Hi, I'm Chris Fulmer. I'm one of the faculty members for the Stanford O'Connor Sports Medicine Fellowship. In this case, the patient presents with lateral ankle pain after suffering an inversion injury. Typically, the way I start my exam is to, after inspecting and performing range of motion, when I do my palpatory exam, I start proximally and move distally. I do this for several reasons. First, usually the patient's pain and their focus is all right around their ankle, so I think this is an easy way to begin your palpation and avoid the most tender areas first. Secondly, you want to make sure that you don't miss an injury to the proximal aspect of the fibula, such as a proximal fibular fracture or, in a very specific case, fracture at the fibular head-neck region, which is called a mesoneuve fracture. So what I'll do is I'll palpate and find the fibular head. I'll palpate along both the posterior and anterior aspects of the fibular head and then begin palpating down along the length of the fibula. Ideally, you would palpate all the way from the fibular head down to the lateral malleolus. Sometimes this is not necessary, but it's never a bad habit just to make sure you're palpating the entirety of the whole fibula. After this, you want to make sure that any signs of more severe injury, including fracture or syndesmosis injury, would be included in your exam. So you're going to make use of the Ottawa foot and ankle rules by palpating the strategic points that would help you determine whether you're going to obtain initial radiographs or not. So those areas would be the distal aspect of the fibula, so technically speaking, the last six centimeters, palpating along the posterior aspect of the distal fibula, including the posterior aspect of the lateral malleolus, palpating for the foot elements of those rules, the base of the fifth metatarsal, the posterior six centimeters of the distal tibia and the medial malleolus, and then the navicular tuberosity. After I've done this, I will palpate the other soft tissue elements of the ankle, including the ligaments, and making sure that I'm palpating the deltoid ligament. If you find any tenderness of the deltoid ligament, your index of suspicion for more severe injury should be higher, including either a fracture or a syndesmosis injury. One of the other things that I use as a clue for looking for syndesmosis injury is tenderness over the anterior inferior tibiofibular ligament, so palpating the anterior elements of the ankle here and seeing if there's tenderness in the area where that ligament would reside. Certainly if there's tenderness there, that would be not typical for a classic lateral ankle sprain and could be more indicative of an injury to the syndesmosis. Other tests that you can perform if you're suspicious for a syndesmotic injury would be the dorsiflexion external rotation test. So the first thing I'll do is I'll stabilize the lower leg over the tibia and the fibula. I'll bring the patient's ankle into maximal dorsiflexion, and then I'll induce external rotation. If there's pain with that or if you can actually feel gapping of the tibia and the fibula, that would be supportive of a clinical diagnosis of a syndesmosis injury. Next, you can perform the squeeze test. As you do the squeeze test, you want to make sure that you're doing this away from the area where the patient has their pain and tenderness and assess if they report pain when you're doing it. Ask them if that pain is above where you're squeezing or below. This again will help you be less likely to miss a proximal fibular injury. So to do this test, you're going to place both palms around both the tibia and the fibula and compress medially. You want to make sure you're applying enough force to actually create mobilization of the fibula or potential gapping of the syndesmosis. Lastly, one other test that you can use to detect for a more subtle proximal fibular injury would be the cross leg test. You simply have the patient cross the affected leg over the other one, and as they rest their injured leg on their non-injured leg, this creates a bowing force across the fibula, which if there's a fracture will cause pain. You can also accentuate this by just placing a little bit inferior directed pressure on their knee to maximize that bowing force.

2nd Edition, CASE 10

2nd Edition

Foot and Ankle

lateral ankle pain

inversion injury

Ottawa ankle rules

syndesmosis injury

fibular injuries