The anamnesis is composed by civic information, physical activity or hobbies, occupation, history of the disease as well as the patients bio-psychosocial environment.
The various bio-psychosocial factors are important to take into account when managing a patient with chronic pain.
Ankle Assessment
The different part of the ankle and foot assessment
- Anamnesis
- Type of pain
- Objectives
- Red flags
- Neurological assessment
- Joint assessment
- Muscle assessment
- Synthesis
- Patient follow-up
- Appendices
- Sources
1. Anamnesis
2. The type of pain
Pain is first assessed by determining the part of the sensory and the emotional in the pain intensity. Then thanks to a body chart adapted to lumbar pathologies, where the patient can himself represent his pain.
Finally, for a good treatment, it is useful to clearly define the type of pain. Pain can be classified into three categories, nociceptive, neuropathic or by central sensitization (see source 1), in particular thanks to the questionnaires of Neuropathic Pain (DN4, here) and of the Central Sensitization Inventory (CSI, here).
3. Treatment goals and objectives
The objectives are defined with the patient in order to know this expectations of the treatments.
They allow us to know how are the expectations of the patient ‘s pain evolution.
They help the patients compliance and adherence to the therapeutic plan to achieve the goals developed together.
4. The Red Flags
Red flags (see source 2) specific to the ankle must be identified and the patient refered if necessary.
A summary table helps to check that the patient does not have infection, fracture particular thanks to the Ottawa criteria (see source 3), tumor, an inflammatory or vascular pathology, in particular a deep vein thrombosis, thanks to the simplified Wells rules (here).
Ottawa’s criteria
5. Neurological assessment
If nervous tissue damage is suspected, an assessment of sensitive and motor deficits is done to start the neurological examination.
In peripheral involvement, a local examination of the ankle and the foot is carried out to demonstrate nerve damage, in particular of the superficial fibular, sural and tibial nerve, especially when they passes through the tarsal tunel.
Suspecting of Mortons neuroma, Mudler’s test is performed. If necessary, the lumbar spine is inspected (see lumbar assessment).
6. Joint assessment
After ankle trauma, all ligaments are evaluated by specific tests. After a trauma in dorsiflexion and external rotation of the ankle, a lesion of the tibio-fibular syndesmosis can be suspected and assessed by a set of clinical signs and tests (squeeze test and external rotation test) (see source 4).
Residual or chronic pain on the anterolateral part of the ankle may result from a previous ankle impingement. Several clinical signs confirm the diagnosis as well as the forced dorsiflexion test. A posterior ankle impingement can cause pain on the posterior part of the ankle. It’s evaluated by the heel thrust test (see source 5). Cuboid syndrome, as well as a stress fracture, can be the source of persistent pain.
7. Muscle assessment
Tendinopathies are assessed on the medial, anterior, lateral and posterior compartments ans with the Royal London Hospital test for the Achilles tendon.
In case of plantar pain, the Windlass test will allows to sreen for plantar fasciitis (see source 6).
Pain at the inner edge of the tibia may be due to tibial periostitis (medial tibial stress syndrome) detected by characteristic clinical signs.
Postural control will be assessed, as well as the factors resulting in chronic ankle instability in the event of recurrent sprains.
Windlass test
9. The Synthesis
The summary makes it possible to highlight the essential points of the assessment and to avoid confusion in the face of all the information provided by the patient.
10. Patient follow-up
A part is dedicated to patient follow-up in order to note the changes session after session as well as the advice and exercises to be performed.
11. Appendices
The complete appendices and details each section of the assessment with a description of the clinical signs, the reference values of the tests, with summary tables and diagrams.
In case of doubt, a quick glance at the appendices will provide the answer to your question.
Sources
- Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–S15. doi:10.1016/j.pain.2010.09.030.
- Young Jae Kim. Red flag rules for knee and lower leg differential diagnosis. Ann Transl Med. 2019 Oct; 7(Suppl 7): S250.
- Barelds I, Krijnen WP, van de Leur JP, van der Schans CP, Goddard RJ. Diagnostic Accuracy of Clinical Decision Rules to Exclude Fractures in Acute Ankle Injuries: Systematic Review and Meta-analysis. J Emerg Med. 2017 Sep;53(3):353-368.
- Sman AD, Hiller CE, Rae K et all. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med. 2015 Mar;49(5):323-9.
- Lavery KP, McHale KJ, Rossy WH, Theodore G. Ankle impingement. J Orthop Surg Res. 2016 Sep 9;11(1):97.
- Martin RL, Davenport TE, Reischl SF et all. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014 Nov;44(11):A1-33.
