition and potential diagnosis.
 Asking the patient questions in relation to previous health conditions and over
all general health ensures they are screened appropriately (refer to chapter on
Subjective Interview). Major illness such as cancer or a past history of cancer
(a history of cancer is considered a red flag if associated with other symptoms
such as unremitting night pain, unexplained weight loss, and a general feeling
of unwell) may indicate an onwards referral to another medical specialist is
required.

Red flags:
Red flags are signs and symptoms that indicate the possible presence of a serious
underlying pathology. A therapist may become suspicious of a red flag either during
the subjective interview or objective examination. The presence of a red flag may
indicate the need for onwards referral or in some cases immediate medical
assessment (refer to chapter on Subjective Interview for more detail on red flags).
An example of red flags that require further questioning and /or testing include:

 Patient over 50 years old

 History of cancer
 Fever
 Unexplained weight loss
 Severe unremitting night pain
 Long term steroid use

Questionnaires:
Functional questionnaires can be used to establish functional limitations and
subsequent goals of treatment. The Western Ontario and McMaster Universities
Arthritis Index (WOMAC) is a widely used questionnaire used to evaluate patients
with conditions affecting the lower limb (Martin et al, 2010). The lower limb task
questionnaire (LLTQ) is another questionnaire used to explore lower limb function
(McNair et al, 2007).
For further detail regarding the WOMAC questionnaire click hereLinks to an external
site..

Objective Assessment
Observation and postural analysis:
The purpose of ‘observation’ is to gain information on visible defects, functional
deficits, and abnormalities of alignment. This can be achieved by inspecting static,
and dynamic postures during functional tasks. Informal observation can begin when
first meeting the patient in the waiting room, which continues once the patient, enters
the treatment room. Watching how they sit, walk, and get undressed is important to
note including their overall manner, attitude, and willingness to cooperate. The
patient is often unaware that you are observing them at this time so will behave more
naturally whilst they perform these tasks. The more official examination process can
then proceed after this. For more detail on observation refer to the chapter on
Objective Examination.

 Static alignment/symmetry

o Head posture
o Spinal curves
o Pelvis orientation
o Femoral-pelvic orientation
o Hip/knee/ankle/foot orientation
o Weight bearing status
o Muscle bulk, atrophy (calf region)
o Foot posture
 Dynamic assessment of posture including assessment of gait and functional
activities e.g stairs, squat (refer to Hip and Knee chapters for more detail).
 Squat

Neurological examination
If indicated in the subjective interview, a neurological examination must be
performed (refer to the Neurological Examination section in the chapter on Objective
Examination for further detail on neurological examination).

Tests of function
Functional tests: Whilst observing the following tasks record ROM, symmetry of
movement, willingness to move and symptom reproduction.

 Gait: walking forward/backwards

o Assess running, jumping, lunge, hopping if appropriate.

 Squat– assess for range of dorsiflexion (pain with squatting may indicate a
TCJ dysfunction -refer to figure).
 One leg stand and small knee bends (performed repeatedly) – looking at the
alignment of the whole kinetic chain for control with movement and pain
reproduction (refer to the Hip chapter for more detail on the biomechanical
assessment of the lower limb).
 Stairs: some things to consider when observing stairs are: Which leg do they
lead with? Is the task smooth & controlled? Is the ankle going in to full ROM
as the patient goes up or down stairs?
 Assess movements described by the patient as their aggravating movements.

Assessment of proprioception:
When assessing proprioception there are two things to consider:

1. Kinesthesia (the patients ability to detect passive motion) and

2. Joint position sense (the patients ability to reproduce passive positioning).

Dynamic joint function and stability requires a complex neuromuscular feedback

mechanism whereby afferent feedback to the brain and spinal pathways is mediated
by skin, articular, and muscle mechanoreceptors, therefore the assessment of
proprioception requires an appropriate examination of these processes. A
misconception regarding proprioceptive assessment is that proprioception is
evaluation by the patient performing balance tasks. However, placing a patient on a
wobble board only assesses the patient’s balance so is not a direct measure of
proprioception. Balance retraining however has shown to be effective in the
prevention of injuries (McKeon & Mattacola, 2008).
Click on this link for further detail on the assessment of proprioception (Lephart et al
1998).

Active ankle ROM tests :

Active movements are those performed by the patient therefore involve both
contractile and non-contractile structures. Active ankle movements can be performed
in weight bearing (as in those activities of function described above) or in non-weight
bearing with the patient supported on the plinth. Depending on whether the patient’s
symptoms are produced in weight bearing or non-weight bearing the therapist will
select the most appropriate position to examine ROM. Clinically ankle ROM is
typically examined in both positions.

Examiner tests for: Physiological ROM, quality of

movement, pain and other symptoms

In standing:
 Ankle dorsiflexion, planter flexion, inversion and eversion
 Asking the patient to walk on their toes, heels and medial or lateral borders of
their feet will give an indication of weight bearing function and symptom
reproduction
 A squat is a functional position to examine dorsiflexion range
 The ankle lunge test has shown to be a practical and reliable tool for
measuring weightbearing dorsiflexion post ankle fracture (Simondson et al,
2012)

In supine lying:
 Ankle dorsiflexion and planter flexion
 Inversion and eversion
 Toe flexion and extension

Ankle joint and foot ROM ‘normative’ values:

 Ankle (TCJ): Planter flexion = 40-45°, dorsiflexion = 15- 20°
  Subtalar joint (STJ): Inversion= 30- 40°, Eversion= 15-20°
 Great toe extension (1st MTP): 80-100°

Note:
Active movement of joints below & above the ankle joint should also be screened.

Talocrural joint (TCJ):

Closed pack position: Talocrural joint in maximal dorsiflexion (Kaltenborn, 2002).
Resting position: 10° plantar flexion mid way between max inversion and eversion
(Kaltenborn, 2002).

Passive ankle ROM testing:

Passive tests are performed by the therapist and eliminates the contractile structures
from being activated through out the test, aiding the provisional diagnosis.

Examiner tests for: Physiological ROM, quality of

movement, end feel and reproduction of symptoms

Ankle and foot movements to be assessed:

 Plantar flexion, dorsiflexion, inversion and eversion.

o Loss of dorsiflexion (DF) ROM is fairly typical after an injury to the TCJ.
o Loss of DF range will affect simple tasks as to walk up stairs.
o If a patient presents with a loss of DF it needs to be established
whether the loss of range is due to muscle shortening of the plantar
flexors or due to loss of joint glide of the TCJ.
 1st Metatarsal phalangeal joint ROM (MTP)
 Great toe extension test- extension is required for the push off phase of gait
therefore range of the 1st MTP must be examined.

o ROM: 80-100° DF

Resisted muscle testing of the ankle:

Strength testing of muscles provides information about muscle strength and
symptom reproduction. Calf strains are a common injury significantly affecting
function particularly if a large tear is present. Level of weakness and severity of
symptoms reproduced on testing will provide an indication as to the level of injury to
the muscle (refer to the chapter on Subjective Interview and Objective Examination
for more detail regarding responses to isometric testing).

Muscles typically examined in the lower leg region include:

 Calf complex (plantar flexors),

 Dorsiflexors
 Invertor and evertor muscle groups.

Specific muscle testing may also include the following:

 Gastrocnemius and soleus which provide power and stability respectively

 Peroneals- provide last line of defence for lateral ligament sprain
 Tibialis Posterior- controls pronation of the foot region

Dysfunction within these muscle groups could lead to the production of faulty
movement patterns leading to the production of symptoms.

Muscle length:
Muscle lengthening or shortening may contribute to patterns of faulty movement
especially in those patients who present with an insidious onset of symptoms in the
lower limb. A typical example is the patient who presents with chronic medial shin
pain. Reduced muscle length of the calf region causing a reduction in dorsiflexion
has been proposed as a contributing factor to causing increased stress to the medial
tibial region. Pain in this region could indicate a medial tibial stress fracture. There is
an increased tendency for the foot to over pronate when ankle dorsiflexion is
restricted (Brukner & Kahn, 2012). Examination of calf muscle length is therefore
important.

Palpation of the Ankle Region:

Like the knee, structures around the ankle region are relatively easy to locate and
palpate. Hence reproduction of symptoms with palpation can assist the development
of the provisional diagnosis. Structures palpated in the ankle region that may be
associated with pathology include:

 Medial malleolus
 Lateral malleolus
 Sustentaculum tali
 Navicular tuberosity
  Dome of talus
 Medial collateral ligament (deltoid ligament)
 Lateral ligaments (anterior talofibular, calcaneofibular & posterior talofibular
ligaments)
 Achilles insertion and tendon
 Tuberosity of 5th MT (peroneus brevis insertion)

When palpating any of these structures the therapist

records symptom reproduction, tenderness, changes in
tissue tension, thickness and texture and altered
temperature etc.

Ankle Lunge Test to Assess Calf Length

Special Tests of the Ankle Region

Passive accessory joint testing
Accessory joint tests are performed to determine if there are any changes in joint
play, tissue resistance and/or symptom reproduction (refer to Joint Assessment and
Treatment chapter for further detail).
Passive accessory movement tests in the ankle region include:

 Traction, glide and compression of the TCJ

 Traction and glide of the STJ
 Glide of the tarsal (cuboid and navicular) and phalanges joints (1st MTP joint).

Ligament testing
Ligament tests are performed in the ankle region to examine the integrity of the
ligaments that support the ankle region. The anterior drawer and talar tilt tests are
used to examine the ligaments of the TCJ, in particularly the ATFL, CFL and PTFL
as these ligaments are more commonly injured in acute ankle injuries. On testing, a
change in end feel may indicate damage to these stabilising structures. As with knee
ligament injuries, there are three grades of ligament injures (refer to Joint
assessment and treatment chapter for more detail). With a grade 3 ligament injury
increased laxity and an empty end feel is found on assessment of the ligaments
indicating the ligament has been ruptured.

Note:
Reported sensitivity and specificity of the anterior drawer test has been reported
between 75 and 100% which indicates that these tests are useful in diagnosing
ligamentous damage (Cook & Hegedus, 2012).

Ankle Joint Assessment Techniques

The first stage of an examination of the ankle region is to exam static posture and
dynamic posture during various activities. This will provide information as to how the
lower limb is functioning and may provide insight as to why the patient is presenting
with symptoms.
As part of the general observational component of the assessment process an
examination of the foot and ankle region must be included. Whilst the patient is in a
static stance position, the natural posture of the foot can then be examined. It can be
established if the talus is in a neutral position by palpating the anterior aspect of the
head of the talus on the medial and lateral side. With the talus in neutral the medial
and lateral aspect of the talar head should be felt equally with palpation. Increased
prominence of the medial aspect of the head compared to the lateral aspect
indicates that the foot is pronated. If there is increased prominence of the lateral
aspect then the foot may be supinated. Refer to Brukner and Kahn ‘s Clinical Sports
Medicine text (4th edition) chapter 8 for more detail on biomechanical assessment of
the lower limb.
 Examination of the Talar Head Position

Examination of the posterior view of the ankle region also provides information
regarding the posture of the foot region. With a neutral foot position the
rarefoot/calcaneus should be perpendicular to the floor. A valgus rearfoot relative to
the floor indicates that the foot is pronated, whereas a varus rearfoot indicates a
supinated foot (refer to Figure X below). Examination of the talus and rarefoot
position are part of an examination procedure known as the Foot Posture Index
(Brukner & Khan, 2012).
 Examination of Rear Foot Posture

Assessment of balance
To assess balance in a patient with a musculoskeletal dysfunction the patient is
required to stand on one leg either on a flat surface or on a piece of foam
approximately 1 cm thick. Safety is paramount depending on the ability of the patient
to balance.
The test consists of 4 parts. Each part is to be maintained without falling or using any
external support for 30 seconds. If the first stage is achieved then the tests is
progressed to the next stage.

I. The patient stands on 1 leg, arms held wide at their sides if necessary.
 II. The patient stands on 1 leg with their eyes closed, and arms held wide.
III. The patient stands on 1 leg, with their head tipped backwards, and arms held
wide.
IV. The patient stands on 1 leg on a piece of foam, and arms held wide.

A positive test is when the patient loses balance in any of the 4 test positions, or
within 30 seconds.
A negative test is when the patient is able to maintain all positions without falling or
using external support for 30 seconds.

Note:
Test positions ii – iv, all remove a certain type of feedback which contributes to the
patient’s ability to balance. If the patient is unable to maintain a position but capable
of another, there may be a problem with that feedback mechanism. e.g. Unable to
stand with eyes closed – patient uses their eyes as the predominant sensory organ
in balance, therefore vestibular and proprioceptive senses need further sensitising to
reduce the reliance on vision for balance. Refer to Lephart et al (1998) for further
detail on proprioception of the ankle and knee.

Assessment of Ankle Dorsiflexion

The ankle lunge test
The ankle lunge test (also known as knee to wall test) is a method used to assess
ankle dorsiflexion ROM and has been shown to be a reliable tool for measuring
weight bearing dorsiflexion post ankle fracture (Simondson et al, 2012).

Ankle lunge test

Patient position:
The patient stands close to wall with one foot placed in front of the other.
The foot is placed approximately 10cm away from the wall.

Procedure:
The patient is asked to bend their knee to try and touch the wall. In doing so their
ankle dorsiflexes.

Analysis of the test:

A patient with good length of the soleus muscle will be able to touch the wall with
their knee easily (refer to figure x).

Ankle lunge test

A patient with reduced dorsiflexion will have difficulty touching the wall. A
measurement of the distance to the wall from the knee can be used as an outcome
measure.

A patient with very limited dorsiflexion will not need to have their foot positioned
away from the wall. They can have their toes right up against the wall for the
measurement to be taken.

Note:
A patient with limited dorsiflexion may use faulty movement patterns to reach the
wall with their knee. One of which might be lifting their heel off the ground. Another
movement pattern commonly seen is to pronate the foot to gain more dorsiflexion.
So be aware of these movement patterns. Limited dorsiflexion may be due to poor
muscle flexibility or reduced glide of the talocrural joint therefore these structures
with need to be further examined so that the appropriate treatment may be
undertaken.

Heel raise test

Heel raise test – gastrocnemius and soleus

Calf muscle strength can be assessed in both supine lying and standing.
Assessment of strength during weight bearing provides important information due to
the increase in load going through the joint whilst in standing. Assessing strength in
standing may be a more useful test to select when a patient complains of symptoms
only in weight bearing.
Patient position:
To assess gastrocnemius the patient is positioned in single leg standing with the
knee extended (refer to figure). Alternatively the patient can be position on a step
box with the hind foot placed off the end of the box. To assess soleus, the test is
repeated with the knee is slight flexion.

Heel raise test

Procedure:
The patient is instructed to raise the heel from a neutral position through to end
range plantar flexion (refer to figure ). The heel is then lowered back to the starting
position.
This is repeated 20 times. No rests are to be taken.
To test gastrocnemius the knee must remain straight
To test soleus the knee must be kept flexed.

Analysis of the test:

If the patient can perform 20 repetitions without signs of fatigue or loss of control this
is considered normal strength.
Decreased strength is indicated when a patient cannot plantar flex the ankle through
full range, or cannot complete 20 repetitions before fatiguing or losing control.
Inclining the body forwards and flexing at the knee are common faulty movement
patterns that indicate the calf maybe weak. Tibialis posterior and peroneal muscles
need to have normal strength to stabilise the forefoot and provide counter pressure
to the floor during this plantar flexion test. Therefore compensatory movements may
be related to weakness in these muscle groups.

Accessory Joint Assessment of the Talocrural Joint (TCJ)

If a patient presents with a reduction or increase in ankle joint ROM either actively or
passively, the therapist will be suspicious of a joint dysfunction. Accessory glides can
next be used to assess joint play of the TCJ to further investigate this hypothesis.
Refer to Principles of Joint Assessment and Treatment chapter for more detail
regarding passive accessory joint assessment.

Accessory Assessment of the Talocrural Joint (TCJ)

Antero-Posterior (AP) glide of the ankle (TC J)
This glide is also referred to as a Posterior glide.

Patient position:
Patient is lying supine with the foot placed over edge of plinth with the ankle in the
resting position of 10°plantar flexion (PF). A sand bag is placed underneath the distal
tibia to aid stability of the proximal aspect of the joint during the mobilisation.

Therapist position:
The therapist stands to the side of the patient of the ankle joint being assessed and
manually fixates the distal tibia and fibula against the plinth/ sandbag with the web
space of one hand and supports the talus on the anterior aspect with the other hand
close to the joint line of the ankle joint.
The talus sits in the web space of the thumb and index finger.

Accessory assessment of the Talocrural joint (TCJ)

Procedure:
The therapist applies an antero-posterior force parallel to the treatment plane to the
anterior aspect of the talus to examine the posterior glide of the talus (refer to figure
& video).
Positive test: Whilst performing the glide assess for symptom reproduction,
resistance to joint glide or increased joint play of the TCJ. Compare findings with the
unaffected side.
A reduction in joint glide may indicate joint hypomobility, whereas an increase in joint
glide may indicate the joint is hypermobile.

Postero-Anterior (PA) glide of the ankle (TC J)

This glide is also referred to as an Anterior glide.

Patient position:
Patient is lying supine with the foot placed over edge of plinth with the ankle in the
resting position of 10° plantar flexion (PF). A sand bag is placed underneath the
distal tibia to aid stability of the proximal aspect of the joint during the mobilisation.

Therapist position:
The therapist stands to the side of the patient of the ankle joint being assessed and
manually fixates the distal tibia and fibula against the plinth/ sandbag with the web
space of one hand and with the other hand cups the calcaneus (supporting the
patients foot on their forearm if necessary, to maintain the ankle in the resting
position).

Postero-anterior glide of the TCJ

Procedure:
The therapist applies a postero-anterior force parallel to the treatment plane to glide
the talus indirectly via the calcaneus to examine the anterior glide of the talus (refer
to figure & video) whilst maintain the resting position of the TCJ.
Alternatively the postero-anterior (PA) glide can be performed with the patient lying
in prone with their foot resting off the end of the plinth with the distal tibia on a sand
bag, and the TCJ in the resting position. The postero-anterior glide of the talus
directed via the calcaneous is performed parallel to the treatment plane to examine
the anterior glide of the talus.

The Ankle Joint: Ligamentous Testing

Anterior drawer test (ATF Ligament stability test)

The anterior drawer test assesses the integrity of the anterior talofibular (ATF)
ligament.

Lateral ankle ligamentous testing

Patient position:
The patient is lying in supine with the ankle in 20° plantar flexion positioned over the
edge of the plinth. The knee is straight. A sand bag is placed underneath the distal
tibia to aid stability of the proximal aspect of the joint during the assessment.

Therapist position:
The therapist stabilises the tibia just proximal to the ankle joint with the web space of
one hand pressing it firmly against the plinth/sandbag. The other hand cups the
calcaneus (supporting the foot in the resting position with their forearm if required).
Refer to figure.

Anterior drawer test

Procedure:
A postero-anterior force is applied to the talus via the calcaneus to glide the talus
anteriorly parallel to the treatment plane. Initially a small amount of give will be
appreciated as the slack is taken up in the ligament followed by an increase in
resistance. To confirm whether the end feel of the ligament is firm or empty, a small
amplitude thrust in an anterior direction is applied to the talus. The displacement of
the talus on the fixed tibia is also analysed. (Review the video to see the thrust being
demonstrated).
Positive test: An empty end feel with an increase in anterior joint play of the TCJ
indicates that the ligament has been ruptured.
As with the knee ligaments, there will be some degree of joint play prior to reaching
the end feel. An increase in joint play with a firm end feel may indicate some of the
ligament fibres have been torn. The grading classification described in the Principles
of Joint Assessment and Treatment chapter can be applied to the ankle ligaments.

Tips
This technique is performed similarly to the accessory assessment of the talocrural
joint, however the small amplitude thrust applied to the talus, evaluates the end feel
of the ligament.
Posterior glide of the Tibia- Alternative method to assess
the ATF ligament
An alternative method to assess the ATF ligament is to stabilise the talus and glide
the distal tibia posteriorly. The patient is positioned on the plinth with the knee in
flexion and the ankle still in 20° plantar flexion. The foot can be stabilised in this
position by being placed on a firm wedge. Whilst fixating the talus with the web
space of one hand, the other hand whilst fixated on the anterior aspect of the distal
tibia, glides the tibia in a posterior direction [refer to figure x]. The ATF ligament is
stressed as the tibia glides posteriorly. A gentle thrust is applied at the end of the
glide to assess the end feel.

ATF Ligament alternative test

Inversion talar tilt test (Calcaneofibular ligament test)

The inversion talar tilt test assesses the integrity of the calcaneofibular ligament
(CFL).

Inversion talar tilt test

Patient position:
The patient is lying in supine with the ankle in 10° plantar flexion positioned over the
edge of the plinth. The knee is straight. A sand bag is placed underneath the distal
tibia to aid stability of the proximal aspect of the joint during the assessment.

Therapist position:
The therapist stabilises the anterior aspect of the talus distal to the TCJ with the web
space of the stabilising hand. The calcaneus is cupped with the thenar eminence of
the mobilising hand placed on the lateral side of the calcaneus (refer to figure).

Procedure:
The integrity of the CFL can be assessed by inverting the calcaneous (or applying a
varus force by tilting the calcaneous into inversion). Initially a small amount of give
will be appreciated as the slack is taken up in the ligament followed by an increase in
resistance.
To confirm whether the end feel of the ligament is firm or empty, a small amplitude
thrust is applied (refer to video). (Review the video to see the thrust being
demonstrated).
Positive test: An empty end feel with an increase in joint play indicates that the CFL
has been ruptured.
As with the knee ligaments, there will be some degree of joint play prior to reaching
the end feel. An increase in joint play with a firm end feel may indicate some of the
ligament fibres have been torn. The grading classification described in the Principles
of Joint Assessment and Treatment chapter can be applied to the ankle ligaments.

This test is called the talar tilt because inversion of the

calcaneus causes the talus to tilt within the ankle mortise.

Eversion talar tilt test (Medial deltoid ligament)

The medial deltoid ligaments can be assessed with the eversion talar tilt test. The set
up for the test is the same as the inversion talar tilt however the talar tilt is performed
in the opposite direction.
The integrity of the medial deltoid ligament can be assessed by everting the
calcaneous (or applying a valgus force by tilting the calcaneous into eversion).
Initially a small amount of give will be appreciated as the slack is taken up in the
ligament followed by an increase in resistance. To confirm whether the end feel of
the ligament is firm or empty, a small amplitude thrust is applied (refer to figure ).

Eversion Talar Tilt Test

Ankle Joint Treatment Techniques

The following techniques are typically used in the management of joint dysfunction in
particularly joint hypomobility, and pain in the ankle region.
Traction of the TCJ:

Traction of the Ankle Joint (Talocrural Joint - TCJ)

Patient position:
The patient is lying supine with the foot placed over the edge of the plinth with the
ankle in the resting position of 10° plantar flexion.

Therapist position:
The therapist stands at the end of the plinth and grips the talus (refer to figure x and
video). One hand is placed on the anterior aspect on the talus while the other hand
supports the calcaneus.
Alternative the patient can support the talus with both hands. The fingers interlock
over the anterior aspect of the talus close to the joint line (refer to figure).

Traction of the ankle joint (TCJ)

Procedure:
To traction the TCJ joint the therapist leans back pulling the talus in a caudal
direction perpendicular to the treatment plane. The appropriate grade of movement
for the condition being treated is applied.

Note:
Pull too firmly too quickly will mean that the whole body ends up being
tractioned rather than just the ankle joint so take care the traction is applied.

Antero-Posterior glide of the TCJ in the resting position

This technique is useful for either pain modulation or to improve dorsiflexion.

Patient position:
Patient is lying supine with the foot placed over edge of plinth with the ankle in the
resting position (10°plantar flexion). A sand bag is placed underneath the distal tibia
to aid stability of the proximal aspect of the joint during the mobilisation.

Antero-Posterior (AP) Glide of the Ankle - Treatment

Progression

Therapist position:
The therapist stands to the side of the patient of the ankle joint being assessed and
fixates the distal tibia and fibula against the plinth/sandbag with the web space of
one hand and supports the anterior aspect of the talus with the web space of the
other hand. Both hands are positioned close to the joint line of the ankle joint. The
talus sits in the web space of the thumb and index finger.

Antero-Posterior (AP) glide of the ankle (TCJ) in resting

position

Procedure:
The therapist applies an antero-posterior force parallel to the treatment plane to the
anterior aspect of the talus to glide the talus posteriorly (refer to figure & video).
The appropriate grade of movement for the condition being treated is applied.

Antero-Posterior glide of the TCJ in dorsiflexion

This technique is useful for pain modulation and improving dorsiflexion.

Patient position:
Patient is lying supine with the foot placed over edge of plinth with the ankle resting
in a neutral position. A sand bag is placed underneath the distal tibia to aid stability
of the proximal aspect of the joint during the mobilisation.

Therapist position:
The therapist stands to the side of the patient of the ankle joint being assessed and
fixates the distal tibia and fibula against the plinth/sandbag with the web space of
one hand, and supports the anterior aspect of the talus with the web space of the
other hand. Both hands are positioned close to the joint line of the ankle joint.
The therapist passively dorsiflexes the ankle just short of the limit of dorsiflexion, or
position that provokes the patient’s symptoms.

Procedure:
The therapist applies an antero-posterior force parallel to the treatment plane to the
anterior aspect of the talus to mobilise the TCJ (refer to figure & video).
The appropriate grade of movement for the condition being treated is applied.

Antero-Posterior (AP) glide of the ankle (TCJ) in

dorsiflexion
Mobilisations with Movement (WMW)
MWM techniques can be applied in the ankle when there is a restriction of joint ROM
and symptoms affecting function.

MWM Posterior glide of the TCJ in dorsiflexion (non-

weight bearing).
This technique is useful for pain modulation and improving dorsiflexion.

Patient position:
Patient is lying supine with the foot placed over edge of plinth with the ankle resting
in a neutral position. A sand bag is placed underneath the distal tibia to aid stability
of the proximal aspect of the joint during the mobilisation.

MWM Posterior Glide of the Ankle (TCJ) in Dorsiflecion in

Weight

Therapist position:
The therapist stands to the side of the patient of the ankle joint being assessed and
fixates the distal tibia and fibula against the plinth/sandbag with the web space of
one hand, and supports the anterior aspect of the talus with the web space of the
other hand. Both hands are positioned close to the joint line of the ankle joint.
The therapist passively dorsiflex’s the ankle just short of the limit of dorsiflexion, or
position that provokes the patient’s symptoms.

Procedure:
The therapist applies an antero-posterior force parallel to the treatment plane to the
anterior aspect of the talus to mobilise the TCJ followed by passive dorsiflexion of
the ankle joint (refer to video). When applying MWM techniques, the therapist needs
to consider the PILL response as described by Mulligan (Hing et al, 2015):
PILL response:
P = pain free
I= Instant result
LL= Long lasting
The antero-posterior glide is sustained throughout the movement. Overpressure is
applied at the end of the range. The technique is then repeated. The goal is to have
the patient perform the dorsiflexion whilst the glide is being performed.
A progression of this technique is to perform it in weight bearing.

Note:
There must be no pain at any time the technique is being performed. If there are any
symptoms, stop and alter the angle or degree of force, or the change the technique.

MWM Posterior glide of the TCJ in dorsiflexion (weight

bearing).
This technique is useful for pain modulation and improving end range dorsiflexion.

MWM for Ankle Dorsiflexion

Patient position:
Standing with affected ankle placed on the end of a plinth (or chair) with the knee
flexed and holding on to the back of the chair for support.
Therapist position:
Kneeling in front of the plinth, and the patient’s ankle joint being treated.
The therapist supports the posterior aspect of the calcaneous with one hand, and
blocks the anterior aspect of the talus with the web space of the other hand.
(Alternatively the patient’s knee could be supported to guide the patient’s knee over
their foot during the lunge movement to maintain good biomechanical alignment).

MWM for ankle dorsiflexion in WB

Procedure:
The patient dorsiflexes their ankle by lunging forward to just short of the limit of
dorsiflexion, or position that provokes their symptoms. The therapist then applies an
antero-posterior force parallel to the treatment plane to the anterior aspect of the
talus to enable the tibia to move anteriorly..
The patient lunges forward again to produce dorsiflexion at the ankle joint. The
therapist moves in coordination with the patient to ensure the antero-posterior glide
of the talus is sustained throughout the movement in the correct plane. Overpressure
is applied at the end of the range. The technique is repeated.
When applying MWM techniques, the therapist needs to consider the PILL response
as described by Mulligan (Hing et al, 2015).

There must be no pain at any time the technique is being

performed. If there are any symptoms, stop and alter the
angle or degree of force, or the change the technique.

MWM for dorsiflexion in weight bearing with treatment

belt.
This technique is useful for pain modulation and improving end range dorsiflexion.

MWM for Dorsiflexion in Weight Bearing with Treatment

Belt

Patient position:
Standing with affected ankle placed on the end of a plinth with the knee flexed and
holding on to the back of the chair for support.

Therapist position:
Kneeling in front of patient’s ankle joint being treated.
The therapist supports the patient’s knee to guide it over their foot during the lunge
movement to maintain good biomechanical alignment during the technique.
The talus is blocked on the anterior aspect by the web space of the therapist other
hand. Alternatively the both hands of the therapist can be used to fixate the talus
(refer to figures).
A seatbelt is placed around the distal end of the tibia and around the pelvic region of
the therapist. Foam can be used underneath the belt for comfort and to protect the
Achilles region.

Procedure:
The patient dorsiflexes their ankle by lunging forward to just short of the limit of
dorsiflexion, or position that provokes their symptoms. The therapist then leans back
in to the belt so that a postero-anterior glide of the distal tibia is performed.
The patient lunges forward again to produce dorsiflexion at the ankle. The therapist
moves in coordination with the patient to ensure the posteroanterior glide is
sustained throughout the movement in the correct plane. Overpressure is applied at
the end of the range. The technique is repeated.

MWM for dorsiflexion in weight bearing with treatment

belt

Note:
Direction of glide is slightly downwards so that the glide remains parallel to the
treatment plane as the dorsiflexion occurs.

There must be no pain at any time the technique is being performed. If there are any
symptoms, stop and alter the angle or degree of force, or the change the technique.
When applying MWM techniques, the therapist needs to consider the PILL response
as described by Mulligan (Hing et al, 2015).
When using non-weight bearing and weight bearing
MWM’s as treatment techniques what is the rationale for
their use and what are the general rules to consider when
applying Mulligan MWM techniques?