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Special tests for the ankle joint. Ankle Anterior Drawer Test, Medial Subtalar Glide Test, Talar Tilt Test, Impingement Signs, Liu et al. Clinical Prediction Rule for Impingement, Navicular Drop Test, Ottowa Ankle, and Foot Rules. The reliability, specificity, sensitivity, validity, safety, and screening for ankle joint, ankle pain, chronic ankle instability, ankle ligament (ATFL), subtalar joint stability/integrity, collateral ligament integrity, ankle impingement, ankle and foot fractures. 

Special Tests: Ankle Joint

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I have almost completed my CPT certification and am half-way through the Human Movement certification to inform my massage practice. The different modalities of reading, watching audiovisual materials, and attending live or recorded webinars have been important to my learning style and for review.

Brookbush Institute has the most detailed, specific and effective tools for online learning for movement and/or bodywork professionals. I love the combination of the videos as well as the text available online.

I recently completed the CPT course. It was demanding yet practical. I would highly recommend it for anyone wanting an education about human movement.

I have my personal trainer certificate through here and am almost finished my human movement specialist certification. Overall, the education that Brookbush has packaged together for clinicians and trainers is invaluable. I am a physio assistant so coming from more of a rehab background I appreciate that this education has been beneficial both as a trainer and in a rehab setting. I love that I have been able to do all learning at my own pace and able to work around my schedule. Thank you for setting up this platform! Highly recommend :)

I have been a massage therapist for 10 yrs and I feel like all the “pieces” I’ve learned throughout the yrs have been put into place and can see the full picture. I am also a member to tons of great content since I love to learn! I plan to get my CPT through them as well.

I have been following Brent Brookbush for nearly a decade- back when I was a personal Trainer and now as a Physical Therapist. BBI is an incredible resource for any movement nerds and corrective exercise specialists! The information is thorough with multiple real world applications. I am looking forward to an in-person Manual Therapist course the second they do one a little bit closer to Virginia ;)

I have taken both the Human Movement Specialist and Certified Personal Trainer certificate programs and have found the value in understanding the how and ways the body moves and functions and from evidence, non-biased, outcome, conceptual, theoretical, and practical approach to helping my clients/patients look better, feel better, and move better.

Over the last years I've returned time and again to Brookbush Institute for stellar coursework as I've worked toward a Human Movement Specialist certification. (I'm currently ACE CPT, and in training with Anatomy Trains for Structural Integration Manual Therapy.) Every Brookbush Institute module is fantastic and each one includes detailed informational videos, written descriptions of how to-do, and, more importantly, why to-do!

I am a 70 yr old chiropractor and no other healthcare provider was able to come up with an exercise protocol particular to my structural and balances and muscle deficits and keep me in the game. And as for continuing education on human skeletal movement, the website is phenomenal full of great exercises for particular mechanical dysfunction.

The H.M.S. is the most valuable certificate I have earned and was a fraction of the the cost of my others. Define the best bang for your buck!

Brookbush is the most efficient Personal Training Certification I have ever come across. All the lessons are well thought out and very straight to the point.

I am getting my Master's degree in Kinesiology, and I would like to say that I have benefited greatly from the rich, comprehensive, well-documented scientific content of Brookbush Institute that links theory to practical applications. Proudly I've got my CPT certificate, and I am on my way to get my HMS certificate.

Having courses count towards different certifications makes it so users can transition seamlessly from one certification to another. In my case, going from earning the BI CPT to earning the BI HMS was an easy decision and I am proud to have earned both certifications. I have also had the pleasure of going to a Live HMS workshop that was well taught by Instructor Boettcher and that was excellent to see how the methods and techniques are implemented.



I have been a member of BBI for years and every course I have taken has been incredibly informative. I learn more from these courses than I do at local CEU courses for my PTA license. I also earned my CPT and HMS certifications through the platform. It was so convenient and the content was top notch! Forever member.

We learn principles in academia, we learn cool new modalities via whatever specialty certification, but BBI really concentrates on the nuances of passive treatment and they do a fantastic job. The format in which BBI instructs soft tissue specialists (DPTs, Chiros, ATs) like myself feels like almost like an apprenticeship. You get a thoroughly detailed explanation of the “why’s”, and a visual comprehension of how to apply. Personally, I believe application is where the good and the great are distinguished.

Brookbush has been incredibly helpful since I was in massage school and now as I’m in my career! I run my own practice and it gives me the resources I need to not only improve what I already know, but also help me navigate better, more efficient ways of treatment.

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Challenging concepts are explained in very understandable terms without dumbing down the material, and I find this program to be superior in quality to other personal training programs.

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Liu et al. Clinical Prediction Rule for Impingement

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.

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 

 exhibits good sensitivity and specificity, and the 

 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 

 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.

 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.

 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 

, 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.

 recommends that all clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) are aware of these tests. The 

 can highlight ligament injuries that result in significant ankle instability and imply that further testing is strongly indicated. The 

 highlight the potential of ankle or foot fracture, a "red flag" issue, which implies immediate referral for further testing. The 

 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 

 can be used as a continuous interval measure to track the efficacy of interventions intended to improve pronation.

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:

Courses covering Special Tests for the Lower Extremity

Special Tests: Lower Body Neurodynamic Tests

Special Tests: Knee - Meniscus Tears, Patellofemoral Pain and Fracture

Course Description: Special Tests: Ankle Joint

Introduction

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

Reviewing the research on tests for the ankle, a general statement may be made about the lack of research investigating their accuracy. Very few high quality studies are currently available. An attempt has been made in this course to choose the "Best Tests" for the orthopedic clinician. This started with the careful exclusion of any test that was unlikely to improve diagnostic accuracy over chance, and further exclude 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 due to convention; it is often considered a "special test" despite functioning like a 

Ankle Anterior Drawer & Medial Subtalar Glide Test

Medial and Lateral Talar Tilt

Ankle and Foot Bones and Ligaments

Ligament Integrity

Ankle Impingement

Liu et al. Clinical Prediction Rule (CPR) for Anterior Impingement

Five of six symptoms is considered positive for Anterior Ankle Impingement

Pain with single-leg squat on the affected side

Ankle Joint Range of Motion

Pronation - Navicular Drop Test

The examiner manually cues the patient into neutral pronation supination (subtalar neutral).

This position may be found by using the index finger and thumb to palpate the talus on the medial and lateral sides, just inferior to the malleoli, and adjusting the talus back and forth until medial and lateral aspects of the talus are felt in equal amounts in each finger.

The examiner then palpates the navicular tubercle and marks it with a pen.

A 3 x 5 card may be used to document the height between the ground and the navicular tubercle.

The examiner may have the patient relax, or take several steps and then relax. The examiner then takes the measurement again in the patient's "normal" stance.

A significant difference between one side in comparison to the opposite is considered a positive finding.

Note: The Brookbush Institute prefers to use a ruler and track the progress of this metric as a continuous interval measure; similar to the way 

Feet Flatten

Ottowa Ankle and Foot Rules

Ottawa Ankle and Foot Rules

Red Flags 

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

Anterior Drawer Test and Medial Subtalor Glide Test

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

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. 

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. 

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

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

Liu, S. H., Nuccion, S. L., & Finerman, G. (1997). Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. 

Loudon, J. K., & Bell, S. L. (1996). The foot and ankle: an overview of arthrokinematics and selected joint techniques. 

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

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. 

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. 

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

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. 

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. 

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. 

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. 

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. 

Anis, A. H., Stiell, I. G., Stewart, D. G., & Laupacis, A. (1995). Cost-effectiveness analysis of the Ottawa Ankle Rules. 

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." 

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

Aradi, A. J., Wong, J., & Walsh, M. (1988). The dimple sign of a ruptured lateral ligament of the ankle: brief report. 

Bibliography

Questions, comments, and criticisms are welcomed and encouraged

Special Tests: Ankle Joint

Related Courses:

Course Description: Special Tests: Ankle Joint

Introduction

Ligament Integrity
2 Sub Sections

Ankle Impingement

Pronation - Navicular Drop Test

Red Flags
1 Sub Section

Bibliography

Related Courses:

Comments

Guest

Special Tests: Ankle Joint

Related Courses:

Course Description: Special Tests: Ankle Joint

Introduction

Ligament Integrity2 Sub Sections

Ankle Impingement

Pronation - Navicular Drop Test

Red Flags 1 Sub Section

Bibliography

Related Courses:

Comments

Guest

Ligament Integrity
2 Sub Sections

Red Flags
1 Sub Section