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Download the app here 👾 https://geekymedics.com/geeky-medics-app/ for early access to our latest content and offline functionality. To see the written guide alongside the video, head over to our website https://geekymedics.com/ankle-and-foot-examination/ This video aims to give you an idea of what's required in a Foot and Ankle Examination OSCE scenario.

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The goal of the assessment is to:

Determine the extent of the injury

Identify what has been injured

Establish a framework that can be negotiated with the patient regarding:

Timeline

Further referral

Treatment plan

Treatment strategy

Gathering information during the history provides the clinician with clues as to what structure is likely affected, further guiding the physical examination. For example, the mechanism of injury is important as it provides information on what forces went through what structure, and in what direction. This will further provide information on what tissues and/or structures are likely stretched or damaged.

Example: a valgus force may indicate a deltoid ligament sprain, whereas a varus force may be suggestive of injury to the anterior talofibular ligament (ATFL) and/or calcaneofibular ligament (CFL).

The patient's history should include questions related to:

The time of the injury (acute vs subacute vs chronic)

The mechanism of the injury and forces involved in the injury (loose vs locked position)

The activity that leads to the injury (an athletic event vs recreational activity vs activity of daily living)

Contributing factors (shoes, terrain, medical history, medications, general health)

Training history

Previous treatment (successes vs failures)

The results from the interview should assist with establishing risk factors and precautions during the objective assessment.

"At the end of the patient's interview, the physiotherapist must have a good idea of what needs to be examined objectively. The clinician must later determine if the results of the assessment match the subjective signs and symptoms the patient complained about." Helene Simpson

Red flags are signs and symptoms found in the patient history and clinical examination that may be suggestive of serious pathology. If serious pathology is suspected, immediate referral to a medical doctor is indicated and the physiotherapist's concerns should be noted.

Red Flags specific to foot and ankle assessment:

Unable to bear weight: rule out fracture (Ottawa Rule)

Bilateral pins and needles or numbness in the lower limbs

Bowel and bladder dysfunction (i.e. the patient is unable to feel themselves going to the toilet)

Urinary Incontinence

Paraesthesia in the groin region

Loss of pulses in the lower leg (vascular compromise)

Obvious deformity

Joint dislocation

Positive Babinski sign

Unable to calf raise: rule out Achilles tendon rupture

Yellow Flags specific to foot and ankle assessment:

Severity of symptoms do not match the subjective information→more tests

Pain preventing objective assessment→detailed assessment delayed

Observation

Perform with the patient in supine, sitting or standing

Watch for the presence of swelling

Assess skin colour

Check skin temperature

Watch for signs of muscle wasting

Notice foot and toes deformities: bunions, hammertoes, claw toes, calluses

Posture assessment

If the patient is able to stand: observe in quiet stance and assess weight-bearing distribution; pay attention to foot arches; observe walking with or without assistive device: watch for back deformity: scoliosis, lordosis, kyphosis; observe gait pathology, eg., Trendelenburg; notice any changes in the lower leg alignment: knee valgus or varus, foot pronation or supination; observe gait cycle: heel strike, toe-off.

If the patient is unable to stand: observe in sitting, feet flat on the floor, assess the weight-bearing distribution and the patient's ability to take a load while preparing for a sit to stand transition

The choice of functional tests is based on the patient's signs and symptoms and the physiotherapist's initial list of suspected pathologies. It may include:

Sit to stand

Squat: defines the integrity of the syndesmosis joint

Deep squat

Tandem stance

Lounge position

Step forward and backwards: weight transfer

Single leg stance: assess postural and balance control

Step-up

Step down + step overs

Knee to wall test - knee extended might relate more to the range of dorsiflexion in gait: helps to assess ankle dorsiflexion range of motion

Squeeze test: helps to diagnose the syndesmotic ankle sprain

External rotation test: assesses the integrity of the syndesmotic ligaments

Anterior drawer test: defines ankle mechanical instability

For high-level performance athletes, additional tests may include a jump or a hop.

Additional details can be found on the Foot and Ankle Assessment-Investigations and Tests page.

Balance Assessment

The results of the balance assessment in the foot and ankle injury help to develop a sensory targeted rehabilitation programme that stimulates sensory receptors. The following are the examples of balance tests:

Static postural control :

Palpation can be performed in supine, prone and or seated position. The clinician checks for points of tenderness:

On the medial, lateral, posterior and anterior part of the lower leg and the around calcaneus

Along joint lines

At the attachments of the medial and lateral ligaments

At the Achilles tendon, peronei and other extrinsic muscles

The neurologic assessment can assist the clinician to identify a potential neurological aetiology for the observed ankle or foot pathology. It includes peripheral neuropathy or central nervous system impairment.

The complete neurological examination should include:

This video demonstrates the anatomy of the dermatomes of the lower extremities. The sensory testing needs to be performed when pathology or referral from the lumbar spine is suspected:

If compromised circulation is suspected, the clinician should palpate to assess pulses of the dorsalis pedis artery. The state of the vascular system can also be assessed by the response of symptoms to positions of dependence and elevation of the lower limbs.

When assessing ankle and foot active range of motion (AROM) and passive range of motion (PROM), all testing positions must be comfortable for the patient. For example, ankle dorsiflexion and plantarflexion are assessed when the patient is prone. If the patient cannot get into the desired position, the clinician can modify the position and document this for future testing. When an ankle fracture is ruled out, but the patient cannot fully participate in the range of motion assessment because of pain, the best option is to immobilise the ankle joint and delay the examination for a few days until the pain subsides.

The following are the basic range of motion testing in foot and ankle injury:

Plantarflexion(PF)/ dorsiflexion (DF)

Toe extension/ flexion

Pronation/supination

Big toe extension/ flexion

This video demonstrates a complete foot and ankle ROM assessment:

Joint mobility: test each individual joint with a glide and compare to the contralateral side and to normal values

These videos demonstrate specific joint mobility assessments:

This video demonstrates manual muscle testing of the lower extremities:

A foot assessment can be used to classify foot type, as well as to identify possible aetiological factors relating to injury in order to properly prescribe therapeutic interventions.

Details can be found on the Biomechanical Assessment of the Foot and Ankle page.

Patient-Reported Outcomes (PROs)

Patient-reported outcome measures allow clinicians to prioritise the outcomes most important to patients. In the foot and ankle assessment, it has been determined that physical performance and pain interference were at the top of the patients' priorities when assessing their satisfaction with treatment.

Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI)

One PRO is the Patient-Reported Outcomes Measurement Information System (PROMIS) which takes information from multiple domains to assess patient-reported outcomes. Pain and function are two domains measured by PROMIS PI, a patient-reported outcome measure that defines patients' satisfaction with foot and ankle treatment in response to improvement with these two domains. PROMIS PI detects pain at lower levels than the Visual Analogue Scale, a standard patient-reported pain scale. .

Visual Analogue Scale (VAS)

The Visual Analogue Scale (VAS) is a generic patient-reported pain scale that is used to assess the patient's perception of pain only. The scale may not be reliable in the assessment of the elderly population presenting with mild cognitive deficits or who show difficulties in understanding the instructions for the VAS.

Foot and Ankle Ability Measure (FAAM)

The Foot and Ankle Ability Measure (FAAM) is a self-report outcome instrument developed to assess physical function for individuals with foot and ankle related impairments. This self-report outcome instrument is available in English, German, French and Persian. The Foot and Ankle Ability Measure is a 29-item questionnaire divided into two subscales: the Foot and Ankle Ability Measure, 21-item Activities of Daily Living Subscale and the Foot and Ankle Ability Measure, 8-item Sports Subscale.

Detailed information is available on the Foot and Ankle Ability Measure page.

What→ so what→ now what

At the end of the examination, the clinician should return to the initial list of potential problems/suspected diagnoses and choose the three most likely diagnoses.

The foot and ankle assessment is completed when the clinician is able to provide a response to the following questions:

What were the consequences of the incident?

How are the consequences of the incident going to be treated?

What is the treatment plan?

What is the treatment strategy?

What are the short and long term goal?

What is the timeline for goal completion?

Telehealth is a well-established alternative to in-person visits as a response to the COVID pandemic and beyond. Development of objective assessment tools for telehealth is a priority in order to demonstrate the outcome of treatments provided via telehealth.

Virtual assessments for foot and ankle pathology have been developed and tested. The following is the guideline for the virtual examination.

Prior to the virtual visit, the patient should obtain a pre-visit form and information regarding wardrobe expectations and the camera set up during the examination. The pre-visit form needs to be completed by the patient or the caregiver and it consists of the questions regarding:

Patient's chief complaint and reason for the visit

Patient's past and present medical and surgical history

Medication and allergies

Social history

Additional information may include biometrics (height and weight) and vital signs (HR, blood pressure, body temperature).

The foot and ankle examination includes:

1. Inspection

Patient in standing and seated

Camera set up to provide front, side and back view of the foot and ankle

The elements of inspection are as follows: alignment, muscle atrophy, joint deformity, incisions, scarring, rash, swelling, ecchymosis, erythema. In addition, the plantar aspect of the foot must be examined for ulcers, abrasions, and skin breakdown.

2. Palpation
Patient uses one finger to point to the area of maximal pain or discomfort

3. Range of motion testing

Use a web-based goniometer

Performed actively (patient's own muscle power) and passively (family member manipulates the joint)

4. Strength testing

Assisted by the family member

Exam performed on both sides at the same time and differences reported

5. Functional assessment

6. Neurovascular assessment
Patient touches the skin on both sides and reports differences, however sensory feedback from the patient's own fingers touching the skin is a limitation.

Additional tests for flatfoot, cavovarus foot, hallux rigidus, and Achilles rupture may be added if the pathology is suspected.

1. Wikstrom EA, McKeon PO. Predicting balance improvements following STARS treatments in chronic ankle instability participants. J Sci Med Sport. 2017 Apr;20(4):356-361. doi: 10.1016/j.jsams.2016.09.003. Epub 2016 Sep 20.

2. Bernstein DN, Kelly M, Houck JR, Ketz JP, Flemister AS, DiGiovanni BF, Baumhauer JF, Oh I. PROMIS pain interference is superior vs numeric pain rating scale for pain assessment in foot and ankle patients. Foot & ankle international. 2019 Feb;40(2):139-44.

3. Eble SK, Hansen OB, Ellis SJ, Drakos MC. The Virtual Foot and Ankle Physical Examination. Foot & Ankle International. 2020;41(8):1017-1026.

4. Ravi B, Kapoor M, Player D. Feasibility and reliability of a web-based smartphone application for joint position measurement. J Rehabil Med. 2021 May 10;53(5):jrm00188.

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Original Editor - Ewa Jaraczewska based on the course presented by Helene Simpson

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Improve Article 👀

Ankle and foot examination frequently appears in OSCEs and you'll be expected to identify relevant clinical signs using your examination skills. This ankle and foot examination OSCE guide provides a clear step-by-step approach to examining the ankle and foot, with an included video demonstration.

Musculoskeletal examinations can be broken down into four key components: look, feel, move and special tests. This can be helpful as an aide-memoire if you begin to feel like you've lost your way during an OSCE.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the examination will involve using patient-friendly language.

Gain consent to proceed with the examination.

Adequately expose the patient's legs from the knee down.

Position the patient standing for initial inspection of the ankles and feet.

Ask the patient if they have any pain before proceeding with the clinical examination.

Look

General inspection

Clinical signs

Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology:

Body habitus: obesity is a significant risk factor for joint pathology due to increased mechanical load (e.g. osteoarthritis).

Scars: may provide clues regarding previous lower limb surgery.

Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.

Objects or equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

Walking aids: the ability to walk can be impacted by a wide range of knee, hip and ankle pathology.

Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient's recent medications (e.g. analgesia).

Gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying attention to:

Gait cycle: note any abnormalities of the gait cycle (e.g. abnormalities in toe-off or heel strike).

Range of movement: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).

Limping: may suggest joint pain (i.e. antalgic gait), weakness or joint instability (e.g. ligamentous injury).

Leg length: note any discrepancy which may be the cause or the result of joint pathology.

Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.

Height of steps: high-stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy (e.g. trauma, surgery).

Ask the patient to walk on their tip-toes and then on their heels to further screen for pathology. Patient's with arthritis or lower limb muscle weakness will struggle to perform these tasks.

Gait cycle

1. Heel-strike: initial contact of the heel with the floor.

2. Foot flat: weight is transferred onto this leg.

3. Mid-stance: the weight is aligned and balanced on this leg.

4. Heel-off: the heel lifts off the floor as the foot rises but the toes remain in contact with the floor.

5. Toe-off: as the foot continues to rise the toes lift off the floor.

6. Swing: the foot swings forward and comes back into contact with the floor with a heel strike (and the gait cycle repeats).

Closer inspection of the ankles and feet

Ask the patient to stand and turn in 90° increments as you inspect the ankles and feet from each angle for evidence of pathology.

Anterior inspection

Inspect the anterior aspect of the ankles and feet noting any abnormalities:

Scars: note the location of scars as they may provide clues as to the patient's previous surgical history or indicate previous joint trauma.

Bruising: suggestive of recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting disorders such as haemophilia).

Swelling: note any evidence of asymmetry in the size of the ankle joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis, haemarthrosis, Charcot joint).

Psoriasis plaques: typically present over extensor surfaces and important to note due to the association with psoriatic arthritis.

Fixed flexion deformity of the toes: subtypes include hammer-toe and mallet-toe.

Big toe misalignment: note any evidence of lateral (hallux valgus/bunion) or medial (hallux varus) big toe angulation.

Calluses: thickened, hardened skin that develops as a result of repetitive friction which may be caused by poorly fitting footwear or a gait abnormality.

Lateral inspection

Inspect the lateral aspect of the ankles and feet, noting any abnormalities:

Foot arch: inspect for evidence of flat feet (pes planus) or an abnormally raised foot arch (pes cavus).

Posterior inspection

Inspect the posterior aspect of the ankles and feet noting any abnormalities:

Scars: again look for scars indicative of previous trauma or surgery.

Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the lower leg suggestive of disuse atrophy or a lower motor neuron lesion.

Heel misalignment: may be caused by a valgus or varus deformity of the ankle joint.

Achilles tendon: discontinuity and swelling may indicate tendonitis and/or rupture.

Feel

Ask the patient to lay on the clinical examination couch.

Temperature

Assess and compare ankle joint and foot temperature using the back of your hands.

Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis or inflammatory arthritis.

Pulses

Posterior tibial pulse

The posterior tibial pulse can be located posterior to the medial malleolus of the tibia.

Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Dorsalis pedis pulse

Palpate the dorsalis pedis pulse:

The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones.

Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Metatarsophalangeal joint squeeze

Gently squeeze across the metatarsophalangeal (MTP) joints and observe for verbal and non-verbal signs of discomfort. Tenderness is suggestive of active inflammatory arthropathy.

Ankle and foot palpation

Palpate the ankle joints and the various joints/bones of each foot, noting any swelling, irregularity or tenderness:

Metatarsal and tarsal bones

Tarsal joint

Ankle joint

Subtalar joint

Calcaneum

Medial/lateral malleoli

Distal fibula

Achilles tendon palpation

Palpate the gastrocnemius muscle and the Achilles tendon:

Note any focal tenderness or swelling suggestive of tendonitis.

Note any discontinuity in the tendon suggestive of rupture.

Move

The ankle joint and the joints of the feet should be assessed and compared.

If the patient is known to have an issue with a particular ankle or foot, you should assess the 'normal' ankle or foot first for comparison.

Active and passive movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of active movements to assess joint function. As the patient performs each movement, note any restrictions in the range of the joint's movement and also look for signs of discomfort. It's important to clearly explain and demonstrate each movement you expect the patient to perform to aid understanding.

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of movement.

Ask the patient to perform all of the below actively and then repeat the movements passively.

Foot plantarflexion

Normal range of movement: 0-50°
Instructions: "Push your feet downwards, like you are pressing a car pedal."
Foot dorsiflexion
Instructions: "Extend your feet backwards, like you're trying to point them up towards your head." Instructions: "Curl up your toes as tight as you can." Instructions: "Extend your toes backwards, like you're trying to point them towards your head."
Normal range of movement: 0-20º
Instructions: "Try to touch the soles of your feet together."
Toe flexion
Instructions: "Try to angle the soles of your feet outwards as far as you are able to."
Toe extension

Ankle/foot inversion

Normal range of movement: 0-35º

Ankle/foot eversion

Normal range of movement: 0-15º

Passive movement only

The movements of the following joints need to be assessed passively as they are difficult to isolate with active movements:

Special tests

Simmonds' test

Simmonds' test is used to assess for clinical evidence of Achilles tendon rupture:

1. Ask the patient to kneel on a chair with their feet hanging over the edge.

2. Squeeze each of the patient's calves in turn.

Interpretation

In healthy individuals, the foot should plantarflex when you squeeze the calf due to the contraction of the gastrocnemius muscle and the subsequent pulling force transmitted via the Achilles tendon.

There will be no movement of the foot if the Achilles tendon is ruptured due to loss of continuity between the gastrocnemius and the foot.
"Today I examined Mrs Smith, a 32-year-old female. On general inspection, the patient appeared comfortable at rest, with no stigmata of musculoskeletal disease. There were no objects or medical equipment around the bed of relevance. "The ankles and feet appeared normal on inspection and the patient's gait was unremarkable. The range of movement throughout the ankles and feet was normal." "In summary, these findings are consistent with a normal ankle and foot examination." "For completeness, I would like to perform the following further assessments and investigations."
To complete the examination...

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.
Trauma & Orthopaedic Surgeon (ST7)
Summarise your findings.

Example summary

Further assessments and investigations

Neurovascular examination of both lower limbs.

Examination of the knee and hip joint.

Further imaging if indicated (e.g. X-ray and MRI).

Reviewer

Mr Tejas Yarashi

References

1. J. Terrence Jose Jerome. Adapted by Geeky Medics. Licence: CC BY.

2. James Heilman, MD. Adapted by Geeky Medics. Psoriasis plaque. Licence: CC BY-SA.

3. Richard Huber. Adapted by Geeky Medics. Hammer toe. Licence: CC BY-SA.

4. Lamiot. Adapted by Geeky Medics. Hallux valgus. Licence: CC BY-SA.

5. Gzzz. Adapted by Geeky medics. Hallux varus. Licence: CC BY-SA.

6. Jmarchn. Adapted by Geeky Medics. Foot calluses. Licence: CC BY-SA.

7. Benefros. Adapted by Geeky Medics. Pes cavus. Licence: CC BY-SA.

8. Grook Da Oger. Adapted by Geeky Medics. Licence: CC BY-SA.

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Ankle and Foot Examination - OSCE Guide | Geeky Medics

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Improve Article 👀 Ankle and foot examination frequently appears in OSCEs and you'll be expected to identify relevant clinical signs using your examination skills. This ankle and foot examination OSCE guide provides a clear step-by-step approach to examining the ankle and foot, with an included video demonstration.

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Abstract

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4-5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.

New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option.

ankle sprain

sprain prevention

guideline

inversion trauma

cost-effectiveness

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Introduction

A lateral ankle sprain (LAS) is a frequently incurred musculoskeletal injury, with a high prevalence among the general population and individuals who participate in sports. 1 2 About 40% of all traumatic ankle injuries occur during sports. For indoor sports, an incidence of 7 LAS per 1000 exposures has been reported. 3 Despite the high prevalence and incidence of LAS injuries, it has been reported that only approximately 50% of individuals who incur a LAS seek medical attention. 4 A large proportion of individuals who sustain a LAS will develop chronic ankle instability (CAI). 5-7 CAI may be defined as persistent complaints of pain, swelling and/or giving way in combination with recurrent sprains for at least 12 months after the initial ankle sprain, 8-11 which in turn may lead to (long-term) absenteeism from work and sports. Treatment costs in combination with sick leave lead to a high socioeconomic burden. 4 7 12 Additionally, associations with joint degeneration and osteochondral lesions have been reported over time. 13 Adequate diagnosis, treatment and prevention of injury recurrence could forestall the development of long-term injury-associated symptoms and hence substantially reduced the associated socioeconomic burden.

Despite the increasing number of published studies on this topic, heterogeneity in treatment strategies persists worldwide. This necessitated the development of an international evidence-based clinical guideline. 14 Since the publication of this guideline, additional studies have been undertaken and published on this topic.

In order to provide an update of the multidisciplinary clinical guideline, a multidisciplinary guideline committee was formed. The committee included health professionals who were directly involved in the care of patients with LAS in clinical practice or research environments and included general practitioners, emergency physicians, musculoskeletal radiologists, occupational physicians, orthopaedic surgeons, rehabilitation physicians, physical therapists, athletic trainers, sports massage therapists, sports physicians and trauma surgeons. This clinical guideline incorporates the most recently published peer-reviewed literature on the topic of LAS injury. The aim of this updated evidence-based clinical guideline is to facilitate uniformity of diagnosis and treatment of acute LAS injury, with the primary purpose of reducing the long-term injury-associated symptoms resulting from this prevalent injury.

The multidisciplinary guideline committee developed this update in order to assist all healthcare professionals, in both primary and secondary care settings, involved in the care of patients who have sustained an acute LAS injury. These include general practitioners, emergency physicians, musculoskeletal radiologists, occupational physicians, orthopaedic surgeons, rehabilitation physicians, physical therapists, athletic trainers, sports massage therapists, sports physicians, trauma surgeons and other professionals involved in lower extremity musculoskeletal injuries. This updated Clinical Practice Guideline (CPG) will enable these healthcare professionals to benefit from and implement the most up-to-date evidence-based recommendations concerning LAS.

Materials and methods

The initial guideline was constrained in its recommendations due to limitations in available published literature, limiting assessment by means of meta-analyses. 14 Due to the considerable number of new studies on LAS, it was decided by the guideline committee that an update of the original document was warranted.

Search and data collection

To provide updated recommendations on the diagnosis and treatment of acute LAS injuries and the prevention of injury recurrence, a search was performed to identify all potential relevant articles published from January 2009-the search date of the initial guideline-up to September 2016 (online supplementary appendix 1). The search was performed in Embase, MEDLINE, Cochrane and PEDro using the database-specific search translation on the topics of predisposing and prognostic factors, diagnostics, treatment, prevention and return to work and sports. For each subtopic addressed in this guideline, an individual search was performed, which is available in the appendix. All searches consisted of the common terms 'ankle sprain', 'ankle injury' and their database-specific synonyms, combined with topic specific terms such as 'prevention' and all available synonyms. To ensure all relevant articles were identified, the current search results were combined with the articles identified by the initial guideline and references of all relevant articles were checked for possibly missed inclusions.

Inclusion and exclusion criteria

Studies were deemed eligible for inclusion if they included individuals aged at least 16 years with acute LAS. Studies published in Dutch, English, German, French, Spanish, Danish or Swedish were all eligible for inclusion. Narrative reviews, case reports and cadaveric analyses were excluded. Additional exclusion criteria were reported medial ankle involvement, fractures or other concomitant injuries/pathology and CAI. In addition to the original search, a manual search of all reference lists of included studies was performed to identify relevant articles that may not have been identified by the search strategy. There were no inclusion or exclusion criteria formed regarding outcome measures. In addition to including all outcomes assessed in the previous guideline (see the individual searches in online supplemenatry appendix 1), all other outcomes concerning risk/prognostic factors, diagnostics, treatment, prevention and work/sports resumption were included. If multiple follow-up time points were included in the assessment, the latest postintervention assessment was included.

Data selection

After duplicate removal all studies were screened by two researchers (GV and AH/BFWvdD) independently using the Rayyan 15 screening tool as advised by the Dutch Cochrane Society. Disagreements among the researchers who performed the initial screening were resolved in a consensus meeting. Subsequently, the same pair of researchers assessed full texts independently, followed by another consensus meeting to resolve disagreements. If disagreement persisted, the senior author (GMMJK) was consulted to reach consensus. To avoid loss of original data for systematic reviews, all the included studies were manually checked for eligibility and relevant data.

Evidence and guideline quality

Quality of evidence of included articles was classified in order of scientific value ( tables 1 and 2). Recommendations were based on the best available evidence. Statements formed by evidence from multiple studies, and the summarised level of evidence of the full statement was provided. The same was done for the level of evidence of the recommendations.

As this guideline concerns an update, as recommended by the EQUATOR-network, the CheckUp list was used for this guideline to help emphasise new information and changes implemented in this updated CPG. 16 Additionally, theAppraisal of Guidelines for Research & Evaluation (AGREE) II criteria were followed in order to ensure complete reporting of methods and results and improve transparency and quality.

Data extraction

All outcomes that were described by at least two of the included studies were extracted for the meta-analyses (online supplementary appendix 3). If outcomes concerned the same variable and were measured similarly (eg, pain on an 11-point Likert scale), they were pooled using Review Manager (RevMan; V.5.3, The Nordic Cochrane Centre, Copenhagen, The Cochrane Collaboration, 2014). Data that could not be pooled were assessed qualitatively.

Formulation of recommendations

Individual topics were assigned to the appropriate coauthors depending on their field of expertise in order to formulate recommendations based on the collected evidence. They subsequently received the corresponding studies to enable them to write the corresponding paragraph according to the method section predefined content to ensure uniformity. Results of these diagnostic, treatment and preventive recommendations were provided with the corresponding levels of evidence of the included conclusions. Aspects such as potential harm of interventions, patients' perspective, costs and logistics were carefully considered when formulating the final recommendations. Recommendations were explicitly mentioned under 'Recommendations'; including the full recommendation based on all the available evidence and including a statement about whether this recommendation changed since this update.

In addition to recommendations on diagnostics, an overview of treatment and prevention strategies is provided in tables 3 and 4 by pooling the data of studies assessing the same treatment/preventive measure (number of patients (N); relative risk (RR) or mean difference (MD) and 95% CI).

New information was explicitly mentioned under 'What's new?'.

Implementation

To ensure implementation of a multidisciplinary view in this CPG in all phases of rehabilitation after sustaining a LAS, the guideline committee consisted of an emergency medicine physician, epidemiologists, general practitioner, musculoskeletal radiologist, orthopaedic surgeons, movement scientists, physiotherapists and rehabilitation specialist (see affiliations). All members, apart from the two senior supervisors (RAdB and GMMJK), participated either in the search and selection of evidence or in reading, extracting and implementing data into this CGP. Apart from full review by all coauthors, the two senior authors additionally functioned as external reviewers by means of full detailed review to ensure this CPG was compliant with the AGREE II criteria and to optimise quality, assess applicability in clinical practise and feasibility of results.

Terminology

functional treatment: treatment during which the function of the joint (ie, freedom of movement) is retained;

functional support: support such as tape or brace, preserving joint motion, but limiting extreme joint positions such as maximum inversion;

functional outcome: outcome of treatment that leads to improvement of function such as pain reduction or range of motion (ROM) increase enabling patients to return to their preinjury level of activity and participation.

Results

To systematically evaluate and summarise all available evidence concerning LAS, a broad literature search was undertaken specifically related to the following areas: (1) predisposing and prognostic factors; (2) diagnostics, (3) treatment, (4) prevention and (5) return to work/sport. This search resulted in the identification of a total of 10 067 studies. After title and abstract screening and reading full texts, a total of 194 articles were eligible for inclusion in this guideline (online supplementary appendix 2). All fields of evidence with regard to relevant diagnostic tools, reliability of diagnostics, different treatment modalities and their efficacy, as well as prevention interventions including their cost-effectiveness will in turn be discussed. Recommendations will be provided based on the available level of evidence ( tables 1 and 2).

Predisposing factors

Predisposing factors are defined as factors that increase the risk of sustaining a LAS. Risk factors for LAS can be classified as either intrinsic (patient-related factors, eg, proprioception) or extrinsic (eg, sports or environmental characteristics). An important aspect that should be considered by clinicians when addressing predisposing factors is whether they can be modified or not. Modifiable risk factors may be targeted by (preventive) treatment.

Intrinsic risk factors

There are a number of intrinsic risk factors, which substantially heighten the risk of sustaining a LAS. These include limited dorsiflexion ROM, 17-19 reduced proprioception 18 20-23 and (preseason) deficiencies in postural control/balance (positive single-leg balance test (RR 2.54, 95% CI 1.02 to 6.03) 20-22 24-28 (level 1). In addition, other modifiable risk factors which heighten the risk of sustaining a LAS include body mass index (BMI) and high medial plantar pressures during running 28-33 (level 3). Concerning BMI, included results are conflicting as to whether a higher or lower BMI increases the risk of incurring a LAS. Our meta-analysis showed a greater risk of sprains in patients with a lower BMI (mean difference (MD) −0.08, 95% CI −0.14 to -0.02) 23 34 (level 2). Additional factors that may contribute to an increased risk are reduced strength, 18 20-23 35 coordination, 25 cardiorespiratory endurance, 25 limited overall ankle joint ROM and decreased peroneal reaction time 18 20-23 (level 3).

Concerning non-modifiable risk factors, females have a higher risk of sustaining a LAS compared with males (RR 1.25, 95% CI 1.17 to 1.34) 29 36 (level 3). Despite a history of LAS being described as a strong predictor, pooling results lead to a non-significant risk ratio (RR 1.44, 95% CI 0.96 to 2.16) 18 21 22 37-39 (level 2). Additional factors correlated to an increased risk of sustaining a LAS are physical characteristics such as greater height, ankle joint configuration, foot posture index, anatomical abnormalities in ankle and knee alignment and multiple clinical defects 28-33 (level 3).

What's new: An increase in available data made it possible to identify female sex as well as potentially a lower BMI being risk factors for ankle sprains. Additionally, a recommendation is provided which was missing in the original guideline.

Recommendation (new): When treating patients with an acute LAS, modifiable risk factors such as deficiencies in proprioception and ROM should be identified and if possible included in a prevention and/or rehabilitation programme to mitigate the risk for recurrent sprains (level 3).

Extrinsic risk factors

Irrespectively of patients' wish to switch sports, the main modifiable extrinsic risk factor for LAS appears to be the type of sport practised. The highest incidence of LAS was found for aeroball, basketball, indoor volleyball, field sports and climbing. 29 40 41 The incidence of LAS was dependent on the level of participation. 29 40 41 In volleyball, landing after a jump is the most important risk factor 41 42 (level 2). Playing soccer on natural grass (vs artificial turf: RR 0.53, 95% CI 0.48 to 0.59) 43-45 as well as being a defender (42.3% of all sprains) 46 47 increased the incidence of LAS (level 2). Concerning shoe wear, high heels (9.5 vs 1.3 cm) heighten the risk of incurring a LAS 48 (level 3).

The only non-modifiable factor was sex. Despite girls having an increased risk of LAS compared with boys, in-competition risk for LAS is higher in boys (RR 3.42, 95% CI 3.20 to 3.66) compared with girls (RR 2.71, 95% CI 2.48 to 2.95) 36 (level 3).

What's new: The new search resulted in a significant increase in data. The subsequent performed meta-analyses made it possible to identify the size of the increased risk of playing soccer on natural grass, the risk associated with being a defender and the risk while playing sports at a competitive level. New recommendations are provided concerning the high impact of sport.

Recommendation (new): Extrinsic risk factors, although outside of the patient, may provide a significant increase in the risk at sustaining a LAS. Healthcare professionals involved in treating patients who sustain a LAS should take notice especially of the type of sport practised but also of other extrinsic risk factors, as modifications may lower the risk at future sprains and other ankle injuries (level 2).

Prognostic factors

Following an acute LAS, pain decreases rapidly within the first two weeks after injury. 49 However, a substantial proportion of patients report long-term unresolved injury-associated symptoms. At a follow-up of 1-4 years, 5%-46% of patients still experience pain, 49-51 3%-34% of patients experience recurrent sprains 49-51 and 33%-55% of patients report instability. 49 51 Additionally, a higher physical workload load may be associated with an increased risk of recurrent sprains (RR 1.09, 95% CI 0.52 to 1.19; RR 0.96, 95% CI 0.36 to 1.2) and ankle instability (RR 1.16, 95% CI 0.71 to 1.18; RR 1.10, 95% CI 0.57 to 1.19). 51 Even clinical signs of anterior impingement were found in 25% of patients, of which 82% were radiographically confirmed 50 (level 3).

Despite initial treatment consisting of taping/bracing and physical rehabilitation, up to 40% of individuals who have sustained a LAS develop CAI. 52 This may indicate that not all factors contributing to the success or failure of rehabilitation are known. Some of the known unfavourable prognostic factors identified for the development of CAI were an inability to complete jumping and landing within 2 weeks after a first-time LAS, deficiencies in dynamic postural control, 53 altered hip joint kinematics 54 and lack of mechanical stability/increased ligament laxity 8 weeks after an ankle sprain. 55 56 Other factors that may influence the prognosis are sports participation at a high level, 57 being a young male, 52 increased BMI 52 and greater body height 52 (level 3). Finally, acute postural balance impairments persisting after LAS may also contribute to the development of CAI. 58 Due to the neuromuscular origin of some of these prognostic factors, physical therapy might be helpful to improve physical impairments after a LAS and prevent progression to CAI. 59 60 Based on the limited evidence concerning the risk factors for developing CAI following an ankle sprain, further research on prognostic factors is required and may provide additional and more uniform insights. 61 62

What's new: Over the past years more data have become available on negative prognostic factors that may indicate slow or incomplete rehabilitation. This enabled us to modify the previous recommendation, which lacked a conclusion due to insufficient evidence.

Recommendation (modified): Following acute LAS, adequate attention should be directed towards the patient's current level of pain, their workload and level of sports participation. These may all negatively influence recovery and increase the risk of future injury recurrence. Hence, they should be addressed early in the treatment process (level 3).

Diagnostics

In case of a severe ankle sprain, a fracture should be excluded by proper use of the Ottawa ankle rules (OAR), and if indicated, conventional radiographic imaging should be undertaken ( table 5). Since only 15% of patients with LAS, who are examined using a radiograph, are diagnosed with an ankle fracture, the OAR have been developed to rule out a fracture. 63 The OAR are an accurate and valid tool, which can be used with patients who have a suspected ankle/foot fracture within 1 week after the initial trauma (level 1). 63-67 A high incidence of less serious traumas may lower the predictive value of the OAR in clinical practice. 68 69 To avoid unnecessary use of radiographs, the OAR are recommended as a primary physical examination tool to rule out the likelihood of foot/ankle fractures by emergency physicians, general practitioners or physiotherapists 63 70-73 (level 1). The Bernese ankle rules (BAR) have been developed as response to the high rate of unnecessary radiographs based on OAR findings. However, the sensitivity of the BAR is too low to promote clinical use 74 (level 2).

In general, ankle ligament injuries are classified into three grades representing increasing injury severity: grade I, mild ankle sprain; grade II, moderate sprain/microligament lesions; and grade III, severe sprain/full ligament lesion. 75 In cases where a haematoma is present, accompanied by pain on palpation around the distal fibula and/or a positive anterior drawer test, a rupture of the lateral ankle ligaments likely exists. The sensitivity (84%) and specificity (96%) of physical examination using the anterior drawer test are optimised if clinical assessment is delayed for between 4 and 5 days post injury 68 69 76 77 (level 2). Ultrasonography has similar sensitivity (92%) but lacks specificity (64%) compared with delayed examination, and additionally depends on the availability of an experienced technician and equipment. 69 78 In case of suspicion of high-grade ligament injuries, osteochondral defects, syndesmotic injuries and occult fractures, an MRI can be performed 78 because of its excellent sensitivity (93%-96%) and specificity (100%) for visualising these injuries. 79-83 Poor availability of MRI in combination with the high prevalence of ankle sprains limits the use of MRI in acute settings, but in case of persisting symptoms it may be used to diagnose underlying joint damage. In case of suspicion of complete uncomplicated rupture of the anterior talofibular ligament, an MRI is not needed as the sensitivity and specificity of delayed physical examination are sufficient. 69 Other diagnostic modalities are stress radiographs and arthrography. Due to the limited diagnostic value of stress views in combination with pain in the acute setting while stressing the ligaments, these are regarded as obsolete and should not be used. As arthrography is an invasive procedure and its sensitivity and specificity are equal to delayed physical examination, it is also not recommended as a diagnostic tool in the acute setting 78 (level 2).

What's new: To ensure readability, the OAR were included in this diagnostics section. To make sure this guideline provides a complete overview of the many decision rules which the OAR belong to, table 5 was added including the parametric properties of the most popular clinical decision rules. The recommendation includes a short summary by providing an overview of the most important diagnostic steps, which was missing in the previous guideline.

Recommendation (new): Regarding the clinical assessment of damage to the anterior talofibular ligament, the sensitivity (84%) and specificity (96%) of assessment using the anterior drawer are optimised if clinical assessment is delayed for between 4 and 5 days post injury. In case of a suspected fracture, the OAR should be applied (level 2).

Treatment

Rest Ice Compression Elevation (RICE)

RICE is a conservative treatment method that has not been rigorously investigated, and the efficacy of this combination is questionable. The individual elements of ice and compression have been the subject of numerous scientific investigations; however, there is little scientific support for their efficacy in reducing injury-associated symptoms following acute LAS.

The limited available evidence showed that the efficacy of cryotherapy for reducing acute LAS injury-associated symptoms is unclear (33 randomised controlled trials (RCTs), n=2337) 84 85 (level 1). There are no indications that the isolated use of ice can increase function, as well as decrease swelling and pain at rest among individuals who have sustained an acute LAS (27 RCTs, n=1670) 84 86-90 (level 2). In combination with exercise therapy, cryotherapy has a greater effect on reducing swelling compared with heat application (one RCT, n=30) 86 (level 2). The combination of cryotherapy and exercise additionally results in significant improvements in ankle function in the short term, allowing patients to increase loading during weight bearing compared with standard functional treatment (one RCT, n=101) 91 (level 3).

Evidence regarding the efficacy of compression therapy after acute LAS is also inconclusive (three RCTs, N=86) 87-89 (level 2).

As a combined therapeutic modality, the use of RICE plus multimodal physiotherapy compared with RICE alone provides no additional benefits. Both treatments provide pain reduction, increase patient function and reduce ankle swelling (one RCT, n=28) 92 (level 2).

Regarding the individual effects of rest and elevation after LAS, no evidence was available.

What's new: No new statements could be made based on the newly identified studies. The increased evidence indicates that the individual aspects of RICE are not effective, apart from cryotherapy, if provided in combination with exercise therapy.

Recommendation (modified): There is no evidence that RICE alone, or cryotherapy, or compression therapy alone has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE alone in the treatment of acute LAS (level 2).

Non-steroidal anti-inflammatory drugs

NSAIDs are commonly prescribed for patients who have sustained an acute LAS, with the primary purpose of reducing pain. Pooling the results of current studies shows that the use of oral or topical NSAIDs results in less pain in the short term (<14 days) without significantly increasing the risk of adverse events compared with placebo (26 RCTs, n=4225) 93-97 (level 1) ( table 3). However, studies that included other NSAIDs instead of a placebo were excluded from this review 98-102; additionally, the included participants were relatively young and healthy and thus potentially less prone to side effects. A comparison between selective NSAIDs (celecoxib 200 mg two times daily) and non-selective NSAIDs (ibuprofen, naproxen or diclofenac) (four RCTs, n=1490) concluded that celecoxib was non-inferior to non-selective NSAIDs for the primary outcome of pain following an acute LAS injury. Adverse events did not occur more frequently 99 103-105 (level 1). Diclofenac showed superior results at days 1 and 2 compared with piroxicam (two RCTs, n=201) and ibuprofen (one RCT, n=60) for reducing pain during motion in patients with mild-to-severe acute ankle sprains and equal adverse event rates 98 101 (levels 2 and 3). Contradicting results have been reported on the effect of diclofenac for pain during rest, swelling and inflammation,. 98 101 No differences in effect were seen when comparing a fixed dosage (500 mg two times daily) to an as-needed naproxen dosage (one RCT, n=135, MD pain−0.13 (−0.38 to 0.12)) 106 (level 3). Despite dose differences, paracetamol (cq. acetaminophen) seems to be equally effective as NSAID usage (three RCTs, n=450) for pain (one RCT, n=86, MD 1.80, 95% CI −1.42 to 5.02), swelling (two RCTs, n=186, MD −0.07, 95% CI −0.29 to 0.14) and ROM (one RCT, n=100, MD 0.70, 95% CI −0.62 to 2.02) 107-109 (level 1). Opioid analgesics are equally effective for pain relief, but lead to significantly more side effects (two RCTs, n=869) 100 110 (level 2). The use of NSAIDs may delay the natural healing process as the inflammation suppressed by NSAIDs is a necessary component of tissue recovery. 111

Besides these commonly prescribed analgesics, other pharmaceutical treatment modalities were described: venotonic drugs did not result in enhanced outcomes for pain and swelling compared with paracetamol and RICE 112 (level 2); platelet-rich plasma injections were not superior for pain and functional outcomes compared with placebo injections (one RCT, n=37) 113 (level 3), and topically applied Traumeel (one RCT, n=449) 114 (level 2) was not superior compared with diclofenac topical gel for ankle oedema, pain and function. Periarticular hyaluronic acid injections compared with placebo (two RCTs; n=158) did show a positive effect on pain, nor did they result in a quicker time to return to sport or reduced prevalence of recurrent sprains 115 116 (level 2).

What's new: Based on the search results concerning treatment, the committee agreed on implementing a topic on NSAIDs. Over the past years much research has been undertaken on NSAIDs in relation to musculoskeletal injuries, and in many countries they are available without prescription. However, before recommending NSAIDs, their effect in the specific context of an ankle sprain had to be assessed.

Recommendation (new): NSAIDs may be used by patients who have incurred an acute LAS for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications (level 2) and may suppress or delay the natural healing process.

Immobilisation

A minimum of 4 weeks in a lower leg cast following an acute LAS results in less optimal outcomes compared with functional support and exercise strategies with a duration of 4-6 weeks 117 , 118 (22 RCTs, n=2304) (level 1). More recent evidence (three RCTs, n=694) showed that a short period (<10 days) of immobilisation with a plaster cast or rigid support can be of added value in the treatment of acute lateral ligament injury as it decreases pain and oedema and improves functional outcome 119-122 (level 2).

What's new: Despite the inclusion of new recent studies, there were no new findings.

Recommendation (not changed): Use of functional support and exercise therapy is preferred as it provides better outcomes compared with immobilisation. If immobilisation is applied to treat pain or oedema, it should be for a maximum of 10 days after which functional treatment should be commenced (level 2).

Functional treatment

Functional support

Functional supports in the form of an ankle brace or tape are often used following acute LAS. These external supports differ from rigid immobilisation and allow the patient to load the damaged tissues in a protected manner. Treatment with any type of real ankle support was more effective compared with treatment with less adequate support such as a compression bandage or a tubigrip 5 122 (level 2). Wearing compression stockings beyond the acute phase is not helpful in the treatment of acute lateral ankle ligament injury 123 (level 3). The success of functional treatment is, however, dependent on the severity of the injury. For example, if a sprain is complicated by a ligament avulsion fracture results may be inferior to those in patients with isolated ligament injury. 124

The superiority of one external support over another is debated rigorously in the literature. 125-127 A meta-analysis (n=892) showed a lace-up brace or a semi-rigid brace should be preferred to the use of an elastic bandage 125 (level 1). Use of an ankle brace results in better outcome compared with other types of functional treatment such as sports tape (non-elastic) or kinesiotape (elastic), without showing any side effects. 128 Based on a small systematic review (n=276), it can be concluded that kinesiotape is unlikely to provide sufficient mechanical support in unstable ankles 129 (level 1).

What's new: New evidence emphasises that the use of external supports (ie, braces) is preferred over immobilisation. Additionally, the preferred time frame during which the use of external support is advised is outlined. Overall, the core message of this section remains unchanged.

Recommendation (modified): Use of functional support for 4-6 weeks is preferred over immobilisation. The use of an ankle brace shows the greatest effects compared with other types of functional support (level 2).

Exercise

Among patients who seek professional healthcare following an acute LAS, exercise therapy is often an integral component of the treatment administered. Exercise therapy programmes mainly consist of neuromuscular and proprioceptive exercises. Exercise therapy programmes that are initiated early following an acute LAS injury have established efficacy. They can reduce the prevalence of recurrent injuries 130-132 (10 RCTs, n=1284) (RR 0.62, 95% CI 0.51 to 0.76), as well as the prevalence of functional ankle instability 131 133 (3 RCTs, n=174) (RR 0.80, 95% CI 0.64 to 1.00). Furthermore, they are associated with a quicker time to recovery and enhanced outcomes 130 133-136 (level 1). Including supervised physiotherapy has shown to have some benefit in patients with a severe ankle sprain compared with a mild LAS as measured by PROMs, 60 and whence compared with a home exercise programme 137 138 (level 1). Additionally, supervised exercise therapy may lead to improvements in ankle strength 138 and proprioception, 138 faster return to work 139 and sport, 134 compared with performing the exercise programme without supervision or guidance (level 1). Many articles, however, contradict these findings, concluding that there is no effect from the addition of supervised exercise therapy to conventional treatment alone (two RCTs, n=130) 140 141 (level 2) nor an improvement of postural balance after exercise therapy 131 142 (level 1).

What's new: New evidence has become available on the specific effects of different types of exercise/rehabilitation programmes; especially the beneficial effect of exercise therapy on preventing recurrent sprains, reducing the risk of functional instability and expediting the recovery of ankle joint function.

Recommendation (modified): Exercise therapy should be commenced after LAS to optimise recovery of joint functionality. Whether exercise therapy should be supervised or not remains unclear due to contradictory evidence and requires further research (level 1).

Manual mobilisation

Manual joint mobilisation can provide a short-term increase in ankle joint dorsiflexion ROM following acute LAS 131 143-147 (12 RCTs, n=427) (level 1). Additionally, joint mobilisation has been reported to decrease pain 143 (level 1). Manual therapy combined with exercise therapy resulted in better outcomes compared with exercise therapy alone 137 (level 3).

What's new: Despite findings by the previous version of this guideline that manual mobilisation only results in short-term treatment effects, current evidence shows added value of manual mobilisation when used in combination with exercise therapy.

Recommendation (modified): A combination with other treatment modalities, such as exercise therapy, enhances the efficacy of manual joint mobilisation and is therefore advised (level 3).

Surgical therapy

Surgical therapy for acute lateral ligament injuries has been performed abundantly until it was recognised that conservative treatment provides equal effects and that not all patients require surgery in order to resolve complaints 148-151 (level 1). Nowadays, surgery is mainly reserved for patients who have chronic instability after a LAS and who have not responded to a comprehensive exercise-based physiotherapy programme. Long-term effects of surgical treatment in cases of acute lateral ligament injury correspond with those of functional treatment. Surgery seems superior at decreasing the prevalence of recurrent LAS, which is important as recurrent LAS in turn may increase the risk for the subsequent development of osteoarthritis (one RCT, n=51) 13 (level 2). There is limited evidence for longer recovery times, higher incidences of ankle stiffness, impaired ankle mobility and complications in patients who received surgical treatment (20 RCTs, n=2562) 150 (level 1). More recent studies show that outcomes in terms of recovery of ankle activity and instability are significantly better for surgical treatment than for functional treatment (12 RCTs, n=1413) 152 (level 1). As a previous sprain is a predictor for recurrent ankle sprains, this may be related to increased ligament laxity. This laxity is resolved during surgery. Based on this indirect evidence, it may be suggested that surgical therapy helps prevent recurrent ankle sprains. However, a large percentage (60%-70%) of individuals who sustain a LAS respond well to non-surgical treatment programmes, 149 and therefore treating all patients with LAS would mean unnecessary exposure to an invasive intervention for many patients, not to mention costs (level 1).

What's new: New evidence supports the rationale for being reserved with the recommendation of surgery for all patients following LAS. This lead to refinement of the recommendation regarding surgery.

Recommendation (modified): Despite good clinical outcomes of surgery after both chronic injuries and an acute complete lateral ligament rupture, functional treatment is still the preferred method as not all patients require surgical treatment. This also helps to avoid unnecessary exposure to invasive (over) treatment and unnecessary risk of complications 149 152 (level 1). However, treatment decisions have to be made on an individual basis. In professional athletes, surgical treatment may be preferred to ensure quicker return to play. 151

Other therapies

Other treatment modalities less frequently used do not always show a treatment effect. For example, no effect on pain, oedema, function and return to play has been shown for ultrasound 153 154 (level 1), laser therapy 155 (level 1), electrotherapy 156-158 (level 1) and shortwave therapy 159-163 (level 2) in the treatment of acute LAS. Evidence on acupuncture is inconclusive concerning the therapeutic effect due to large heterogeneity between studies 164 165 (level 1). A small cohort study indicated that local vibration therapy may be effective in patients with LAS by increasing dorsiflexion and eversion and decreasing perceived ankle stiffness, 166 while another study indicated the possible beneficial effect of Bioptron light therapy in addition to cryotherapy 167 (level 3).

What's new: Acupuncture, vibration therapy and Bioptron light therapy were added to the present update. Concerning the other identified therapies, new evidence did not change previous statements.

Recommendation (not changed): As no strong evidence exists on the effectiveness of these treatment modalities, they are not advised in the treatment of acute LAS (level 2).

Communication between professionals

Since there are various disciplines involved in the care for patients with LAS, it is preferable to make working arrangements at a regional level on indications for referral, division of tasks and what information is provided by healthcare professionals. The different disciplines involved in primary and secondary care are emergency physicians, sports masseurs and physical therapists, sports physicians and general practitioners, orthopaedic and trauma surgeons, radiologists, medical officers for occupational medicine and rehabilitation physicians. Within referral between healthcare professionals, optimal communication is preferred. What information should be communicated between healthcare professionals depends on the phase of LAS; the diagnostic phase, the treatment phase and the guidance phase. 14 168-170

What's new: The checklist and statements from the previous version of this guideline were not subject to change. The most important factor remains communication.

Recommendation (not changed): To refine communication between healthcare professionals involved in the treatment of patients with LAS, a communication check list is recommended ( table 4). 14 168-170

Prevention

Functional support

The use of brace or tape reduces the risk of both recurrent (RR 0.30, 95% CI 0.21 to 0.43) and first-time ankle sprains (RR 0.69, 95% CI 0.49 to 0.96), especially in those who participate in sports 4 125 171 172 (level 1). Kinesiotape may also have a preventive effect in patients who have already sustained a LAS due to its effects on postural control 171 (five RCTs, n=276) (level 1). The use of a brace or tape is a personal choice and based on practical usability and costs. Associated adverse events are rare. 4 125 171 172 Ankle brace or tape usage has not shown any beneficial effects on proprioceptive acuity in patients who sustained recurrent ankle sprains or those who have functional ankle instability (eight RCTs, n=152) (level 1). This conclusion was consistent when the two aspects of proprioception, sense of movement and joint position, were considered separately. 129 No differences in prevention of recurrent sprains were found between different types of tape and brace as support. 117 172 173

What's new: In addition to updating the risk ratios by including new studies, a risk ratio is provided for the preventive effect of tape and brace for first-time ankle sprains. Additionally information on the effect on proprioception and adverse events was included. This new evidence did not change the previous recommendation.

Recommendation (not changed): Both tape and brace have a role in the prevention of recurrent LAS despite limited evidence on mechanisms that leads to these beneficial effects (level 1). The choice of usage should depend on personal preferences.

Exercise therapy

Coordination and balance training have been shown to prevent recurrent ankle sprains. 4 The assessment of the effect of exercise therapy as in neuromuscular training (mainly proprioception) has shown a positive effect towards prevention of LAS 132 139 173-175 and especially recurrent LAS. A meta-analysis (two RCTs, n=130) illustrated that exercise therapy had a protective effect compared with usual care on preventing recurrent LAS (RR 0.62, 95% CI 0.51 to 0.76). Usual care was defined as 'any form of rehabilitative treatment used by the athlete, without any interference from the authors' (cited from Hupperets et al). 176 This effect is even larger in athletes (RR 0.38, 95% CI 0.23 to 0.62) 38 177 (level 1). When exposing athletes with recurrent sprains to proprioceptive training, to improve joint position sense, their risk of recurrence of LAS is reduced to the same level as healthy controls 4 42 177-180 (level 3). Exercise therapy such as coordination and balance training mainly seem to be effective for recurrent ankle sprains up to 12 months after the initial sprain, 4 131 176 181 but not on first-time ankle sprains 21 38 175 182 (level 1).

What's new: More positive effects of different training programmes have become available, strengthening the recommendation of the previous guideline.

Recommendation (not changed): For this reason, it is advised to start exercise therapy, especially in athletes, as soon as possible after the initial sprain to prevent recurrent LAS. Exercise therapy should be included into regular training activities as much as possible as home-based exercise (level 1). The preventive effect of exercise therapy for first-time LAS lacks evidence (table 6).

Footwear

No evident conclusions exist on the role of footwear in the prevention of ankle sprains (level 2). Wearing low-fitted or high-fitted shoes did not show any difference in preventive effect (three RCTs, n=3410) 4 172 183 (level 1). Despite the lack of evidence, some authors prefer high-fitted shoes, 73 117 whereas other authors describe a preference of low-fitted shoes 120 (level 1). Possibly shoes being new is of greater importance compared with the height of the shaft of the shoe in preventing ankle sprains. 4 Also, no difference in LAS incidence is seen when wearing sports shoes with or without a cushioned column. 91

What's new: New evidence corresponded with the evidence found in the previous guideline.

Recommendation (not changed): Due to the inconclusiveness of evidence, no recommendations can be made concerning shoe wear (level 1).

Resuming work

To facilitate return to work, discrimination between different degrees of injury can support the initial treatment and identification of the prognosis in relation to return to work 184 (level 4). Additionally, a schedule for work resumption ( table 7), which takes into account all task requirements, may assist in optimisation of the reintegration process 185 186 (level 3). Two systematic reviews stated wearing a brace provided better functional outcome compared with no brace, without limiting return to work (two RCTs, n=157) 125 128 (level 2). Immediate post-traumatic mobilisation and functional treatment also seem to have a positive effect on the treatment of acute LAS and lead to shorter sick leave and faster return to work compared with immobilisation 131 187-189 (level 1).

What's new: With the current focus on productivity and socioeconomic burden, return to work is of substantial importance. Based on new available evidence, table 7 was expanded and the advice on return to work was further specified.

Recommendation (modified): To speed up return to work, a brace and immediate functional treatment in combination with a return to work schedule are advised (level 3).

Sport resumption

LAS may lead to multiple problems such as proprioception disturbances. These disturbances seem to originate from the central nervous system above the level of the spinal reflex (level 2) and may result in functional instability. 190-192 Additionally, delayed response time of the peroneal muscle has been detected, possibly due to traction injury of the peroneal nerve. 193 However, motor-unit insufficiencies seen after a LAS seem to last shorter than those after other lateral ankle injuries not based on an inversion trauma mechanism 178 193-195 (level 2). Strength deficits are present following LAS. For these reasons, early functional treatment is advised and should address proprioception, muscle response time and muscle strength, 196-200 enabling early return to sport participation 187 188 (level 2).

What's new: In addition to the many new and varying types of rehabilitation programmes, recent results showed that supervised exercise provides better outcomes compared with non-supervised training.

Recommendation (modified): Supervised exercises focusing on a variety of exercises such as proprioception, strength, coordination and function will lead to a faster return to sport in patients after a LAS 134 and are therefore recommended (level 1).

Cost-effectiveness

Costs of injury

Estimated societal costs of ankle sprains, as reported in the literature, vary between €360 201 and €1100 202 per individual (level 2). This disparity in reported costs is due to, among others, variations in healthcare system, population, and type and severity of injury. Although most patients with ankle sprain do not receive supervised rehabilitation 203 (level 3), these values indicate that ankle sprains have a substantial financial impact on society. Additionally, added to these costs in the short term, patients with ankle sprain are at risk of developing chronic conditions, which in turn may lead to subsequent costs. Consequently, optimised treatment and prevention will provide economic benefits in addition to clinical effects for the individual.

Diagnostics

The OAR provide a valid and reliable cost-effective tool to diagnose fractures after an ankle sprain 203 (level 3). In 1995, it was shown that implementing the OAR as opposed to existing hospital protocols resulted in cost savings between €7.01 and €30.96 per patient 204 (level 3). More recently, implementation of the OAR through emergency department nurses has been shown to be a cost-effective method to diagnose and manage ankle sprains 205 (level 3). As an alternative to the OAR, the low-risk ankle rule provides a cost-effective tool to diagnose paediatric ankle fractures, with an estimated reduction in required radiographs of around 60% 206 (level 3).

Treatment

Functional treatment is clinically the treatment strategy of choice for ankle sprains. No full cost-effectiveness studies are known to compare functional treatment against immobilisation as treatment. In regards to indirect costs, a functional approach (3-5 days of rest, ice, compression and elevation with early weight bearing, after which active exercise is commenced) leads to the fastest resumption of work and daily life activities compared with any other kind of treatment 207 (level 3). For protection, ankle support may be indicated to facilitate return to work. A semirigid brace is suggested to be the most cost-effective option compared with taping 208 (level 3).

Prevention

Preventive efforts against first-time and recurrent ankle sprains have shown high cost benefits 208 (level 3). Both neuromuscular training and ankle braces have been proven beneficial as a preventive investment due to lower societal costs, mainly achieved through reduced indirect costs 209 (level 2). Comparisons between measures have indicated bracing to be superior to taping 210 and neuromuscular training 211 as a preventive option (level 1). Of note is that the latter statement is only valid for the preventive value of bracing. Neuromuscular training has been associated with clinical benefits other than prevention alone, which should also be considered 212 (level 1) (table 8).

Discussion

After an acute LAS it is important to first exclude the presence of any fractures. To this end the OAR can be used, having a high sensitivity and specificity. Subsequently, functional treatment in the form of exercise and functional support (ie, brace or tape) is preferred over immobilisation. Still a short time of immobilisation may help diminish complaints of pain and swelling in case of a lateral ligament injury. In case of ROM restriction, mobilisation therapy may provide help, but combination with exercise therapy is advised. Surgery should be reserved for patients with lateral ligament ruptures to avoid unnecessary invasive treatment and risk of complications. In the prevention of ankle sprains, functional support is effective in patients with both first-time and recurrent LAS, but seems most effective in preventing recurrent sprains. Exercise therapy, however, has only shown a significant preventive effect for recurrent ankle sprains. For first-time LAS, there was mainly a lack of evidence as studies did not explicitly name whether their included population had previously suffered a LAS or not. Additionally, this may be explained by a lack of research on exercise in a population who has never suffered a LAS as exercise is mostly commenced after injury during rehabilitation.

Overall there is no clear evidence on the role of other forms of therapy such as (high-fitted and low- fitted and sports) shoe wear, vibration and electrostimulation therapy in the treatment and prevention of (recurrent) LAS. There are no conclusions on acupuncture since there were no studies that involved a sham acupuncture group. On the exact role of BMI, we cannot provide any conclusive recommendations. Whereas a lower BMI seems to increase the risk of sustaining an initial ankle sprain, a higher BMI seems to be a prognostic factor for persistent complaints and incomplete recovery.

Apart from the side effects reported for NSAIDs usage and complications resulting from surgery, no complications have been reported for functional support devices such as tape or brace. 213 This is despite some known adverse effects such as rashes, which may need more detailed reporting in articles studying such devices.

By development of this CPG on ankle sprains, all current evidence is considered to provide insight into the best evidence-based practice. To ensure readability, all information was categorised, summarised and recommendations provided separately explicating the effectiveness per treatment or preventive modality. Overall, this guideline provides strong evidence per treatment and preventive modality by combining multiple RCTs showing consistent results. The AGREE II reporting guidelines have been used in an attempt to optimise the quality of this CPG.

Provided evidence may, however, be influenced by publication bias, indicated by the limited amount of evidence on negative effects or treatment without any clinical effect. Level of evidence and bias assessment using GRADEpro were not possible due to the large amount of included studies. As an alternative, each statement was provided with a level of evidence according to tables 1 and 2. There is also the effect of selection bias. Ankle sprains are very common, and many people sustaining LAS do not seek medical advice. Therefore, the effect of 'no intervention' on the outcome after LAS remains unknown. Most contradictory results were found in small studies showing both positive and negative effects, levelling out to a neutral MD or RR. Additionally, most studies only included injured patients, whereas there is some conflict in the evidence of certain preventive measures in patients with first-time LAS. For this, more research is needed to enable adequate comparison between preventive effects based on a history of ankle sprains, preferably within the same study group. The best available evidence has been included in this guideline. However, the preferred approach by both patients and healthcare professionals in the diagnostic process, treatment and prevention of LAS has not. This is due to a lack of evidence on subjective data, apart from patient satisfaction after undergoing a certain treatment. More evidence on this topic may help identify the best treatment strategy per patient.

By including all steps that may be encountered by a patient from the moment of sustaining an ankle sprain up to full recovery, this guideline also includes all procedures considered and possibly performed by healthcare professionals. Thus, this guideline has a clinical focus and may provide support for all healthcare professionals encountering patients with ankle sprain irrespective of the phase of rehabilitation the patient is in. Many of the steps addressed in this guideline are steps in daily clinical practice, whether they are proven effective or not. There is a need for a clear policy that can be implemented worldwide. By updating the guideline on ankle sprains, the first step is taken towards such a policy. Further awareness regarding this guideline, to enable healthcare providers to follow the state-of-the-art recommendations, must be raised by means of scientific publication, scientific referral, congresses and raising awareness among the various professional associations.

Future perspectives and research

This update provides the most recent evidence on diagnostics, treatment and prevention for acute LAS. As more evidence has become available, often of a higher evidence level, this enabled the use of meta-analyses where there was a lack of evidence in the initial guideline. However, not all recommendations were supported by meta-analysis. Also, some recommendations lack evidence from RCTs. A future update might be required if enough new studies become available. Thus this guideline may be updated after 5-10 years to ensure content and recommendations remain up to date using the same methodology and search strategy. If relevant new treatment methods, preventive techniques or other aspects are identified, these will receive appropriate attention depending on their importance for patients who sustained a LAS. In a future update, the methodological quality may be included to formulate conclusions based on the quality and reliability of results, as may be done using the GRADEpro tool.

Future research is required in the field of different functional treatment and prevention strategies, identifying superiority between different types of support and training and for which specific subpopulations these are effective (eg, recurrent or first-time LAS). Additional research may be performed on preferences of patients and healthcare professionals: what do patients prefer on forehand before undergoing treatment and what were their experiences? Which treatments do healthcare professionals prefer and is this dependent on injury severity, and so on, as this may contribute to formulating future recommendations.

Acknowledgments

The authors thank Clare Ardern for her support in the methodological approach for this update and her advice concerning structure and the most efficient approach of the meta-analyses. Additionally they thank F S van Etten, clinical librarian of the AMC.

Read the full text or download the PDF:

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Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline

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This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies.

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CKS content is produced by Clarity Informatics Ltd (trading as Agilio Software | Primary Care). It is available to users outside the UK via subscription from the Agilio | Prodigy website.

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foot and ankle history and clinical examination guide

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foot and ankle history and clinical examination guide

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Abstract

This review summarises the key points in taking a history and performing a comprehensive clinical examination for patients with foot and/or ankle problems. It is a useful guide for residents who are preparing for their specialty exams, as well as family doctors and any other doctor who has to deal with foot and ankle problems in adults.

Keywords: Foot, Ankle, History, Examination and clinical assessment

Core tip: Patients present with foot and ankle problems can have either single or multiple pathologies. Obtaining adequate history and performing good clinical examination is a key in reaching the accurate diagnosis. Adjuvant tools like radiological images can be used to confirm what has been clinically suspected.

INTRODUCTION

Patients commonly present with foot and ankle problems, either in primary or secondary care clinics. However, many physicians find it challenging to assess these patients[ 1]. This is probably related to the complexity and multiplicity of joints in this part of the body.

There are 26 bones, 33 Joints and more than 100 ligaments, tendons and muscles in each foot[ 2]. On average, we walk 10000 steps per day, 1000000 steps per year and 115000 miles in our lifetime. The foot stands 3-4 times body weight during running.

This review summarises the keys points in taking a full history and performing a systematic clinical examination for patients with foot and ankle problem. It is a useful guide for residents who are preparing for their specialty exams, but also for any doctor who may have to deal with these problems in practice.

HISTORY

The common reasons for patient's presenting to the foot and ankle clinic are: Pain, swelling, deformity, stiffness, instability and/or abnormal gait[ 2]. For new patients or when the diagnosis has not been confirmed before, we recommend that the examiner should not read the previous notes prior seeing the patient. This good practice allows the examiner to have more lateral thinking, with fresh eyes looking into the problem.

Pain

Ask the patient to finger point to the exact site of the maximum pain. If the pain was diffuse and not localized to one spot, try to identify the area/side of maximum discomfort. Correlate the site with the anatomical location as described in Table . Ask about the radiation of pain and quality or nature of it (sharp, dull or burning), whether it is related to weight bearing (degenerative changes, stress fracture or Inflammatory conditions like plantar fasciitis), the radiation (towards the toes or up the leg), severity of the pain (0-10), prevents activity, waking up during the night, time (early morning or night pain which disturbs the sleep), duration, pattern (constant/intermittent), aggravating factors (like walking distance, walking on flat or uneven floor; Going up and down the stairs; relation with shoes), and any alleviating factors (rest, analgesia, preferred type of foot wear)[ 3].

Table 1

Ankle joint capsule injury ex. Sport injury with maximum ankle joint plantar flexion

Forefoot pain - 2 nd, 3 rd and 4 th toe

Claw toe Hammer toe

Mallet toe

The chronicity and the severity of the pain can help to establish whether there is an element of central sensitization where by the patient becomes more sensitive and experiences more pain with less provocation. Factors like sleep deprivation and depression can drive central sensitization[ 4]. Finally, it is important to clarify what is the patients' belief about their foot pain.

Deformity

Enquire about the duration and when the patient or their family member first noticed the deformity, which area it involves, is it progressing, and whether it associated with other symptoms (for example, skin ulcer, pain, recurrent infection, rapid wear of shoes, or cosmetic).

Swelling

It is important to establish whether the swelling is localized to one area or the whole leg or ankle, whether it is uni- or bilateral, associated with activities, as well as the frequency and the duration of swelling. Generalized bilateral swelling that involves the whole foot and ankle is usually related to more systematic pathology, such as cardiac or renal problems. Swelling which includes the area only around the ankle joint may be related to the tibio-talar joint (for example, degenerative changes or inflammatory arthropathy). On other hand, localized swelling is more likely result from a specific local pathology. As an example, swelling anterior to the distal fibula may indicate chronic injury of the anterior inferior tibio fibular ligament (ATFL) and swelling posterior to the distal fibula may indicate peroneal tendon pathology[ 5]. Acute painful or painless swelling with or without the deformity of the mid foot deformity could result from Charcot neuropathy.

Instability

Enquire as to when the first episode of instability or sprain occurred, how often it happens and what can precipitate it[ 6].

History of trauma

History of trauma with details of immediate symptoms and treatment, surgery, injections or infection with date and details of any identified.

Associated symptoms

It is important to look out for red flags symptoms such as night sweating, temperature or weight loss, which may be related to an infection or neoplasm. Neurological symptoms like numbness, limb weaknesses or burning sensation are usually related either to spinal problem or peripheral neuropathy.

General medical history

It is important to cover all the key points that are summarised in Table .

Table 2

Important key points not to be missed in general medical history

Age

Occupation

Participation in sports

History of lower back pain

History of problems with other joints (for example, hip and knee)

Diabetes

Peripheral neuropathy

Peripheral vascular disease

Inflammatory arthropathy

Rheumatoid arthritis

Vasculitis

CLINCIAL EXAMINATION

The examination begins from the first moment of meeting the patient by observing the gait and whether he/she uses any walking aids. The patient should be adequately exposed and ideally patients should wear shorts with bare feet. Ask for chaperone if appropriate.

Inspection of the patients footwear, insole, and walking aides

Start by examining the patient shoes and whether they are commercial or surgical shoes. Look at the pattern of the wear, which usually involves the outside of the shoe heel. Different patterns of wear indicate abnormal contact of the foot with the ground. Early lateral, proximal, and mid shoe wear, indicates a supination deformity; wear on the medial border indicates a pronation deformity[ 2]. In case of absence of any wear, it may simply reflect new or unused pair of foot wears. Look for any orthosis or walking aides. Inspect any insole and ask the patient which type of insole is comfortable and which type is painful.

Examination in a standing position

In most clinical setting the patient is sitting on the chair at the start of the examination. First ask the patient to stand up, and assess the alignment of the lower limbs as a whole. In particular look for any excessive varus or valgus knee deformity. Inspect the alignment of the spine in case of scoliosis, and look for any pelvic tilt. Inspect for any thigh or calf muscles wasting[ 7].

Look from the side for the feet arches (is there any pes cavus or pes planus), any swelling or scars. Inspect for any big toe deformity (hallus valgus, hallux valgus interphalangeus or hallus varus), lesser toes deformity (mallet toe, hammer toes, claw toes)[ 1]. In normal ankle, you should not be able to see the heel pad on the medial side when you inspect from the front. If this was visible then it is called "peek a boo" sign which exists with pes cavus[ 2]. It is important to compare both sides as a false-positive sign may be caused by a very large heel pad or significant metatarsus adductus[ 8].

Inspect the ankle from the back for any bony bumps like calcaneal boss[ 1]. The normal ankle alignment is neutral. Also notice if there is a "too many toes" sign. In a normal foot you should not be able to see more than 5 th and 4 th toes when you look at it from behind. If there were more toes visible (3 rd or 3 rd and 2 nd), then it is called "too many toes" sign which can indicate an increased heel valgus angle.

Ask the patient to stand onto tiptoes. Both ankles should turn into varus. This indicates normal subtalar movement and, in case of flat feet, if a medial arch forms on standing on tip toes then this is a flexible pes planus[ 1].

Gait: Enquire if the patient can walk without a support and be prepared to provide support for elderly patients and those who may unsteady on their feet. Ask the patient to walk as per their normal gait. Observing the gait from the front and the back help to assess the shoulder and pelvic tilt. Looking from at the hip movements, knee movements, initial contact, three rockers, stride length, cadence and antalgesia.

The patient should then be asked to walk on his/her tiptoes, then heels, inner borders and finally the outer borders of the feet. Correlate your finding with possible causes as described in Tables and . Beware not to miss a foot drop.

Table 3

Tiptoe walking

Ankle flexibility Posterior impingement Achilles/tibialis post function Midfoot function MTPJ problems Fractures (Stress) S1/2 function

Heel walking

Ankle mobility Anterior impingement Tibialis anterior function L4/5 EHL/EDL function Plantar fasciitis/heel problems

Inner borders (inversion)/outer borders (eversion) foot walking

Sub talar mobility Tibialis posterior function Peroneal tendons function 5 th ray problems Medial and lateral gutter impingement 1 st ray problem

Examination in a sitting position

By this stage, a fair idea of the possible diagnosis may have been established. Hence, you should be able to direct the rest of the examination accordingly. We recommend at this stage to ask the patient to sit on the examining couch, with the legs hanging loosely from the side. Raise the bed so the patient's foot is at the level of the examiner's hand, and sit on a chair opposite the patient.

Look: Start with meticulous inspection of the sole then the rest of the foot. Look for skin discoloration, scar, ulcer, lack of hair (circulatory changes), nails, any skin thickening (callosity), hard/soft corns and any signs of infection[ 7].

Feel: First ask the patient if there are any areas which are painful to touch, so you can try to avoid causing pain during the examination. Then you start with gentle feel of the skin temperature, always comparing to the other side.

The second part of the palpation is to establish area of tenderness. Always follow a systematic method of palpation so you will not miss any part. We recommend to start the palpation for tenderness from proximal fibula, Achilles tendon, distal fibula, peroneal tendons, PTFL, CFL, ATFL, AITFL, Sinus tarsi, Calcaneum, Calcaneocuboid (CC) joint, Cuboid, lesser Metatarsals, Phalanges, 1 st IP and MTP joint, 1 st ray, TMT joints, Cuneiforms, Navicular, TN joint, Talus, Ankle joint, Medial malleolus, Tibialis post, Tibialis anterior, extensors and other flexors and finally plantar fascia.

Move: Start with active movement by asking the patient to perform dorsiflexion, plantar flexion, inversion, and eversion. Always compare both sides (Table ).

This will be followed by passive movement of dorsiflexion: As the patient is already sitting, the knee is flexed to 90 degrees then repeat the test with knee straight (Silfverskiold test). Keep the foot in a neutral position (0 degree of inversion and eversion), hold the back of the leg with one hand and use the palm of the other hand to push the sole of the examined foot[ 9]. Now move the palm of the hand to the dorsum of the examined foot to produce the passive plantar flexion.

Supination and pronation are triplanar movements. Supination is the combination of Inversion, Plantarflexion and adduction. Pronation is the combination of Eversion, Dorsiflexion and Abduction.

Inversion: Place one hand over the back of the leg and use your other hand to grasp the calcaneus between your index finger and thumb and use your forearm to fully dorsiflex and lock the talus in the ankle. Rotate the calcaneus in a medial direction to test for inversion and move your hand in a lateral direction to test for Eversion[ 9].

Midfoot movements: Stabilize the calcaneus and talus with one hand and use the other hand to move the foot medially to test for Adduction). Move the foot laterally to test for the abduction[ 9]. It is also important to examine the motion of midfoot (transverse tarsal joint) on sagittal plane (specially for patients with end stage ankle arthritis). The motion of 1 st TMT joint should be examined as well (for patients with hallux valgus or flexible flatfoot).

Forefoot movements (metatarsophalangeal and interphalangeal joints): You should test the movement in each joint separately. If there is any deformity, try to find whether it is correctable or not (for example, a fixed flexion deformity).

The examination of muscular function and the special tests should be the next step of the assessment. Both of these aspects are summarised in Table , Table , Table and Table . The strength of each muscle is assessed using the medical research council (MRC) scale Table .

Table 9

Pes cavus

Claw toes Examine peroneal tendons Tibialis anterior and posterior Coleman block test Examine the Achilles tendon Full lower and upper limb neurological examination Hand - inspect for muscle wasting Spine

Pes planus

Single leg sustained tip toe test Testing tibialis posterior power Too many toes sign Examine the Achilles tendon

Hallux valgus/ rigidus

Dorsal osteophyte Passive ROM Grind tests Correct the deformity Examine the Achilles tendon

Table 10

Grade 0

No contraction

Grade 1

Flicker or trace of contraction

Grade 2

Active movement with gravity eliminated

Grade 3

Active movement against gravity

Grade 4

Active movement against gravity and resistance

Grade 5

Normal power

The examination of the foot and ankle is not complete until you perform neurovascular examination, an examination of the spine (deformity like scoliosis, hair tuft on the lower back), leg length, hip joint examination and knee joint examination.

Finally, it is important to consider Functional testing which is important and needs to be appropriate to the level and background of the patient for instance, a single leg squat or squat jump for higher level athletes may indicate issues not obvious with more static tests.

CONCLUSION

The assessment of foot and ankle pathology can be challenging, hence the importance of following a systematic method for its clinical assessment. We have described here one way of performing the clinical examination. It has been built using the best available evidence, and has been tested and evolved through the experience of the senior author. We recommend this approach for residents who are preparing for their specialty exams, for clinicians in family or sports medicine, and for any physician who has to deal with foot and ankle patients.

Footnotes

Conflict-of-interest statement: None.

Manuscript source: Invited manuscript

Specialty type: Orthopedics

Country of origin: United Kingdom

Peer-review report classification

Grade A (Excellent): 0

Grade B (Very good): B, B

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): 0

Peer-review started: September 20, 2016

First decision: October 21, 2016

Article in press: November 29, 2016

P- Reviewer: Chen GS, Papanas N S- Editor: Ji FF L- Editor: A E- Editor: Wu HL

References

1. Papaliodis DN, Vanushkina MA, Richardson NG, DiPreta JA. The foot and ankle examination. Med Clin North Am. 2014;98:181-204. [[ PubMed] Google Scholar]

2. Coughlin MJ, Saltzman CL, Anderson RB. Mann's surgery of the foot and ankle. Amsterdam: Elsevier Saunders; 2014. p. 2186. [ Google Scholar]

3. Reider B. The Orthopaedic Physical Examination. 2nd ed. Amsterdam: Elsevier Saunders; 2005. p. 383. [ Google Scholar]

5. Simpson MR, Howard TM. Tendinopathies of the foot and ankle. Am Fam Physician. 2009;80:1107-1114. [[ PubMed] Google Scholar]

6. Harris N, Ali F. Examination Techniques in Orthopaedics. England: Cambridge University Press; 2014. [ Google Scholar]

7. Roberts PJ, Tandon S, Wade RH. Clinical Examination for FRCS (Trauma & Orthopaedics). 1st ed. Oswestry: The Institute of Orthopaedics (Oswestry) Publishing Group; 2002. p. 149. [ Google Scholar]

8. Thevendran G, Younger AS. Examination of the varus ankle, foot, and tibia. Foot Ankle Clin. 2012;17:13-20. [[ PubMed] Google Scholar]

9. Gross J, Fetto J, Rosen E. Musculoskeletal Examination 3rd ed. New Jersey: Wiley-Blackwell; 2009. p. 463. [ Google Scholar]

10. Davies H, Blundell C. Clinical examination of the foot and ankle. Orthopaedics and Trauma. 2011;25:287-292. [ Google Scholar]

Articles from World Journal of Orthopedics are provided here courtesy of Baishideng Publishing Group Inc

# data[].attributes.attachment_link.title
Foot and ankle history and clinical examination: A guide to everyday practice

# data[].attributes.attachment_link.description
This review summarises the key points in taking a history and performing a comprehensive clinical examination for patients with foot and/or ankle problems. It is a useful guide for residents who are preparing for their specialty exams, as well as family ...

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The Ottawa Ankle Rule rules out clinically significant foot and ankle fractures to reduce use of x-ray imaging.

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Three bones form the ankle joint - tibia, fibula and talus. Ankle fractures are usually bony injuries involving the distal tibia (medial malleolus) or distal fibula (lateral malleolus). Occasionally the articular surface of the talus can be injured.

Standard views

Anterior-Posterior (AP) and Lateral. The AP or 'mortise' view is not a true Anterior-Posterior projection but rather at an angle to optimise visualisation of the ankle joint without being overlapped by the fibula.

Ankle ligament anatomy

Ankle injuries may involve bones or ligaments in isolation, or a combination of bones and ligaments. X-rays directly visualise bone injury, but understanding of the anatomical position of ligaments is required to appreciate the presence of ligament injuries which are not directly visualised.

Ankle injuries

Fractures of the medial or lateral malleoli can lead to ankle joint instability and loss of normal ankle joint alignment. The posterior edge of the distal tibia is sometimes referred to as the 'posterior malleolus'.

Ligamentous injury may also lead to instability of the joint, but this is not always appreciated if there is no displacement.

Lateral malleolar fractures are categorised according to their position in relation to the distal tibiofibular syndesmosis at the level of the ankle joint.

Maisonneuve fractures

A 'Maisonneuve fracture' is a fracture of the proximal fibula associated with injury to the medial side of the ankle and disruption of the distal tibiofibular syndesmosis. The medial ankle injury may be either a visible medial malleolus fracture or an invisible injury of the medial ligaments.

An isolated fracture of the medial malleolus, or widening of the ankle joint with no visible fracture seen on ankle X-ray, should raise the suspicion of an associated fracture of the fibula. If this is not visible in the distal fibula then further X-rays of the proximal fibula should be performed. Imaging of the proximal fibula should also be considered in the setting of any severe ankle injury or if the proximal fibula is tender to palpation.

Osteochondral fractures

Occasionally ankle trauma causes a fracture of the talus bone surface. These 'osteochondral' injuries are often subtle and so this area should be assessed carefully on all post-traumatic ankle X-rays.

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Musculoskeletal x-ray trauma tutorial - Radiology Masterclass. X-ray tutorial discussing the anatomy of the ankle as seen on X-ray. Bones and ligaments of the ankle can be injured causing instability of the ankle not appreciated on X-ray of the ankle.

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advice for professionals on ankle injuries and sprains

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advice for professionals on ankle injuries and sprains

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See also the separate Ankle Fractures article.

Ankle sprains and injuries are common in primary care, A&E and sports medicine . Most are inversion and plantar flexion injuries that lead to damage to the lateral ligaments .

The ankle is a complex joint which is capable of a wide range of movement: flexion, extension, inversion and eversion as well as a combination of these movements. This allows locomotion and balance on both level and uneven ground. The ankle takes the full weight of the body and is subject to considerable force, particularly in running and jumping.

Many ankle injuries are managed conservatively. However, obvious clinical deformity (ie dislocation) or injuries with neurovascular compromise of the foot are an orthopaedic emergency for which immediate reduction is required (see 'Management' section, below).

Two joints allow movement of the ankle:

The true ankle joint (tibiotalar joint) - articulation is between the lower end of the tibia, the malleoli and the body of the talus. This joint allows dorsiflexion and plantar flexion of the ankle.

The subtalar joint - articulation is between the talus and calcaneus. This joint allows inversion and eversion of the ankle.

The distal tibia has a prominent medial malleolus and a less prominent posterior malleolus. The distal fibula is known as the lateral malleolus. The joint capsule and the surrounding ligaments stabilise the ankle. The distal fibula is joined to the distal tibia by the anterior and posterior inferior tibiofibular ligaments, an inferior transverse ligament and a syndesmosis ligament. The anterior and posterior talofibular ligaments join the fibula to the talus. The talus is joined to the calcaneus by the calcaneo-fibular ligament. The deltoid ligament joins the medial malleolus to the talus, calcaneus and navicular bones.

By OpenStax College, Anatomy & Physiology, Connexions Website, Jun 19, 2013, via Wikimedia Commons

Initial assessment should follow the principles for any trauma:

Carry out a primary survey following the 'ABCDE' principles of resuscitation and trauma care.

Assess clinically for obvious deformity and for neurovascular status. If there is neurovascular compromise or dislocation (obvious deformity) of the joint, the fracture should be reduced immediately under analgesia or sedation.

Displaced fractures should be reduced as soon as possible after initial assessment - this reduces pain/swelling and may prevent skin necrosis.

History and examination help to decide whether there has been a significant likelihood of an ankle fracture or foot fracture. Apply and document the Ottawa Rules .

History

Ask how long ago the ankle injury occurred.

Mechanism of injury: injuries are most often whilst crossing uneven ground or after a sudden change of direction whilst playing sport:

Was there excessive inversion or eversion? The injury may have resulted from jumping from a height.

Was there a 'snap' sound? (This does not differentiate between a sprain and a fracture .)

Where is the pain felt?

What happened afterwards? Was the patient able to weight bear immediately? Did they need help to walk? If it was a sports injury, were they able to continue?

Was there immediate swelling? (Immediate swelling is due to bleeding and suggests significant tissue injury.)

Previous ankle injury: establish whether there is underlying weakness or instability in the ankle and whether an old fracture might be evident on X-ray.

Past medical history - eg, osteoporosis or metabolic bone disease.

Drug history - eg, long-term corticosteroid use.

Inspection:

Note whether the patient walked in and, if they did, with how much discomfort and disability.

Look at the ankle and whether there is obvious deformity.

Note whether there is swelling or bruising and whether it looks compatible with the mechanism of injury.

Establish whether an effusion is present. This may be a fullness either side of the Achilles tendon.

Look for any open wounds.

Palpate for crepitus and tenderness, especially over the malleolar regions, over the anterior tibiofibular ligament, the whole length of the fibula and the base of the fifth metatarsal. Note whether calcaneal pressure elicits pain.

Examine for neurovascular injury:

Assessment of neurovascular status is by sensation over the dorsal and plantar surfaces of the foot, measuring capillary refill in all digits and palpating the distal pulses (the dorsalis pedis artery is absent in 2-3% of the population). Vascular compromise is the urgent concern in dislocations and fracture-dislocations. Sural nerve and peroneal nerve palsies are a rare complication of severe sprains.

Examine for co-existing injuries:

Specific tests (if appropriate and tolerable to the patient) include:

Thompson's test: this is to assess if the Achilles tendon is intact. With the patient lying prone with the knee flexed to 90°, squeeze the posterior calf muscles - this should produce a visible plantar flexion at the ankle if the tendon is intact.

The anterior drawer test: this can show excessive anterior displacement of the talus on to the tibia. If the anterior talofibular ligament is torn, the talus will subluxate anteriorly compared with the unaffected ankle. With the ankle in a neutral position, stabilise the leg over the distal tibia with one hand and cup the heel with the other, pulling the foot forward. The patient should be relaxed and both legs compared. A positive sign is a greater anterior movement on the injured side, with the injured side having more movement than the uninjured.

The talar tilt test (also called the inversion stress test): this stresses the calcaneo-fibular ligament. This test is not usually feasible in acute injuries, owing to swelling; however, it may be used to assess stability during healing. With the foot in a neutral position, hold the lower leg in one hand and the heel in the other: invert the ankle. Compare with the other leg.

Tests for syndesmosis injury:

Squeeze test: involves squeezing the tibia and fibula together at the mid calf. If pain is experienced more distally or in the ankle, this is a positive test.

Interosseous membrane tenderness test: this also looks for syndesmosis injury. Position the patient supine. Palpate between the tibia and fibular from the ankle proximally. Note the length of tenderness.

External rotation stress test: externally rotate and then passively dorsiflex the ankle. Pain at the syndesmosis is a positive test.

Examination of the uninjured ankle may give an indication of the normal range of movement and power.

The first question is often how to rule out ankle fracture, particularly where there is difficulty in weight bearing.

Clinically it may be very difficult to differentiate a fracture from a severe sprain without an X-ray unless there is obvious distortion or instability. The Ottawa Ankle Rules were introduced in 1992 as a guideline with which to reduce costs and waiting times when ruling out serious ankle and midfoot fractures in the non-athletic, adult population.

Ankle radiography is indicated only if a patient has pain in the malleolar zone and any of the following findings:

Foot radiography is indicated only if a patient has pain in the midfoot zone and any of the following findings:

Imaging

If an X-ray is performed, anteroposterior (AP), lateral and mortise views can be taken. For the mortise view, the foot is rotated about 15° internally. This allows a better view of the ankle mortise.

If one injury is seen on X-ray, always look for a second.

CT and MRI scanning are sometimes needed for fracture diagnosis and assessment of ligamentous or intra-articular injuries.

The diagnosis and management of ankle fracture is covered in the separate Ankle Fractures article.

The ankle and knee are commonly affected.

The severity of symptoms and signs depends on the severity of the sprain (for example, whether there has been a partial or complete ligament tear). Common symptoms and signs include:

Tenderness and swelling.

Functional loss (for example, pain on weight-bearing).

Mechanical instability (if the sprain is severe).

Marked bruising and swelling, which may indicate a complete ligament tear or fracture.

There is commonly confusion between the terms sprain and strain. A strain includes inflammation of muscles and tendons. A sprain is a ligament injury.

The clinical features of a muscle strain depend on the severity of the injury and the nature of the haematoma.

There may be a history of a strain or 'pulled muscle'.

Pain occurs in the affected muscle.

Large haematomas can occur as a result of tearing of the intramuscular blood vessels.

There may be obvious swelling, although small haematomas or those deep within the muscle are more difficult to diagnose clinically.

Muscle function may be affected, depending on the severity of the strain.

Other causes of acute ankle pain are:

Lateral ankle sprains

Ankle sprains are classified from grade I to grade III depending on their severity:

Grade I injuries - the ligament is stretched, with microscopic (but not macroscopic) tearing. Swelling is mild, with little or no functional loss and no joint instability. The patient bears weight at least partially.

Grade II injuries - the ligament is stretched with partial tearing. Swelling is moderate-to-severe, with ecchymosis.There is moderate functional loss and mild-to-moderate joint instability. Patients usually have difficulty bearing weight.

Grade III injuries - the ligament is completely ruptured. Swelling is immediate and severe, with ecchymosis. The patient usually cannot bear weight (or not without severe pain). There is moderate-to-severe instability of the joint.

Syndesmotic (high ankle) sprain
This is caused by dorsiflexion and eversion of the ankle with internal rotation of the tibia - eg, during skiing or football. The syndesmotic ligaments are the combination of the interosseous ligament and lower tibiofibular ligaments which normally stabilise the mortise joint and fix the fibula in the fibular notch.

Look for widening of the mortise (tibiofibular gap should be <5 mm measured 1 cm above the joint line on AP and mortise views).

Squeeze test, side-to-side test and forced external rotation all cause pain at the syndesmosis.

Healing takes longer than standard lateral sprains - consider the diagnosis in those with continuing pain more than six weeks after the original injury.

Treatment aim is to minimise discomfort and restore function. Most ligament injuries heal well, although there may be scarring.

Functional support is generally preferable to immobilisation, unless the injury is severe. This means the use of a variable or immovable immobilising device in conjunction with exercise.

Lateral sprains are most common and can be treated conservatively.

Simple medial sprains can also be treated conservatively but tenderness over the deltoid ligament, with or without laxity, associated with fractures or instability, may require fixation.

For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function.

Exercise therapy and bracing are supported in the prevention of chronic ankle instability.

Protection, rest, ice, compression and elevation (PRICE)

P rotect from further injury (for example, by a tubular support bandage, ankle tape, brace or high-top high-lace shoes ).

R est the ankle joint for 48-72 hours following injury. Consider the use of crutches in this period. In most cases, early controlled weight-bearing with the ankle well supported is preferable to complete rest.

I ce should be applied as soon as possible after injury, for 10-30 minutes. (Less than 10 minutes has little effect. More than 30 minutes may damage the skin.) Do not put ice directly next to skin, as it may cause ice burn. This may limit pain, inflammation and bruising. Some doctors recommend re-applying for 15 minutes every two hours (during daytime) for the first 48-72 hours. Do not leave ice on while asleep.

C ompression with a bandage will limit swelling.

E levation aims to limit and reduce any swelling.

Avoidance of heat, alcohol, running and massage (HARM)

H eat - which encourages blood flow which will tend to increase bruising and inflammation.

A lcohol, which can increase bleeding and swelling and decrease healing.

R unning, which may cause further damage.

M assage, which may increase bleeding and swelling.

Treatment for the first 72 hours

Analgesia if required.

For simple sprains which are not severe, begin flexibility (range of motion) exercises as soon as they can be tolerated without excessive pain.

For severe sprains (type III) a short period of immobilisation can result in quicker recovery. A short period of immobilisation in a below-knee cast or pneumatic brace may speed recovery compared to a compression bandage alone .

Treatment of syndesmotic sprains may involve a fracture boot, short leg cast or non-weight bearing. Internal fixation may be required if the joint is unstable. See the separate Ankle Fractures article.

Rarely, if ligaments are badly torn or the joint unstable, surgical repair may be indicated.

Physiotherapy may be helpful in restoration to a full range of normal movement, improving the strength of the surrounding muscles and improving proprioception.

Avoidance of sport or vigorous exercise involving the ankle for at least 3-4 weeks after a sprain.

Other treatment

After injury, full rehabilitation to build up the muscles around the joint is important; weak muscles can predispose to further injury. Guided rehabilitation over a period of weeks is recommended .

Athletes with severe sprains may need an ankle orthosis for several months following the injury .

Chronic ankle instability may follow an acute lateral ankle sprain. Initial treatment involves bracing or neuromuscular training. However, if symptoms persist, surgery may be considered .

After a sprain, persistent symptoms remain in up to 30% of individuals .

Rehabilitation after ankle sprain

Prevention of ankle sprain

Prevention of ankle sprains may be facilitated by wearing walking boots that protect the ankle (rather than shoes) when hiking over hills or uneven ground, or for manual labour.

Immobilise the injured muscle for the first few days after the injury. Consider the use of crutches in severe injuries.

Start active mobilisation after a few days if the person has pain-free use of the muscle in basic movements and the injured muscle can stretch as much as the healthy contralateral muscle.

Dr Mary Lowth is an author or the original author of this leaflet.
Management of muscle strain

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Ankle injuries and ankle sprains are common in primary care, A&E and sports medicine. Many ankle injuries are managed conservatively.

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The Paediatric Consultation HPHA 7025 (6)

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The NICE Clinical Knowledge Summary (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories

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See also

Key points

1. Most children presenting with a limp do not require investigations

2. Observing the child's gait may help localise the problem and narrow the differential diagnosis

3. Acute inability to walk or weight-bear is a red flag

4. Septic arthritis is an orthopaedic emergency and should be considered in all limping children with severe localised joint pain and fever

Background

Transient synovitis, acute myositis and minor trauma are common causes of limp in children, but serious pathology should be excluded

Pain causing limp can be referred. Therefore, a thorough assessment of joints above and below (including the spine and other relevant body systems) is essential to accurately localise the source

Assessment

Red flag features in red

History

* Duration of symptoms >7 days
* History of trauma, falls or injury
* Pattern and severity of pain and limp: severe localised joint pain should raise suspicion for septic arthritis
* Change to urinary or bowel habit
* Functional limitations: complete inability to walk or weight-bear may indicate significant pathology
* Nocturnal pain and symptoms
* Systemic symptoms: fever, night sweats, chills, rigors, rash
* Constitutional symptoms eg unplanned weight loss, lethargy/easy fatigue, anorexia (consider malignancy/haematological cause)
* Recent viral infection (acute myositis, transient synovitis)

Examination

Generalised wasting, pallor, interaction with carer

Assess gait if possible - walking +/- running

Joint examination using "Look, Feel, and Move" including joints above and below area of pain

Identify location if possible - bone vs joint vs soft tissue

Look: resting limb position, leg length disparity, swelling, deformities, skin changes e.g. rash, wound, bruising, erythema, pallor

Feel: heat, cold, tenderness (including calf), crepitus, fluctuance

Move:

active: facilitate by placing toy or parent out of reach

passive: assess for limitations and asymmetry in all planes of motion

compare both sides, as well as active and passive range of movement. A marked reduction in range of motion is suggestive of more serious pathology such as septic arthritis

tone, power, and reflexes

Neurovascular assessment of affected limb

Abdomen, scrotum, back/spine

Petechiae/purpura/ecchymosis (consider HSP, malignancy/haematological cause)

Common differential diagnoses:

Transient hip synovitis

Acute myositis

Developmental dysplasia of hip

Perthes disease

Stress fractures & sprains

Traction apophysitis (Osgood Schlatter - tibial tuberosity, Severs - calcaneus)

SUFE

All ages:

Infections: osteomyelitis/septic arthritis, bursitis, discitis, epidural collection

Trauma (see Fractures)

Non accidental or inflicted injury

Malignancy: haematological, bone, soft tissue

Rheumatological/immunological disorders: reactive arthritis, autoimmune arthritis, Henoch Schonlein Purpura, vasculitis, serum sickness, post infectious arthritis, Guillain-Barre syndrome

Intra-abdominal pathology or genitourinary conditions eg appendicitis, ovarian or testicular torsion

Haematological: vaso-occlusive crisis (sickle cell), haemophilia

Functional limp

Management

Investigations

No investigations are indicated if all of the following apply:

no red flags in the history and physical examination

ambulating with mild or no discomfort with simple analgesia

a clear working diagnosis and/or a plan for review within 7 days of onset of limp

Imaging

X-ray (area of suspicion)

pelvis AP or frog leg view is useful for identifying SUFE, DDH (>6 mo), Perthes disease and common pelvic avulsions

normal x-ray does not exclude septic arthritis or early osteomyelitis

Ultrasound (hip)

assess for presence of drainable effusion when septic arthritis is suspected

presence of an effusion often does not differentiate between septic arthritis and transient hip synovitis

Other eg bone scan or localised MRI if still limping at 7 days, consult local paediatric, orthopaedic or radiology services

Laboratory

Raised inflammatory markers (platelets, WCC, CRP +/- ESR) may suggest infective or inflammatory picture. These may be normal in contained or chronic infections

Blood cultures (pre-antibiotics if possible) if osteomyelitis, septic arthritis or septic bursitis are suspected

FBE and film if any concern for haematological malignancy

Treatment

Definitive management is determined by the working diagnosis

Simple analgesia - paracetamol +/- NSAID. Escalation of analgesia may be required but should prompt reassessment for red flags

Child-directed limitation of activity

Splint suspected fractures and manage accordingly

Septic arthritis is an orthopaedic emergency - consult local orthopaedic specialist ASAP

For infective causes, refer to the appropriate sub-specialist team and consult local antibiotic guidelines. If the child is stable and access to surgery will not be delayed, obtaining a surgical sample prior to antibiotic treatment is preferable. If the child is unwell do not delay treatment

Consider consultation with local paediatric team when

There is possible non-accidental injury

There are clinical or laboratory features of malignancy

Systemically unwell

Symptoms last more than 7 days, or child unable to weight-bear or permit movement after analgesia

Suspecting septic arthritis - consult with orthopaedic team

Consider transfer when

Child requires care above the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

The cause of the limp has been identified and adequately managed
OR

Child is ambulating comfortably with or without analgesia AND

High risk diagnoses have been considered AND

Adequate follow up plan in place

Parent information

Additional notes

Kocher Criteria

In a child with hip pain, presence of the following 4 criteria increases the likelihood of septic arthritis:

fever >38.5°C

non weight-bearing

leucocytosis >12.0 x 10⁹/L

ESR >40 mm/h (or CRP >20 mg/L)

Last updated July 2020

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Most children presenting with a limp do not require investigations Observing the child's gait may help localise the problem and narrow the differential diagnosis Acute inability to walk or weight-bear is a red flag Septic arthritis is an orthopaedic emergency and should be considered in all limping children with severe localised joint pain and fever Transient synovitis, acute myositis and minor trauma are common causes of limp in children, but serious pathology should be excluded Pain causing limp can be referred.

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Limp is a defined as an asymmetric gait which is often, but not always, due to pain.

The differential diagnosis is wide and varies with age. Conditions can range from the benign (e.g., splinter in the foot) to the serious (e.g., Juvenile Idiopathic Arthritis), to the life-threatening (e.g., malignancy, sepsis, rheumatic fever or non-accidental injury).
Key points to remember about limp:

Limp is a symptom and not a diagnosis.

Urgent referral is warranted: for non-weight bearing, unwell or febrile, or very young (<3 years) or immunosuppressed.

'Red flags' (e.g., high fever, weight loss, night pain, lethargy) suggest infection or malignancy.

Trauma can cause limp but note that children with pathology may be more prone to falling.

A limp persisting beyond two weeks requires referral to paediatrics, paediatric rheumatology or paediatric orthopaedics (pending local referral pathways).

Careful clinical assessment determines the likely cause, helps identify red flags (history and examination), and guide further investigations and management.

Morning stiffness or 'gelling' (stiffness after periods of rest), even if without obvious joint swelling, suggests inflammatory causes such as Juvenile Idiopathic Arthritis (JIA). Urgent referral is warranted.

It is important to examine all joints and not just the legs ! pGALS is useful and guides further detailed examination.

Many hip pathologies cause limp, but it is important to assess other joints and consider extra-articular causes (e.g., urine infection, hernia, testicular torsion).

Be aware of motor milestones. With delayed milestones consider inherited myopathies. With regression of achieved milestones, consider inflammatory disease (joint or muscle).

Growing pains do NOT cause limp. Be aware of the rules of growing pains

Key points when assessing a child who is limping:

Young children may not verbalise pain and non-verbal clues are important (e.g., facial expression, withdrawal of a limb or non-use of a limb).

You need to observe the whole child and examine all joints as the history may not localise all joint involvement. As a minimum, a pGALS assessment is needed with movements performed passively if the child is young.

You need to be aware of normal musculoskeletal development and motor milestones to identify what is abnormal.

Further information about limp is available - we refer to the Clinical Guidelines from Royal Children's Hospital Melbourne, Australia:
https://www.rch.org.au/clinicalguide/guideline_index/Child_with_limp/

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Limp is a defined as an asymmetric gait which is often, but not always, due to pain. The differential diagnosis is wide and varies with age. Conditions can range from the benign (e.g., splinter in the foot) to the serious (e.g., Juvenile Idiopathic Arthritis) , to the life-threatening (e.g., malignancy, sepsis, rheumatic fever or non-accidental injury ).