History
The history portion of the examination for a suspected talofibular ligament injury should include the following:
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Mechanism of injury
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Time of injury
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Concurrent injuries
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Position of the body at the time of injury
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Rotational component to injury
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Ability or inability to bear weight immediately after the injury
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Time of onset of pain and swelling (immediate or delayed)
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Whether the patient heard or felt a popping sound or sensation at the time of the injury
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Information regarding any previous ankle injuries
Physical Examination
The physical examination for a suspected talofibular injury should include the following:
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Inspect the ankles. Both ankles should be completely uncovered so the injured side can be compared with the uninjured side. Note any swelling, ecchymosis, lacerations, abrasions, or deformities.
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Palpate the injured ankle, noting any tenderness or crepitus.
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Test the range of motion. Patients with ligamentous injuries, especially to the ATFL, will have limited and painful inversion of their ankle.
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Perform a neurovascular examination of the foot distal to the injury. Document the findings.
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Assess the stability of the ankle joint. The anterior drawer test assesses the stability of the lateral ligaments. To perform this test, the foot is placed in slight inversion and 20° of plantar flexion. The heel is grasped firmly and drawn forward by the examiner, while the tibia is stabilized by the examiner's other hand. A positive sign occurs when the talus moves forward on the tibia. The injured side should also be tested for maximal inversion compared with the uninjured side. If the ATFL is torn, forward motion is detected on performing the anterior drawer test. If the ATFL and the CFL are torn, abnormal inversion is elicited.
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Talar tilt test: Assess the stability of the calcaneofibular ligament. Grade I sprains are partial tears of the ligaments and are stable to stress testing. Grade II sprains have a mildly increased anterior drawer test and are stable to inversion. Grade III sprains are unstable to both the anterior drawer test and the talar tilt test. Instability with these tests indicates a complete tear of the ATFL and at least a partial tear of the CFL.
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Perform a neurologic exam. This should include testing the patient's balance. Have them stand on their uninjured foot, initially with their eyes open; then, have them close their eyes. Then have the patient do this with the injured foot and compare. Ankle injuries will often disrupt the nerves, causing the patient to have poor balance.
