Ligament Tests for Ankle Injuries

Anterior Drawer Test

Assesses: Anterior talofibular ligament (ATFL)

Position: Knee joint in flexion and ankle in 10-15 degrees plantar flexion

Maneuver: The examiner exerts a downward force on the tibia while simultaneously attempting to “lift up” the foot while grasping behind the heel.

Interpretation: A significant difference from the unaffected side (>2 mm) or dimpling of the anterior skin (suction or dimple sign) is considered positive.

A: Anterior drawer test; B: Talar tilt test
Source: Polzer H, Kanz KG, Prall WC, Haasters F, Ockert B, Mutschler W, Grote S. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia). 2012 Jan 2;4(1):e5. doi: 10.4081/or.2012.e5. Epub 2011 Dec 14. PMID: 22577506; PMCID: PMC3348693. (CC BY-NC 3.0)

Talat Tilt Test

The patient is positioned in sitting or supine lying with the knee in full extension. The examiner stabilizes the distal leg with one hand while the other hand holds the heel with the ankle:

a. Assess Anterior talofibular ligament: Plantar flexion – inversion

b. Assess Calcaeno-fibular ligament: Neutral position – inversion

c. Assess Posterior talofibular ligament: Dorsiflexion – inversion

d. Assess Deltoid ligament: Plantar flexion – eversion

e. Assess Syndesmotic (high ankle) sprain: Dorsiflexion – eversion

The lateral ankle ligaments consist of:
1. Anterior talofibular ligament (ATFL)
2. Calcaneofibular ligament (CTFL)
3. Posterior talofibular ligament (PTFL)

Involvement in sprains: ATFL > CFL > PTFL

CFL is the only extra-capsular ligament among these 3.

Grading or Classification of Lateral ankle sprains:

GradeHematoma/swelling/tendernessAnterior drawer testTalar tilt testAnatomic lesionStabilityTreatment
1PositiveNegativeNegativeIncomplete tear of ATFLStablePRICE, NSAID, Early weight bearing and Exercise for range of motion
2PositivePositiveNegativeComplete tear of ATFL
Incomplete tear of CFL
UnstableSemirigid ankle brace and Supervised rehabilitation; Surgery for chronic instability
3PositivePositivePositiveComplete tear of ATFL
Complete tear of CFL
UnstableSame as for grade 2

Tests for Ankle syndesmosis

A: External rotation test; B: Squeeze test; C: Crossed leg test
Source: Polzer H, Kanz KG, Prall WC, Haasters F, Ockert B, Mutschler W, Grote S. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia). 2012 Jan 2;4(1):e5. doi: 10.4081/or.2012.e5. Epub 2011 Dec 14. PMID: 22577506; PMCID: PMC3348693. (CC BY-NC 3.0)

Ankle syndesmosis consists of 4 ligaments:
1. Anterior inferior tibiofibular ligament (AITFL)
2. Posterior inferior tibiofibular ligament (PITFL)
3. Interosseous ligament (IOL)
4. Deltoid ligament

The 3 ligaments other than deltoid ligament is often referred to as lateral ligament.

Interpretation: Positive if pain is reproduced in the area of syndesmosis

Maneuvers:

  1. External rotation test: Tibia is fixed with one hand and external rotation stress is applied to ankle with other
  2. Squeeze test: Tibia and fibular are squeezed above the midpoint of calf
  3. Crossed leg test: The patient is seated and the tested leg is crossed at the junction of middle and distal 3rd (pivot point) upon the non-injured knee and a downward force is applied by the patient or examiner on the medial aspect of the knee on the tested side

Grading of syndesmotic injuries:

GradeClinicalX-rayAnatomic lesionStabilityManagement
1Pain upon palpation of AITFLNormalIncomplete tear of lateral ligamentsStableNon-operative
2+ Positive external rotation and squeeze testNormalComplete tear of AITFL and IOLStable/UnstableNon-operative/Operative
3All tests positive>2mm medial clear space widening and/or widened syndesmosisComplete injury to lateral ligaments (AITFL, IOL, PITFL) and deltoid ligament avulsionUnstableOperative


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