Basis:
(1) Direct pressure on a site can elicit pain in the absence of fracture, which results in an increased number of negative imaging studies.
(2) Indirect pressure (pressure applied away from the injury site) can identify significant injuries.
Steps in the clinical examination:
(1) indirect fibular stress
(2) direct medial malleolar stress
(3) compression stress on the mid-foot and hind-foot
Indirect fibular stress maneuver:
(1) Place one hand on the medial aspect of the leg (left hand left leg, right hand right leg) 10 cm proximal to the fibular tip.
(2) Place the other hand on the lateral aspect of the leg 10 cm proximal to the fibular tip.
(3) Compress the hands together over the flat of the hands.
(4) Avoid direct palpation of the distal fibular.
Direct stress on the medial malleolus: Press the thumb flat (not the tip) against the medial malleolus.
Compression stress on the mid and hind foot:
(1) Fix the calcaneus in a neutral position with one hand.
(2) Grasp the fore foot with the other hand palm to sole.
(3) Push the two hands towards each other to generate a compressive force.
Interpretation:
• If any of the tests causes pain, then acute fracture should be suspected and imaging studies performed.
• The indirect examination may be more sensitive to injury than an X-ray. If an indirect test is positive but the initial radiograph is negative, then a CT scan should be considered.
