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The 12-point ankle examination


Source: Patient Care
Originally published: May 15, 2003

  

The 12-point ankle examination


LOREN A. CROWN, MD, Associate Professor, University of Tennessee Health Science Center, Covington; Fellowship
Director and Medical Director, Baptist Memorial Hospital—Tipton, Covington.

Reduce your chances of overlooking injuries and overusing imaging


studies with this focused, sequential, 12-point ankle examination. A
systematic approach is crucial when your patients report a "sprained
ankle."

The 12-point ankle exam allows rapid and thorough evaluation of the most commonly affected structures
when patients complain of a "sprained ankle." This reduces the cost of radiologic studies (which otherwise
might include calcaneal, foot, ankle, lower leg, and comparison views) by making it possible for the
physician to order only the specific views needed and then scrutinize the appropriate aspects of the films.
Patients frequently provide unfocused descriptions of an injury and may mislead an unwary examiner, who
may not actually palpate or inspect the exact area of injury. The routine use of the 12-point examination
technique, coupled with the Ottawa Ankle Rules, facilitates more appropriate orders for radiographs and
reduces the incidence of missed diagnoses.

FIRST STEPS
As always, begin with the history, focusing on how the injury occurred. For example, a fall from a height is
often associated with a calcaneal injury. A sudden audible "pop" with pain in the calf in a parent
scrimmaging with his teenage son may be the result of a ruptured Achilles tendon, and a severely
dorsiflexed foot may produce subluxation of the peroneal tendon. However, the most common injury is the
inversion ankle sprain, which stresses the lateral ligament complex. If the patient was unable to bear weight
and/or walk 4 steps immediately after the injury and at time of presentation, that is a significant observation.
Previous ankle injuries are important, because laxity makes repeat injuries more likely. Additional important
elements of the history include the patient's age, occupation, and comorbid conditions, especially

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osteoporosis and neuropathy.

Ask the patient to point to the area of maximum pain, and examine that area last. Many patients are unable
to identify an area where the pain is worst and will indicate the entire lower extremity. While the old adage
"if everything hurts, then nothing is broken" often comes to mind and is sometimes true, an appropriate
evaluation is still required to determine the area of interest for focused study. Consider examining the
unaffected ankle first and familiarize yourself with the patient's uninjured anatomy. This may also reassure
the patient.

With the patient seated, sit on a stool next to the patient at a 90-degree angle. Gently lift the affected
extremity by supporting it at midcalf, not by the injured area. Place the patient's leg across your own.
Alternatively, stand by the table or stretcher and leave the patient's leg extended beyond the edge with the
midcalf bearing the weight (see Figure 1). Remove the patient's shoe and sock. Inspect the ankle for gross
instability and/or deformity.

  

Click here to view full-size graphic

  

THE 12-POINT EXAMINATION


The 12-point examination tests for the following injuries:

• Fibula fracture

• Tibia fracture

• Interosseus membrane/syndesmosis tear

• Achilles tendon rupture

• Anterior talofibular (ATF) ligament injury

• Fifth metatarsal fracture

• Navicular fracture

• Calcaneal fracture

• Deltoid tear/avulsion fracture of the medial malleolus

• Lateral ligament complex tear/avulsion of the lateral malleolus

• Subluxed peroneal tendon

• Neurovascular damage.

Begin by using the arm that is closest to the patient. Position your hand with your thumb on the fibular head
and your fingers on the proximal tibia. Cup the heel in your opposite hand to steady the lower leg. Slide
your hand distally, compressing (squeeze test) the 2 long bones as you go, to detect shaft fractures and/or
tears of the interosseus membrane and/or the syndesmotic ligament. Stop approximately 2 to 3 cm
proximally to the distal aspects of the malleoli (see Figure 2). (You will return to palpate these at the end of
the examination.) These maneuvers will cause pain if there is injury to the following:

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• Interosseous membrane/syndesmosis ligament binding the tibia and fibula

• Head of the fibula

• Either shaft of the fibula or tibia.

  

Click here to view full-size graphic

  

Remain seated, holding the patient's leg as before (with one hand over the lower leg and the other under
the heel). Palpate the Achilles tendon with your finger, keeping your hand in the cupped position (see
Figure 3). Then perform the anterior drawer test after first putting the patient's foot in the 90-degree
(neutral) position. Let the foot rest along your forearm. The hand cupping the heel pulls anteriorly while the
opposing one stabilizes the lower leg (see Figure 4). There should be a solid and firm end point with scant
excursion as you pull the foot forward. More than 0.5 cm of movement or lack of a firm end point signals a
positive drawer test and a problem with the ATF ligament or the syndesmosis at the distal tibia-fibula joint.
You can also validate instability of the interosseus membrane and/or syndesmotic joint by hyperdorsiflexion
of the foot. Extreme pain locally over the area during hyperflexion signals a positive result. Allow the
patient's foot to continue to rest on your forearm, both to support the injured part and to avoid letting the
foot slip into plantar flexion, which leads to instability and produces erroneous clinical information.

  

Click here to view full-size graphic

  

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Click here to view full-size graphic

  

Then apply pressure from the hypothenar eminence of your hand cupping the heel against the base of the
fifth metatarsal. This maneuver may illicit pain if a fracture is present (see Figure 5). Next, palpate over the
tarsal navicular bone with your thumb (see Figure 6). Finally, slightly rotate your hand and compress the
calcaneus (see Figure 7). Pain indicates the possibility of a fracture here. At this point in the examination,
you have evaluated the patient for

• Achilles tendon rupture

• Sprain of the ATF ligament

• Fracture at the base of the fifth metatarsal

• Tarsal navicular fracture

• Calcaneal compression fracture.

  

Click here to view full-size graphic

  

Click here to view full-size graphic

  

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Click here to view full-size graphic

  

Do not release your hold: Keep the ankle in the 90-degree neutral position. Attempt the talar tilt test by
everting and inverting the ankle mortice, noting excessive motion. Motion that is 10% greater than that in
the normal comparison ankle or the lack of a solid end point indicates possible damage to the deltoid
(medial) or the calcaneofibular (lateral) ligaments. Pain alone is not a sufficient basis for the diagnosis: A
mild sprain might produce pain, but a complete rupture might be nearly painless. Allowing the foot to drop
from the 90-degree position takes the joint out of its firm "locked" position and obscures the findings.

Keep the foot resting on your forearm. With your opposite hand, complete the palpation of the distal medial
malleolus, then of the lateral malleolus (see Figures 8 and 9). Palpations of the posterior aspects of the
distal malleoli are the most productive maneuvers for eliciting pain caused by fractures. Subluxation of the
peroneal tendon may be suspected in a patient with a hyperdorsiflexion injury, pain, and ecchymoses along
the posterior lateral malleolus in the absence of tenderness of the ATF ligament. You have now completed
the examination for

• Medial malleolar avulsion fracture or deltoid ligament tear

• Lateral malleolar avulsion or lateral complex/ calcaneofibular ligament tear

• Subluxation of the peroneal tendon.

  

Click here to view full-size graphic

  

Click here to view full-size graphic

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These last maneuvers are the most likely to cause pain and are therefore usually performed at the end of
the examination. If the patient can identify a specific area of pain, try to sequence the process to examine
that part last. It is worth mentioning that the peroneal tubercle is a protuberance that gives the appearance
of slight puffiness and bluish color to an area that coincidentally overlies the ATF, the most commonly
injured structure in a sprained ankle (see Figure 10). The patient so frequently focuses on this area that I
use it to complete an orthopedic examination that uncovers only nonspecific findings by pointing to it and
saying "and it hurts there the most, right?" The area is frequently swollen, so do not discount the finding.

  

Click here to view full-size graphic

  

The final step in any examination of a traumatized extremity is to assess the circulation (dorsalis pedis and
posterior tibial artery pulses and capillary blush) and sensation (pinch the toes). You are now finished with
the clinical examination. Gently replace the patient's leg on the bed or stretcher. Your last exam maneuver
was inspection of the area overlying the peroneal tubercle and the ATF ligament.

Now order appropriate radiography. This 12-step ankle examination requires a short learning curve to
master and within a few exams the average practitioner can expect to perform the rapid sequence screen
in a minute or two. This rapidly executed and easily mastered exam is compatible with and complementary
to the Ottawa Ankle Examination in which there is an attempt to determine if there is pain along the distal 6
cm of the posterior aspect of the tibia and fibula, and discrete pain at the base of the fifth metatarsal or over
the navicular. If one of these findings is positive and there is a history of immediate and persistent inability
to bear weight and walk 4 steps, then radiographs are required. The 12-point exam is designed to pick up
additional pathology to improve diagnosis, avoid missing important pathology, and allow greater efficiency
in the ordering and interpreting of x-ray films. This exam requires the clinician to inspect more structures
than patients commonly focus on when they report an "ankle sprain." The examination often includes other
important parts of the injured lower extremity.

  

Clinical Pearl
"Letting the foot slip into plantar flexion during the examination leads to
instability and produces erroneous clinical information."

— LOREN A. CROWN, MD

  

PRODUCED BY MARY DESMOND PINKOWISH

  

SUGGESTED READING

Stiell IG, Wells GA, Hoag RH, et al. Implementation of the Ottawa Knee Rule for the use of
radiography in acute knee injuries. JAMA. 1997;278: 2075-2079.

Stiell I, Wells G, Laupacis A, et al. Multicentre trial to introduce the Ottawa ankle rules for use of

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radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. 1995;311:594-
597.

  

The 12-point ankle examination. Patient Care May 2003;37:69-73.

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