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