SPECIAL TESTS

LOWER LEG, ANKLE, AND FOOT

TESTS FOR NEUTRAL POSITION OF THE TALUS

Neutral Position of the Talus (Weight-Bearing Position)

PROCEDURE:• The patient stands with the feet in a relaxed standing

position. The examiner palpates the head of the talus on the dorsal aspect of the foot with the thumb and forefinger of one hand. The patient is asked to slowly rotate the trunk to the right and then to the left, which causes the tibia to medially and laterally rotate so that the talus supinates and pronates.

POSITIVE TEST/IMPLICATION :• If the foot is positioned so that the talar head does not

appear to bulge to either side, then the subtalar joint will be in its neutral position in weight bearing

Neutral Position of the Talus (Supine)• PROCEDURE:The patient lies supine with the feet extending over the end of the examining table. The examiner grasps the patient's foot over the fourth and fifth metatarsal heads, using the thumb and index finger of one hand. The examiner palpates both sides of the head of the talus on the dorsum of the foot with the thumb and index finger of the other hand. The examiner then gently, passively dorsiflexes the foot until resistance is felt. While the examiner maintains the dorsiflexion, the foot is passively moved through an arc of supination (talar head bulges laterally) and pronation (talar head bulges medially). • POSITIVE TEST/IMPLICATION :If the foot is positioned so that the talar head does not appear to bulge to either side, the subtalar joint will be in its neutral nonweight- bearing.

Neutral Position of the Talus (Prone)• PROCEDURE:The patient lies prone with the foot extended over the end of the examining table. The examiner grasps the patient's foot over the fourth and fifth metatarsal heads with the index finger and thumb of one hand. The examiner palpates both sides of the talus on the dorsum of the foot, using the thumb and index finger of the other hand. The examiner then passively and gently dorsiflexes the foot until resistance is felt. While maintaining the dorsiflexed position, the examiner moves the foot back and forth through an arc of supination (talar head bulges later-ally) and pronation (talar head bulges medially). • POSITIVE TEST/IMPLICATION :As the arc of movement is performed, there is a point in the arc at which the foot appears to "falloff" to one side or the other more easily. This point is the neutral, non-weight-bearing position of the subtalar joint.

TESTS FOR ALIGNMENT

Leg-Heel Alignment• PROCEDURE:The patient lies in the prone position with foot extending over the end of the examining table. The examiner then places a mark over the midline of the calcaneus at the insertion of the Achilles tendon, makes a second mark ~1 cm distal to the first mark and as close to the midline of the calcaneus as possible. A calcaneal line is then made to join the two marks. Next, the examiner makes two marks on the lower third of the leg in the midline forming the tibial line, which represents the longitudinal axis of the tibia. The examiner then places the subtalar joint in the prone neutral position. While the subtalar joint is held in neutral, the examiner looks at the two lines. • POSITIVE TEST/IMPLICATION:If the lines are parallel or in slight varus (2° to 8°), the leg-to-heel alignment is considered normal. If the heel is inverted, the patient has hindfoot varus; if the heel is everted, the patient has hindfoot valgus

Forefoot- Heel Alignment• PROCEDURE:The patient lies supine with the feet extending over the end of the examining table. The examiner positions the subtalar joint in supine neutral position. While maintaining this position, the examiner pronates the midtarsal joints maximally and then observes the relation between the vertical axis of the heel and the plane of the second through fourth metatarsal heads. Normally, the plane is perpendicular to the vertical axis.

• POSITIVE TEST/IMPLICATION:If the medial side of the foot is raised, the patient has a forefoot varus; if the lateral side of the foot is raised, the patient has a forefoot valgus.

Coleman Block Test• PROCEDURE:This test differentiates a hindfoot varus resulting from a forefoot valgus from a hindfoot varus resulting from a tight tibialis posterior.If the patient is found to have a hindfoot varus in standing, the examiner places a lift or block under the lateral side of the forefoot. • POSITIVE TEST/IMPLICATION:If the hindfoot varus is corrected it indicates the hindfoot is flexible and the hindfoot varus is due to a plantar flexed first ray or a valgus forefoot. If it does not correct, the tibialisposterior is tight.

TESTS FOR TIBIAL TORSION

Tibial Torsion (Sitting)• PROCEDURE:Tibial torsion is measured by having the patient sit with the knees flexed to 90° over the edge of the examining table. The examiner places the thumb of one hand over the apex of one malleolus and the index finger of the same hand over the apex of the other malleolus. Next, the examiner visualizes the axes of the knee and of the ankle. • POSITIVE TEST/IMPLICATION:The lines are not normally parallel but instead form an angle of 12° to 18° owing to lateral rotation of the tibia.

Tibial Torsion (Supine)• PROCEDURE:The examiner ensures that the femoral condyle lies in thefrontal plane (patella facing straight up). The examinerpalpates the apex of both malleoli with one hand anddraws a line on the heel representing a line joining thetwo apices. A second line is drawn on the heel parallelto the floor. The angle formed by the intersection of thetwo lines indicates the amount of lateral tibial torsion.• POSITIVE TEST/IMPLICATION:If the hindfoot varus is corrected it indicates the hindfoot is flexible and the hindfoot varus is due to a plantar flexed first ray or a valgus forefoot. If it does not correct, the tibialis posterior is tight.

Tibial Torsion (Prone)

• PROCEDURE:knee flexed to 90°. The examiner views from above the angle formed by the foot and thighafter the subtalar joint has been placed in the neutral position, noting the angle the foot makes with the tibia. This method is most often used in children because it is easier to observe the feet from above.

"Too Many Toes" Sign• The patient stands in a normal relaxed position while the

examiner views the patient from behind. If the heel is in valgus, the forefoot abducted, or the tibia laterally rotated more than normal (tibial torsion), the examiner can see more toes on the affected side than on the normal side.

• Similarly, lateral femoral torsion could cause the "too many toes" test to be positive.

• If the talus is positioned in neutral and the calcaneus is in neutral, the "too many toes" sign means the forefoot is adducted on the rearfoot and may be seen with excessive pronation (hyperpronation).

• Hyperpronation is often associated with metatarsalgia, plantar fasciitis, hallux valgus, and posterior tibial tendon pathology.

TESTS FOR LIGAMENTOUS INSTABILITY

Anterior Drawer Test of the AnklePROCEDURE• designed primarily to test for injuries to the anterior• talofibular ligament• The patient lies supine with the foot relaxed. The

examiner stabilizes the tibia and fibula, holds the patient's foot in 20° of plantar flexion, and draws the talus forward in the ankle mortise

POSITIVE TESTExcessive anterior translation. Sometimes, a dimple appears over the area of the anterior talofibular ligament on anterior translation (dimple or suction sign) if pain and muscle spasm are minimal

Prone Anterior Drawer Test

PROCEDURE• The patient lies prone with the feet extending

over the end of the examining table. With one hand, the examiner pushes the heel steadily forward

POSITIVE TEST• Excessive anterior movement and a “sucking

in” of the skin on both sides of the Achilles tendon.

Talar Tilt Test

PROCEDURE• The patient lies in the supine or side lying

position with the foot relaxed. The foot is held in the anatomic (90°) position, which brings the calcaneofibular ligament perpendicular to the long axis of the talus. Talus is then tilted from side to side into adduction and abduction

POSITIVE TEST• Excessive movement on adduction

Squeeze Test of the LegPROCEDURE• The patient lies supine.• The examiner grasps the lower leg at midcalf and

squeezes the tibia and fibula togetherPOSITIVE TEST• Pain in the lower leg may indicate a syndesmosis

injury, provided that fracture, contusion, and compartment syndrome have been ruled out

External Rotation Stress Test (Kleiger Test)

PROCEDURE• The patient is seated with the leg hanging over the

examining table with the knee at 90°. The examiner faces the leg, holds the foot in plantigrade (90°) and applies a

• passive lateral rotation stress to the foot and anklePOSITIVE TEST• positive for a syndesmosis injury if pain is

produced over the anterior or posterior tibiofibular ligaments and the interosseous membrane

Point (Palpation) Test

PROCEDURE• The patient is positioned in sitting or supine. The

examiner then applies a gradual pressure over the anteroinferior tibiofibular ligament (anterior aspect of the distal tibia fibular syndesmosis)

• using the index finger POSITIVE• Pain in the syndesmosis area

Cotton Test

PROCEDURE• The examiner stabilizes the distal tibia and

fibula with one hand and applies a medial and lateral translation force

POSITIVE TEST• Any lateral translation (3 to 5mm) or clunk

indicates syndesmotic instability.

Dorsiflexion ManeuverPROCEDURE• The patient sits on the edge of the table. The

examiner stabilizes the patient’s leg with one hand and with the other hand passively and forcefully dorsiflexes the foot by holding onto the heel and using the forearm to dorsiflex the foot

POSITIVE TEST• Pain on forced dorsiflexion indicates a positive

test

Dorsiflexion Compression TestPROCEDURE• While in bilateral weight-bearing, the patient is asked to

move his or her ankle into extreme. The patient is asked to note whether this maneuver is painful while the examiner notes the end range of motion. The patient then assumes a normal standing position again. The examiner applies a compression force using two hands surrounding the malleoli of the injured leg. While this compression is maintained, the patient is asked to move into dorsiflexion again.

POSITIVE TEST• A decrease in pain on dorsiflexion or an increase in

dorsiflexion range

Crossed Leg TestPROCEDURE• The patient sits in a chair with the affected leg

crossed over the opposite knee so the midpoint of the fibula is resting on the opposite knee. The examiner then applies a gentle force to the medial aspect of the knee of the injured leg.

POSITIVE TESTPain in the area of the distal syndesmosis

Heel Thump Test• The patient is in sitting or lying. The examiner uses

one hand to stabilize the leg. With the other hand, the examiner applies a firm thump on the heel with the fist so that the force is applied to the center of the heel and in line with the long axis of the tibia.

• A positive test (i.e., pain) in the area of the ankle indicates a syndesmosis injury. Pain along the shaft of the tibia may indicate a stress fracture.

Thompson’s (Simmond’s) Test• For Achilles tendon rupturePROCEDURE• The patient lies prone or kneels on a chair with

the feet over the edge of the table or chair. While the patient is relaxed, the examiner squeezes the calf muscles.

POSITIVE TESTAbsence of plantar flexion

Figure-8 Ankle Measurement

The measurement is repeated three times and an average taken.

Test for Peroneal Tendon Dislocation

PROCEDURE• The patient is placed in prone on the examining

table with the knee flexed to 90°. The posterolateral region of the ankle is inspected for swelling. The patient is then asked to actively dorsiflex and plantar flex the ankle along with eversion against the examiner's resistance

POSITIVE TEST• tendon subluxes from behind the lateral

malleolus

Patla Tibialis Posterior Length Test

PROCEDURE• prone lying with the knee flexed to 90° • calcaneus held in eversion and the ankle in

dorsiflexion with one hand. • With the other hand, the examiner's thumb contacts

the plantar surface of the bases of the second, third, and fourth metatarsals while the index and middle fingers contact the plantar surface of the navicular. The examiner then determines the end feel by pushing dorsally on the navicular and metatarsal heads. The end feel is compared with the normal side.

Patla Tibialis Posterior Length Test

POSITIVE TEST• Reproduction of the

patient's symptoms

Swing Test for Posterior Tibiotalar Subluxation

PROCEDUREThe patient sits with feet dangling over the edge of the examining table. The examiner places the hands around the dorsum of the foot using the fingers to keep the feet parallel to the floor. With the thumbs, the examiner palpates the anterior portion of the talus. The examiner then passively plantar flexes and dorsiflexes the foot and compares the quality and degree of movement between feet, especially into dorsiflexion.POSITIVE TESTResistance to normal dorsiflexion in the injured ankle (+) posterior tibiotalar subluxation.

Feiss LinePROCEDURE• The examiner marks the apex of the medial malleolus and the

plantar aspect of the first metatarsophalangeal joint while the patient is not bearing weight, palpates the navicular tuberosity on the medial aspect of the foot, noting where it lies relative to a line joining the two previously made points. The patient then stands with the feet 8 to 15 cm (3 to 6 inches) apart.

• The two points are checked to ensure that they still represent the apex of the medial malleolus and the plantar aspect of the metatarsophalangeal joint. The navicular tubercle is again palpated. The navicular tubercle normally lies on or close to the line joining the two points.

POSITIVE TEST• If the tubercle falls one third of the distance to

the floor, it represents a first-degree flatfoot; if it falls two thirds of the distance, it represents a second-degree flatfoot; if it rests on the floor, it represents a third-degree flatfoot.

Hoffa’s TestPROCEDURE• The patient lies prone with the feet extended over

the edge of the examining table. The examiner palpates the Achilles tendon while the patient plantar flexes and dorsiflexes the foot.

POSITIVE TEST• If one Achilles tendon (the injured one) feels less

taut than the other one, the test is (+) calcaneal fracture.

• Passive dorsiflexion on the affected side is also greater.

Tinel's Sign at the Ankle (Percussion Sign)

PROCEDURE• Tinel's sign may be elicited in two places around

the ankle. The anterior tibial branch of the deep peroneal nerve may be percussed in front of the ankle. The posterior tibial nerve may be percussed as it passes behind the medial malleolus.

POSITIVE TEST • tingling or paresthesia

Duchenne Test• Lesion of the superficial peroneal nerve (L4-S1)PROCEDUREThe patient lies supine with the legs straight. The examiner pushes up on the head of the first metatarsal through the sole, pushing the foot into dorsiflexion.POSITIVE TESTwhen the patient is asked to plantar flex the foot, the medial border dorsiflexes and offers no resistance while the lateral border plantar flexes

Morton’s Test

Test for fracture or neuromaPROCEDURE• The patient lies supine. The examiner grasps the

foot around the metatarsal heads and squeezes the heads together.

POSITIVE TESTPain

Homan’s SignPROCEDURE• The patient’s foot is passively dorsiflexed with

the knee extended. POSITIVE TEST• Pain• Tenderness is also elicited on palpation of the

calf. In addition to these findings, the examiner may find pallor and swelling in the leg and a loss of the dorsalis pedis pulse.

Buerger’s TestPROCEDURE• The patient lies supine while the examiner

elevates the patient's leg to 45° for at least 3 minutes.

POSITIVE TEST• If the foot blanches or the prominent veins

collapse shortly after elevation, the test is positive for poor arterial blood circulation. The examiner then asks the patient to sit with the legs dangling for 1-2 mins. Limb color is restored and test is confirmed positive.