Special Tests: Ankle Joint

Special Tests Covered in this Lesson:

• Ligament Tests
  • Ankle Anterior Drawer Test
  • Medial Subtalar Glide Test
  • Talar Tilt Test
• Impingement Signs
  • Liu et al. Clinical Prediction Rule for Impingement
• Pronation
  • Navicular Drop Test
• Red Flags (Fracture)
  • Ottawa Ankle and Foot Rules

Knee special tests for ligament injuries are relatively accurate, and research demonstrates that their inclusion in a routine combination of exams (patient history, movement assessment, radiography, special tests) results in diagnostic accuracy equivalent to MRI. Generally, the occurrence of knee ligament injury is correlated with acute trauma. Anterior cruciate ligament injuries (ACL) injuries are the most commonly reported, especially during sports; however, most traumatic ACL injuries occur in conjunction with some damage to the other large ligament of the knee (e.g. most commonly the collateral ligaments). When compared to the other major ligaments of the knee, posterior cruciate ligament (PCL) injuries are relatively rare, and most often occur in conjunction with damage to other major ligaments. Clinical movement professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) should be aware of the special tests for ligament injuries, as assessment of a ligament injury should result in referral for further testing and potentially a surgical consultation.

Ankle Test Selection:

After reviewing the research on ankle special tests, it may be worth noting that there are relatively few studies investigating their accuracy or reliability. An attempt has been made in this course to choose the "Best Tests", starting with the careful exclusion of any tests that were unlikely to improve diagnostic accuracy over chance; and further, excluding weak tests that were related to diagnoses rarely seen in an orthopedic setting. Useful ankle tests fell into three categories: ligament integrity, ankle impingement, and ankle fracture. The Navicular Drop Test has been added to this course only due to convention. That is, it is often considered a "special test"; however, it functions like a goniometric assessment.

The limited research available suggests that ankle ligament integrity tests have moderate to good accuracy. The Ankle Anterior Drawer Test exhibits good sensitivity and specificity, and the Medial Subtalar Glide Test and Talar Tilt Tests exhibit better specificity than sensitivity (4, 5). Research investigating reliability should be done given the potential for subjectivity in determining "excessive motion"; further, some evidence suggests these tests have limited clinical utility for first-time ankle sprains (7). It is likely good practice to consider the results of these tests with healthy skepticism. A positive result may be quite obvious, but questionable results should lead to recommendations for further evaluation.

Research indicates that ankle impingement syndrome is likely best assessed with the Liu et al. Clinical Prediction Rule for Impingement which exhibited better accuracy than the Forced Dorsiflexion Test (1, 9). Exhibiting five of six symptoms of the Liu et al. Cluster is considered a positive test for ankle impingement.

Research indicates the Ottawa Ankle and Foot Rules  are more sensitive than specific, although specificity is also high (15 - 19). Several studies have been performed validating the high accuracy and the cost-benefit of implementing these rules in a hospital setting (18-21). Clinical movement professionals should be aware of these criteria, as a fracture is a contraindication to most interventions.

Last, research indicates that the Navicular Drop Test is reliable (10-14), but there is no accuracy data. Based on the function of this test, this should not be surprising. A measurement related to the range of joint motion is goniometry , and not an assessment of pathology. The Brookbush Institute uses this test as a continuous interval measure to track the efficacy of interventions intended to improve pronation.

Brookbush Institute Recommendation:

The Brookbush Institute recommends that all clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are aware of these tests. The Ankle Anterior Drawer Test , Medial Subtalar Glide Test , and Talar Tilt Tests can highlight ligament injuries that result in significant ankle instability and imply that further testing is strongly indicated. The Ottawa Ankle and Foot Rules highlight the potential of ankle or foot fracture, a "red flag" issue, which implies immediate referral for further testing. The Liu et al. Clinical Prediction Rule for Impingement is accurate, but the diagnosis of ankle impingement likely has limited clinical utility. An awareness of the signs and symptoms described in the cluster is likely best used as identifying remarks by patients during a subjective examination. Last, The brookbush Institute recommends using the Navicular Drop Test can be used as a continuous interval measure to track the efficacy of interventions intended to improve pronation.

For an Introduction to Special Tests

• For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:
• Special Tests: Introduction

Courses covering Special Tests for the Lower Extremity

• Special Tests: Sacroiliac Joint (SIJ)
• Special Tests: Hip Joint
• Special Tests: Lower Body Neurodynamic Tests
• Special Tests: Knee Ligament Tests
• Special Tests: Knee - Meniscus Tears, Patellofemoral Pain and Fracture

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Text and Illustrations
• Audio Voice-over
• Technique Videos
• Practice Exam
• Pre-approved Final Exam

1. Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.
2. Dutton, M. (2012). Dutton's Orthopaedic examination, evaluation, and intervention. McGraw-Hill Medical.
3. Magee, D. J. (2013). Orthopedic physical assessment. Elsevier Health Sciences.
   • Anterior Drawer Test and Medial Subtalor Glide Test
4. Hertel, J., Denegar, C. R., Monroe, M. M., & Stokes, W. L. (1999). Talocrural and subtalar joint instability after lateral ankle sprain. Medicine and Science in sports and exercise, 31(11), 1501-1508.
5. Phisitkul, P., Chaichankul, C., Sripongsai, R., Prasitdamrong, I., Tengtrakulcharoen, P., & Suarchawaratana, S. (2009). Accuracy of anterolateral drawer test in lateral ankle instability: a cadaveric study. Foot & ankle international, 30(7), 690-695.
6. Tohyama, H., Beynnon, B. D., Renström, P. A., Theis, M. J., Fleming, B. C., & Pope, M. H. (1995). Biomechanical analysis of the ankle anterior drawer test for anterior talofibular ligament injuries. Journal of Orthopaedic Research, 13(4), 609-614.
7. Doherty, C., Bleakley, C., Hertel, J., Caulfield, B., Ryan, J., & Delahunt, E. (2018). Clinical Tests Have Limited Predictive Value for Chronic Ankle Instability When Conducted in the Acute Phase of a First-Time Lateral Ankle Sprain Injury. Archives of physical medicine and rehabilitation, 99(4), 720-725.
   • Medial and Lateral Talar Tilt Tests (4)
8. Rosen, A. B., Ko, J., & Brown, C. N. (2015). Diagnostic accuracy of instrumented and manual talar tilt tests in chronic ankle instability populations. Scandinavian journal of medicine & science in sports, 25(2), e214-e221.
   • Ankle Impingement
9. Liu, S. H., Nuccion, S. L., & Finerman, G. (1997). Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. The American journal of sports medicine, 25(3), 389-393.
   • Navicular Drop Test
10. Loudon, J. K., & Bell, S. L. (1996). The foot and ankle: an overview of arthrokinematics and selected joint techniques. Journal of athletic training, 31(2), 173.
11. Picciano, A. M., Rowlands, M. S., & Worrell, T. (1993). Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test. Journal of Orthopaedic & Sports Physical Therapy, 18(4), 553-558.
12. Sell, K. E., Verity, T. M., Worrell, T. W., Pease, B. J., & Wigglesworth, J. (1994). Two measurement techniques for assessing subtalar joint position: a reliability study. Journal of Orthopaedic & Sports Physical Therapy, 19(3), 162-167.
13. Smith, J., Szczerba, J. E., Arnold, B. L., Perrin, D. H., & Martin, D. E. (1997). Role of hyperpronation as a possible risk factor for anterior cruciate ligament injuries. Journal of athletic training, 32(1), 25.
14. Vinicombe, A., Raspovic, A., & Menz, H. B. (2001). Reliability of navicular displacement measurement as a clinical indicator of foot posture. Journal of the American Podiatric Medical Association, 91(5), 262-268.
    • Ottawa Ankle and Foot Rules
15. Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & ter Riet, G. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. Bmj, 326(7386), 417.
16. Dowling, S., Spooner, C. H., Liang, Y., Dryden, D. M., Friesen, C., Klassen, T. P., & Wright, R. B. (2009). Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta‐analysis. Academic Emergency Medicine, 16(4), 277-287.
17. Dissmann, P. D., & Han, K. H. (2006). The tuning fork test—a useful tool for improving specificity in “Ottawa positive” patients after ankle inversion injury. Emergency medicine journal, 23(10), 788-790.
18. Plint, A. C., Bulloch, B., Osmond, M. H., Stiell, I., Dunlap, H., Reed, M., … & Klassen, T. P. (1999). Validation of the Ottawa Ankle Rules in children with ankle injuries. Academic Emergency Medicine, 6(10), 1005-1009.
19. Auleley, G. R., Kerboull, L., Durieux, P., Cosquer, M., Courpied, J. P., & Ravaud, P. (1998). Validation of the Ottawa ankle rules in France: a study in the surgical emergency department of a teaching hospital. Annals of emergency medicine, 32(1), 14-18.
20. Anis, A. H., Stiell, I. G., Stewart, D. G., & Laupacis, A. (1995). Cost-effectiveness analysis of the Ottawa Ankle Rules. Annals of emergency medicine, 26(4), 422-428.
21. Stiell, Ian, George Wells, Andreas Laupacis, Robert Brison, Richard Verbeek, Katherine Vandemheen, and C. David Naylor. "Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries." Bmj 311, no. 7005 (1995): 594-597.
    • Additional Research
22. Van Dijk, C. N., Lim, L. S. L., Bossuyt, P. M. M., & Marti, R. K. (1996). Physical examination is sufficient for the diagnosis of sprained ankles. The Journal of bone and joint surgery. British volume, 78(6), 958-962.
23. Aradi, A. J., Wong, J., & Walsh, M. (1988). The dimple sign of a ruptured lateral ligament of the ankle: brief report. The Journal of bone and joint surgery. British volume, 70(2), 327-328.