Ankle Assessments – Avoid These 3 Vital Mistakes

Posted By: Andy Barker

It moves up and down (or dorsi-flexes and plantar-flexes), so the ankle should be a relatively simple joint.

Ankle injuries are common but a big issue is that they are often missed or mis-diagnosed and this is one reason that simple ankle ‘sprain’ or tendon issue can be tricky to manage…

And often take more time than they should to settle down.

Add to this the high rates of recurrent ankle injuries, you have a problem.

So what is it that you might be doing wrong?

Here are 3 mistakes that you must avoid if you want to do a better job with your ankle injury assessments so you can find the right diagnosis, and be confident that you are treating the right problem.

#1 Make Sure It’s Not Broken

Some ankle injuries do not settle well, because they have been mis-diagnosed.

This commonly happens at the ankle when ankle syndesmosis injuries are wrongly diagnosed as lateral ligament i.e. Anterior Talo-Fibular Ligament (ATFL) or Calcaneo-Fibular Ligament (CFL) injuries, despite having complete opposite mechanisms that cause their injuries…

And completely different clinical presentations!

The big problem here is that both these injuries require very different acute management, so if you do not get the diagnosis right, then your management will be wrong, leading a prolonged patient recovery (if they recover at all) and poor patient outcomes.

Almost as common as the mis-diagnosis of ankle ligament injuries is the mis-diagnosis, or missing, of ankle fractures.

So many ankle injuries get cleared in A&E, having no fracture, despite a fracture being present.

Granted, some of these fractures are not obvious, they might include a small ATFL avulsion fracture (this is where the ATFL ligament is injured and pulls off part of the distal end of the fibula where it attaches) or a stress fracture, easily missed by a non-specialist.

I say non-specialist in the nicest possible way, as the doctor usually looking at your x-ray in A&E is not a radiologist. 

Radiology is a specialised profession in it’s own right, so having a doctor that does not have this level of training review x-ray films, they are always going to miss some things.

Even top radiologists miss things sometimes.

So even if a player or patient with an ankle injury has had an x-ray and it was clear, do not take this as 100% proof they do not have a fracture.

If symptoms are not settling in a way that you would expect with an isolated ligament or tendon issue, it might be worth considering further imaging to ensure a bony injury has not been missed.


#2 Do Not Just Test Range of Movement on the Bed

The ankle is a weight-bearing joint, so why is it that so many therapists assess ankle range of movement (ROM) in a non weight-bearing position.

If this is you, try not to despair, as I have seen the best ankle consultants in the country, those that look after some of the biggest names and sports stars in the UK, do exactly the same thing!

The problem?

The ankle assesses very differently in a weight-bearing versus a non weight-bearing position.

A non weight-bearing ankle assessment of dorsiflexion and plantarflexion on the bed is very different to assessing the same movements in weight-bearing i.e. standing knee to wall ankle mobility test.

It stresses the joint in a completely different way.

Just because a patient may have ‘full’ ankle ROM on the bed, does not mean they will have full ROM under load i.e. in standing.

Do not assume this (this would be a big mistake!).

Test both, otherwise you will not know and you could miss something vitally important to the management of your patient or athlete with a restricted ankle joint.


#3 Know Your Ankle Anatomy 

Most structures in the ankle, from the ligaments to the tendons, and most of the bony surfaces are superficial, so can be easily palpated during the objective assessment.

Alongside the rest of your objective assessment like ROM, motor output and the standing movement based tests, your palpation findings will help you confirm the injury and exactly what structure is injured.

But only if you know your anatomy.

The ATFL & AITFL (Anterior Inferior Tibio-Fibular Ligament) are two different ligaments of the lateral ankle.

They sit approx 2 cm away from one another but have two completely different roles…

The ATFL attaches between the talus and the fibula…

The AITFL attached between the tibia and the fibula.

The job of the ATFL is to prevent ankle inversion…

The job of the AITFL is to prevent excessive widening of the syndesmosis joint (distal tibio-fibular joint).

If you do not know your anatomy you could end up palpating the wrong one and in turn make the wrong diagnosis.

That’s not good!

Your anatomy and palpation skills need to be good…

Otherwise you could find yourself mis-diagnosing the wrong patient problem and going down the wrong road with your treatment and rehab plan.

Key Take-Aways

Make Sure It’s Not Broken – Suspect a bony issue until proven otherwise and consider further imaging for ankle injuries that do not settle in the way you would expect.

Do Not Just Test ROM on the Bed – The ankle works different in non weight-bearing and weight-bearing positions so you need to test both as part of your objective assessment or risk missing ankle issues that you need to fix up as part of your treatment plan.

Know Your Ankle Anatomy – Your palpation skills can be used to confirm most ankle injuries, but only if you know your ankle anatomy well.

Hope you found this useful.


The New Grad Physio Mentor

PS. Is the ankle a joint you feel you could get better at assessing, to give you the confidence to differentiate between different ankle problems ?

Would it help to know what treatment techniques work well for different ankle injuries and what rehab exercises to use, ones that actually work and improve patients ROM and strength?

If you would like to learn more about the ankle, I have an entire module of content that just focuses on the ankle.

Everything from assessments, treatment methods and early, mid and end stage rehab exercises…

Plus in depth video and webinar content on specific injuries like lateral, medial and syndesmosis ankle injuries, so you can learn how to easily differentiate and know exactly how to treat each one of these different problems.

Want to learn more…

Head here [] to find out more.