Ankle (stress view)

Andrew Murphy et al.

The AP stress view of the ankle is a highly specialized view used to assess the integrity of the syndesmosis and deltoid ligament. It can be performed one of two ways, with gravity or via manual external rotation. 

In intermediate ankle injuries that have no syndesmotic widening on x-ray — yet a high suspicion of injury — will warrant a stress view to demonstrate dynamic widening of the ankle joint 1.

  • the patient may be supine or sitting upright with the leg straightened on the table
  • the leg must be rotated internally 15° to 20°
  • the second person (often requesting physician) will then place the ankle into supination and external rotation 
  • AP projection
  • centering point
    • the midpoint of the lateral and medial malleoli
  • collimation
    • attempt to avoid hands conducting stress view
    • laterally to the skin margins
    • superiorly to examine the distal third of the tibia and fibula
    • inferior to the proximal aspect of the metatarsals
  • orientation  
    • portrait
  • detector size
    • 24 cm x 30 cm
  • exposure
    • 50-60 kVp
    • 3-5 mAs
  • SID
    • 100 cm
  • grid
    • no

The end-goal here is to have ankle hanging over an edge to replicate a mechanical stress view.

  • the patient can lay in the lateral decubitus position OR sitting in a chair with the ankle in question overhanging a sponge or cushion with the lateral aspect in contact essential placing the ankle into supination and external rotation 
  • the leg must be rotated internally 15° to 20°
  • AP horizontal beam projection
  • centering point
    • the midpoint of the lateral and medial malleoli
  • collimation
    • attempt to avoid persons conducting stress view
    • laterally to the skin margins
    • superiorly to examine the distal third of the tibia and fibula
    • inferior to the proximal aspect of the metatarsals
  • orientation  
    • often held up by a detector holder or using the upright Bucky
    • landscape
  • detector size
    • 24 cm x 30 cm
  • exposure
    • 50-60 kVp
    • 3-5 mAs
  • SID
    • 100 cm
  • grid
    • no
  • the lateral and medial malleoli of the distal fibula and tibia, respectively, should be seen in profile. 
  • there should be no movement present in the form of blurring, a particular risk when performing these views
  • this view can place the patient in considerable pain, explain the procedure carefully so they are prepared 
  • when performing the mechanical stress view, ensure there is clear communication between the radiographer, patient, and physician to ensure there is no movement and the radiograph is captured at the optimal moment 
  • the gravity-assisted stress view can be performed lateral decubitus or sitting, depending on the patient 2
  • when performing the gravity-assisted stress view, it is still important to position the patient as if you were doing a horizontal beam mortise view to ensure there is a clear visualization of the mortise joint
Imaging in practice
Radiographic views

Article information

rID: 78052
Section: Radiography
Synonyms or Alternate Spellings:
  • AP stress view of the ankle

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Cases and figures

  • Case 1: deltoid ligament tear
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  • Case 2: syndesmotic injury
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  • Case 3: ankle fracture - Weber A
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