so now we're going to actually measure range of motion of the ankle which is honestly the one measurement that we would use more often when compared to the toes toes very rare clinical measurement but certainly ankle measurements are important specifically after an ankle sprain so we're going to talk about four different measurements for range of motion the first and probably most common is going to be dorsiflexion range of motion so dorsiflexion is when those feet or toes are going towards the shin okay so in terms of our goniometer anatomy we want to make sure of is that the fulcrum or fixed arm right is going to be on the lateral side of the limb you want to make sure that this metal piece right here is going to be on the lateral malleolus and your movement arm is going to be moving with the fifth metatarsal so let me just show you positioning first okay so metal piece right on the center portion of your fibula you guys might say well how do i know that this is uh where it needs to be so the first thing i'm going to do is have to find that fibular head and then what i typically do i'll extend my finger out to make sure that it's in alignment okay guys so now that i know that this is aligned now that i have my metal piece where i need it to be what i typically do clinically is just place the goniometer at zero degrees or for some of you what we consider to be 90 degrees okay and then what i'll have my patient do is go ahead and dorsiflex keep going suze and i'll look and i'll i'll make sure that this line is very parallel to that fifth metatarsal keep pushing shoes if you can great so in this instance what we would say is suez has about five degrees of dorsiflexion range of motion now you all might be saying well what's normative normative is 15 to 20 degrees of dorsiflexion range of motion which means what about our patient that she is lacking dorsiflexion range of motion which is a terrible thing to lack because what that means is is that she's lacking dorsiflexion the foot's in more plantar flexion which then means she's more susceptible to ankle sprain moments so i would ask my patient a historical question have you sprained your ankle before have you sprained your ankle multiple times and one of the reasons that our patient might be saying yes is because that she's not getting enough dorsiflexion range of motion okay now we're going to move into plantar flexion and believe it or not the setup is the same as it would be for dorsiflexion so stationary arm here metal piece right at the distal portion or tip of the fibula i'm just going to measure to make sure that this is bisecting that fibular head and then what i'm going to have my patient do is i'm going to stabilize here i'm at my patient point their toes down as far as they can go and then i'm going to take that goniometer and i'm going to do the same thing now you're going to be tempted to take it all the way down here but remember we want this black line to be very parallel to that fifth metatarsal so what we're going to do here is we're going to start again and we're going to start at 90. zeus go ahead and flex for me what i'm going to do is look at how much range of motion sews has so seuss has approximately 48 degrees of dorsiflexion range of motion so for plantar reflection she's not lacking because the normal range of motion for plantar flexion is 40 to 50 degrees of plantar reflection range of motion but with that being said there is a subset of population who will have upwards of 70 to 80 degrees of plantar flexion those people are known as dancers acrobatists and gymnasts right because they're going to spend a lot of time in that point position or plantar flex position so don't be alarmed if you get a patient who has 70 to 80 degrees of plantar flexion that would be their what we call new normal okay so we've done dorsiflexion range of motion we've completed plantar flexion range of motion now what we're going to do is assess in version and e version range of motion and what you might notice as you're doing this is number one when we move into inversion we get a lot more inversion than we do eversion right and if you guys are stewards of the anatomy what you would know is that this fibula right on the lateral side comes down more inferiorly than its medial counterpart the tibia so for that reason we can't really move into eversion as much because that fibula is blocking us from moving right whereas on this inversion moment the tibia isn't as long so we can get more motion of the foot so you should expect that when you're measuring your range of motion so with that said with inversion range of motion what we want to do is place the stationary arm of the goniometer along the tibial crest of the bone of the tibia want to place that metal portion of the goniometer in the center of the taylor dome so you'll have to know your anatomical structures so we're going to place that in the center of the taylor dome and make sure this is aligned to the tibial crest and this movement piece is going to bisect the second phalange okay and it's going to move with the second phalange it's important to keep this in mind so if i say to my patient please take your toe and point it inward i'm going to move in this direction here and i'm going to see that suze has 35 degrees of inversion range of motion right you might be saying well what's normal about 15 to 20 right so this is a patient who either spends a lot of time in an inversion moment right and has stretched those ligaments because she has 15 more degrees of inversion range of motion than the normal person would okay then we're gonna have our patient do is go back to just a neutral position and then we're gonna have her push her pinky toe out as far as she can so i'm not kidding you guys when i say that she has exactly zero degrees of eversion range of motion but let me take off the goniometer so you can actually see that visually with your own eyes i'm not making this up right the ideal would be if we're measuring eversion range of motion that your patient would have about five to ten degrees and so what that tells me is she's not maximizing the appropriate amount of motion in the foot but it also tells me that she's spending more time in which direction guys if she can't get any version then she has to be spending more time in inversion right which obviously tells us something she had increased plantar flexion she has increased inversion not enough eversion does it make sense why she continues to sprain her ankle over and over again these are the things in your clinical practice that you have to pay attention to if you really truly want to figure out what is going on with your patient okay so we're moving into ligamentous testing of of the foot and the ankle we're going to start with the most injured ligament in the foot in the ankle which is the anterior talofibular ligament so with that said in order to test the anterior talofibular ligament you have to perform what is called the anterior drawer test the anterior door test can be performed in a few different positions i'm going to show you each of those positions and then make the argument for one of them being the better clinical way to assess uh the anterior talofibular ligament so in with your patients seated with their knee extended uh with their foot hanging off the edge of the table and in a neutral position you are going to do the following you are going to cup the calcaneus just like this you're going to stabilize distal tibia i want to be clear here that we should not be stabilizing right over the ankle joint because that's where they're probably going to be painful right so you're going to get false positive want to make sure we're above the ankle joint to avoid causing pain the next thing that we want to do is make sure that our our hand that's on the calcaneus is in a really good position to support the patient's foot right the last thing we want to do is drop an ankle sprain patient because they won't trust us so what i typically do is cup the calcaneus and make sure that that foot is resting on my forearm right many of you might say what if they have sweaty feet you can wash your forearms after you're done right so stabilize here and then what we're going to do is what's called an anterior drawer test the purpose the function of the anterior drawer test is to glide that calcaneus anteriorly so ultimately what i want is my patient's second ray to kind of touch my nose that's the direction in which i want to do this drawer my teacher taught me that when you do this test you want it to behave like you're pulling your drawer out of your dresser there isn't any upward or downward movement it's just a fluid movement out of out of the socket so same thing here stabilize here make sure you're cupping the calcaneus and you know i think of digits 2 and um or three and four on the achilles and i'm ready to go right so the direction of pull is going to be one from a posterior to an anterior position and it is a slow subtle pull do you guys see that so we're here here and i could keep going right you want to go until you either get an infill right that means a block something's stopping you most often that's going to be that ligament or they have pain right so it's here anterior this would be a positive can you see how i'm getting gapping right here focus right here ready you'll see the gapping from her ankle that would be a positive she's loose there so what is a positive anterior drawer this is a ligamentous stress test so what that means is is do we care if the patient has pain most certainly but a positive test is one in which there is a laxity or looseness about the joint okay a negative test would be if there was no looseness if you tried to move it and it wouldn't move okay so that's an anterior drawer test again used to assess the integrity of the anterior talofibular ligament our next special test is the inversion taylor tilt test it is a test used to test the ligamentous integrity of the calcaneal fibular ligament or the cfl so it's that ligament right here the ligament that's going to hold the fibula to the calcaneus okay it prevents inversion if you remember that from the anatomy section so same hand placement as the anterior door test here and here and relax for me patient foot in a neutral position not dorsiflexed not super plantar flexed but just in a neutral position and this time instead of pulling anterior what i'm going to do is same hand positioning rock the calcaneus inward into inversion okay let's see that again i'm going to rock that calcaneus inward now i have seen students do this test wrong every year it's the first time i'm recording this so i want to make sure that you have it perfect when you come into the class you are cupping the calcaneus this part of the foot is not moving it is not the forefoot it is the calcaneus that we are moving so look at this it's here do you see that one hand it's the calcaneus it is not a forefoot test we'll get there later it is a calcaneus test it is important it is important i'm repeating that you tilt the calcaneus why because the distal attachment of the calcaneal fibular ligament is the you got it it's the calcaneus so if we don't move the calcaneus we will not test the ligament okay so a positive test would be increased range of motion into inversion compared to the uninjured side okay all right our next test is the uh posterior drawer test don't bother searching for it in your textbook it's not there but it only makes sense right if there's an anterior drawer there has to be a posterior drawer so the posterior drawer is going to assess for the posterior tailor fibular ligament and so just like with the anterior drawer we pulled it anterior the posterior drawer we're going to be pushing the calcaneus and the tailless posteriorly stabilize here this time instead of having my hand here i'm going to have my hand anterior now you'll notice that i'm using my thigh right to support the patient's foot i'm going to put my this portion of my hand web into the taylor dome and i'm going to do a posterior glide so i'm now gliding that foot in this direction right increase glide into the posterior direction would mean injury or compromise to the posterior talofibular ligament i'll say this for you guys it is only injured in about five percent of ankle sprain cases so the odds of you getting a positive uh posterior drawer test in your lifetime is is very slim but at least still do it as a part of your actual uh ankle evaluation okay so we've tested all three ligaments the anterior talofibular ligament the cfl or calcaneal fiber ligament and the posterior talofibular ligament our next assessment is going to be of the deltoid ligament itself so we did we did special testing on the lateral side of the foot and so now it becomes important to assess the deltoid ligament which is on the medial side of the foot right remember it's the only ligament but the great thing about the deltoid ligament is it is not injured often and remember it goes back to range of motion we have more inversion range of motion than we do eversion therefore the delta ligament isn't injured very often but when it is injured it takes a lot longer to heal when you compare it to the lateral ankle ligaments so there are a few special tests that we will use to assess the deltoid ligament the first one is the sister to the inversion taylor tilt test it is called the eversion taylor tilt test so your hand positioning is going to be the same i'm going to be here with stabilizing hand i'm going to cup that calcaneus and i'm going to literally try to ever that calcaneus now the no fun part is there's no movement in e-version you guys can see it right i'm trying to evert that calcaneus but it's not going anywhere so most often this e-version taylor tilt test will be positive if you know movement more movement into calcaneal eversion when compared to the other side so you're looking for e more movement into eversion during this test could the patient have pain most certainly but that is not considered to be a positive eversion taylor tilt test they have to have laxity present so some interesting things about the deltoid ligament remember i said it's like it's broken up into four bundles there's this middle bundle which the eversion taylor tilt test will will test but then we have an anterior bundle and a posterior bundle that also has to get tested those don't get tested in the eversion stress test so we then move to what is called the cligers test now most tests that we've done so far have been driven through the hind foot the kleiger's test is a four foot test so with kleiger's test we're going to cup here and stabilize but the difference is in my hand position right guys so with cliggers i'm going to cup all five metatarsals i'm gonna cup the planter aspect of the foot and i'm gonna stabilize here and then what i'm going to do is literally try to evert the forefoot which is so different right here's eversion stress test now here's clyger's why do we need to do cliggers in this position because clyger's if you can't tell is going to be stressing that more anterior portion right of the deltoid eversion stress test is going to be testing that more centralized version of of the deltoid okay clickers can also be done in a dorsiflexed position so we've got a neutral position for cliggers and now we have a dorsiflex position for claggers okay okay so we have been talking about lower ankle ankle sprains but the reality is we have patients who walk into our clinic who also have what are called syndesmotic or high ankle sprains right guys and the special testing for that pathology is so different so there are really three special tests that we can use to kind of roll in or roll out a synthesmatic ankle sprain the first one is cottons so what this is one of the tests that i didn't learn until i actually left and went to graduate school so with cotton's your patient is going to be in a side lying position and you want the lateral side to be pointing down towards the ground with the medial side facing up okay you're going to stabilize like you've always been doing at mid tibia and then what you're going to do with the test hand is you're going to grip the calcaneus in this direction now i wish i could show you my finger position but you want your finger position to to touch you want it to touch the fibula okay because the goal of this test is to see if there's fibular movement or displacement when you slide this calcaneus okay so envision that with me as we do this so my hand is going to be over the calcaneus as you guys can see that there digits three and four are going to be touching the tip of the fibula okay and what i'm going to do is i'm going to glide the calcaneus laterally makes sense so i'm gliding that calcaneus down towards the ground ready so i'm here and then i'm literally trying to glide that calcaneus all while feeling that fibula right what we know about high ankle sprains is if there is a high ankle sprain you will have increased movement from medial to lateral and what you will also feel as that calcaneus glides laterally is the fibula move a little bit right because that ligament has been has been stretched so a positive cotton's test is one in which there's increased translation in the lateral direction so another test that we can do for a syndesmotic ankle sprain is the squeeze test it can also be used for a fracture but we'll talk about that a little bit later in the segment for a syndesmotic ankle sprain what we want to do is essentially squeeze the tibia and fibula together so what i'm going to do is stand on the side of my patient i'm going to take my hands in this position here okay what i want to do is make sure that i'm gripping tibia here and then i'm gripping or have a good grip on the fibula laterally what i'm going to do is squeeze those two bones together hopefully you can see that the goal is when squeezing that essentially we would cause a forking or a spreading of the distal tibia fibula and that would cause pain so a positive squeeze test for a syndesmotic ankle sprain would be increased movement of the fibula and pain in the syndesmatic area last but not least for the syndesmotic ankle sprain is what we call the dorsiflexion eversion test as the name implies that's exactly what we're going to do essentially what we're going to do is force that ankle up into dorsiflexion maximally and then evert the foot maximally at the same time right so i'll do it again go up into dorsiflexion first and then an eversion moment this would be positive if you have increased splaying of the fibula on the lateral side or pain in the area of the syndesmosis so pain in the area of the syndesmosis joint for fractures of the tibia and fibula there really are two special tests that you can use the first is the squeeze test which we talked about for syndesmotic ankle sprains but the squeeze test a little bit different for fractures what you want to do is find the fracture and again you want to place one hand proximal to the fracture and then one hand distal to the fracture and you want to squeeze okay and the question is do they have pain with that okay the other thing that you want to do is you can bump or what is called tap right similar to the toe tap test but on the calcaneus and no i'm not just slapping it right extend the wrist and really tap that calcaneus right because what you want to do with that is send vibratory forces up the tibia or the fibula positive for this would be pain on either the tibia and or the the fibula okay the the probably best special test to use for um for ruling out a fracture of the tibia or fibula is actually the hop test so you're gonna have your patient get off of the table patient's gonna stand right here and what you're gonna have that patient do is hop five times in a row okay so sue's what i want you to do is hop five times a little bit higher good if your patient can do that that means they don't have a fracture but most often what we see with tibial or fibular stress fractures is when they attempt to hop when they go when they come down they essentially will collapse in pain right if they can get to five hops that's a negative typically a patient with a fracture of the tibia or fibula won't get to two hops before they actually collapse so a positive hop test would be collapsing before they hit five hops with this test it's very important to make sure that your patient is hopping high enough so that when they come down they're actually loading the tibia so you want to at least make sure they're about an inch or two off of the ground so there are three uh pathologies that we really couldn't group into special tests so we're going to talk about those now the first one is an oz trigonum injury most often seen in athletes who participate in a lot of plantar flexion moments so again the dancers the gymnasts we see it a lot in soccer athletes as they're participating after a goal and they slide and then they land and their feet are plantar flexed and they're on their knees and they're celebrating um so what is an ostrich gonna injury if we think about ostrich gonams essentially what we're saying is that the talis has a posterior bone called the cedia process and as little itty-bitty infants that stedia process essentially ends up fusing to the posterior aspect of the talus and in most human beings there is no problem but in some patient populations if they are forced into plant reflection they can actually fracture off that stedia process and have experienced a lot of pain the scary thing about a nause trigonum injury is that the only way that it's typically painful is during extremes amount of plantar flexion so the test for an oz trigonum injury is passive over plantar flexion so i'm going to stabilize here and i'm literally going to plantar flex that patient's foot so literally take her into maximum plantar flexion a positive test would be one in which the patient reports extreme amounts of pain during the in range of of plantar flexion our next special test is for an achilles tendon rupture for patient positioning that patient is going to be in the prone position or on their stomach okay they're going to have their leg about midway hanging off the edge of the table so about mid tibia foot's going to be dangling off of the edge of the the the table with the thompson's test you want to be on the side of your patient and you are going to essentially place your hands in the same position position as you did for a squeeze test so we're going to do is place our hands over the bellies of the gastrocnemius and what we're going to do is squeeze and the focus is going to be as i squeeze can you all see the foot moving into plantar flexion right so in a normal patient when i squeeze that foot is going to move into plantar flexion right but in a patient who has an achilles tendon rupture because there has been a disconnect between the distal portion and the proximal portion when i go to compress there will be no plantar flexion occurring at the foot so a positive would be an absence of plantar flexion when you squeeze and finally the the special test that i save for last because it's the most catastrophic is homan's test homan's test is a test of a blood clot in particular an ambulance after a knee surgery so most often what we see is that after knee surgeries patients are at the highest risk for blood clots these blood clots can kill patients so it becomes very important that we're able to identify these patients post surgery and then to know what special tests can be used to rule in or rule out the thrombus embolus pathology because it is life-threatening i think i've told many of you this story but we when we were in virginia my husband's cousin actually fractured his patella went in for surgery was an easy surgery in and out went home the next day his wife found him passed out unconscious in the bathroom and believe it or not it was because he threw a clot during surgery in his calf and so sadly enough he ended up passing away from something so very simple that we didn't recognize so this is an important pathology to identify in the first three days post-surgery you want to test them at nauseam to make sure that they don't have a clot that we can't recognize so homan's test the way this works is post surgery if a patient comes into you and they are complaining of extreme amount of calf pain we have to rule this out again it is life-threatening okay my husband's cousin was only 41 when he passed away right so it can happen to anyone so you want your patient's knee to be extended most often i'll have my patient lay back just so that they're relaxed you want the patient's knee to be extended as the clinician what you're going to do is lift up their injured leg you're going to dorsiflex the foot most often i'll use my body to do that so i'll dorsiflex the foot and then here's the key to this test in between the gastroc heads you are literally going to kind of poke in there right and if they say oh my gosh i have a lot of pain it's an automatic referral to the emergency room did you hear me it's an automatic referral and if they say oh there's nothing wrong it's just a strain then you feel better than having a patient go home and and pass away from something that you could have recognized so again are you ready typically i'll lift the patient's leg up i'll dorsiflex the foot and then i'll go in here with digits two through five right in the middle of those gastroc heads and i'll apply a little tiny bit of pressure there just to see if there's pain if there's pain you either take them you have someone take them to make sure that they don't have a blood clot so that's going to conclude the special testing and range of motions and palpations for for the foot and the ankle