How To Differentially Diagnose The Ankle

Posted By: Andy Barker

The ankle is one of the most simple joints in the body and injuries at this joint are so common, however…

Many therapists often make a hash of their treatments and rehab, even with the most simple of ankle sprains.

One of the big issues I see is therapists missing important clues during the assessment.

You need to be able to gather all the information you need from your patient to nail your diagnosis, so you can be sure you are treating the right problem.

As good as your ankle treatments and rehab might be, if you are treating the wrong problem, the likelihood is your patient or player, will not get better.

With the ankle, the patient’s story and in particular their mechanism of injury is vital.

If you can establish a clear story of how the injury happened then the rest of your assessment will run much smoother as you have a clear idea of the probable probable and this will increase the chances of you getting the right diagnosis.

You injury different structures with different movements.

You can NOT get a syndesmosis injury by rolling your ankle as to stress the syndesmosis joint and ligaments the ankle and foot need to be either fully dorsiflexed under high load and force or be loaded in a dorsiflexed and externally rotated position…

Whereby to ‘roll’ the ankle, the joint is in a position of plantar-flexion and inversion, which most commonly causes injury to the lateral ankle ligaments, namely the anterior talo-fibular ligament (ATFL) and the calcaneo-fibular ligament (CFL).

Two completely different movements, that cause two completely different ligament injuries.

Lateral ligament complex (ATFL, CFL) and syndesmosis ligament injuries are the two most commonly seen ankle ligament injuries, and you need to be able to differentiate between the two, as their management, particularly acutely is very different…

But you also need to be able to spot the others…

Injuries to structures like the deltoid ligament, the joint itself; anterior or posterior ankle impingement, tendon issues; achilles, tibialis posterior and peroneal and not forgetting the foot and the joint, tendon, ligament and soft tissues structures that can be present there.

With all these different structures it is easy to see how you might get your head in a spin when you come to assess the ankle.

The key is always the assessment.

Get your assessment right and you will be sure you have the right problem…

And if you have the right problem then you will know exactly what you are trying to fix.

It’s all well and good prescribing some eccentrics or heavy slow resistance training for an achilles issue, when it is actually posterior joint impingement…

Or giving ankle mobility exercises for an ATFL injury when your patient has an anterior syndesmosis injury and an unstable ankle, where the very last thing they need is to mobilise the ankle!

You were probably sick of hearing how important your subjective history is when you were at Uni.

Every lecturer telling you that you should have a fair idea of what the injury is before you start your objective assessment.

That primary and secondary hypothesis.

But they were right.


If you are getting to your objective assessment and just testing everything at the ankle, then you have not done a great job with your subjective assessment.

Maybe you tell yourself you are testing everything to ‘practice’ or to ‘rule things out.’ 

But it’s a dangerous game and often just leads to more confusion with your diagnosis.

Doing more tests than you need to during your objective assessments can add to your patient’s problem, as many of the tests you use are provocative i.e. they are meant to produce a problem, usually either pain or instability.

The more tests you do, the more likely you are to stir something up and if you are just doing tests for the sake of it, you might stir something up in the ankle that you did not need to.

Firstly, the more tests you do and the more symptoms you reproduce the more chance you have of getting a false positive.

I’m sure you’ve had this before when you test something at a joint and get a positive result when you weren’t expecting it, which then causes you to question your original hypothesis…

And ask yourself ‘Is it really that injury, or is it something else?’ 

Secondly, the last thing you want to do is make your patient or athlete worse, and aggravate them right before you try to start to help them, with your treatments and rehab.

These problems all related to the your assessments and can be avoided if you have a simple and structured way to assess the ankle.

I’ll be covering ankle assessments in more depth in my upcoming FREE webinar…

’Lateral Ankle Injuries – Why A Lateral Ligament Injury Is Much More Than Just A ‘Rolled’ Ankle’

This webinar is happening on Wednesday 9th June 2021 at 19:00 (UK Time) and you can register your free place here.

As well as ankle assessments I’ll also be covering…

  • Why Lateral Ankle Injuries Often Present With Medial Joint Line Pain, What This Means & Why You Need To Be Respectful Of This Problem
  • How To Know When To Immobilise An Acute Ankle Injury & When To Get It Moving (This Is The Key To Quick Injury Recovery)
  • The Special Tests You Need To Know To Rule In An ATFL & CFL Injury To Be Sure You Are Actually Treating A Lateral Ankle Injury
  • How To Make Quick Changes In Ankle Mobility With Both Acute & Chronically ‘Stiff’ Patients & Athletes That Can’t Seem To Get Their ROM Back
  • Specific Lateral Ankle Mid & End Stage Rehab Options To Ensure Your Patient or Athlete Is Ready To Return To Higher Level Activities Like Running & Sport
  • Plus I’ll Be Holding A LIVE Q & A Session To Answer Any Questions


  1. There are only 500 seats for this webinar and my last two injury based webinars were oversubscribed… 

So do not wait around too long to secure your place.

Do it right now here