Ankle sprains: Mastering your assessment
Ankle sprains are a common occurrence, however they can lead to chronic ankle instability if they are not managed appropriately. A thorough ankle assessment can set your patient up for an appropriate management plan, and ultimately, better long-term outcomes. In this blog, we’ll outline some key takeaways from expert physiotherapist David Hillard’s Practical on assessing ankle sprains both on the field and in the clinic.
If you want to learn exactly how top expert David Hillard assesses ankle sprains, watch his full Practical HERE.
The subjective portion of the exam will drive much of the assessment. The main aims during the subjective are to understand the patient’s history, define their goals, and to screen for any referrals needed. Additionally, it is important to get a gauge of the patient’s current functional capacity, as this will inform your general exercise recommendations and rehab program design going forward.
Weight bearing assessments
The first screen is simply performing a squat – this provides a rough gauge of dorsiflexion Range Of Motion (ROM), loading tolerance of the affected side, and general functional capacity. Next, it is important to examine single leg stance, as this tells us more about weight bearing tolerance and lower extremity proprioception.
Assessment of dorsiflexion ROM should ideally be completed in weight bearing, as this is the most functional position. In the below snippet from his Practical, David demonstrates how to measure dorsiflexion in weight bearing:
The single leg heel raise test is another important weight bearing assessment. This test compares the strength endurance of each limb, and results can be compared with normative data for the patient’s age, sex, and sport. It is useful to use a metronome to standardise the tempo of repetitions to 60 beats per minute.
Palpation helps to identify which structures have been affected. David notes it is important to start by palpating structures which are unlikely to be painful; if you poke at painful spots first, it is likely you will lose some trust and rapport with the patient.
If the patient has not had imaging, palpation should begin following the landmarks listed in the Ottowa ankle rules. After clearing the ankle for possible fracture, it’s time to start palpating the ligamentous structures of the medial and lateral ankle. In addition to palpating “expected” areas of tenderness (e.g. anterior talofibular ligament in an inversion sprain), it’s important to screen for additional tender spots, such as medial tenderness as a result of compression injury secondary to lateral ankle sprain – David outlines palpation in the below video taken from his Practical:
Additionally, it is important to palpate muscles such as the tibialis posterior or the peronei, which may be implicated in acute or chronic ankle sprains.
Ligamentous stability tests
After palpation, ligamentous stability tests are key in differential diagnosis and assessment of ankle stability. It is important to be mindful of the patient’s history when completing these tests, as this may influence your findings (e.g. a basketball player with a history of ankle sprains is likely to have more laxity in their anterior drawer test).
The main tests for the lateral ankle are:
- Anterior drawer (and reverse anterior drawer) for the anterior talofibular ligament
- Talar tilt for the calcaneofibular ligament
- Bifurcate ligament test
- Dorsiflexion-external rotation stress test for the anterior inferior tibiofibular ligament
See David demonstrate two ways to perform the dorsiflexion-external rotation stress test in the below video taken from his Practical:
Muscle strength assessments
Strength testing should be completed to gauge the patient’s capacity; it is important to measure your findings against the unaffected side, and consider findings within the context of the demands of the patient’s activities or sport. Ideally, a hand-held dynamometer should be used to enhance reliability.
A key distinction in muscle strength assessment is the difference between a “make force” or a “break force”. A make force is purely isometric, where the patient pushes as hard as possible. A break force is the force at which the therapist’s applied pressure exceeds that of the patient’s muscle force – this is considered an eccentric force measurement.
It is important to assess inversion, eversion and 1st metatarso-phalangeal flexion strength. Watch the below video taken from David’s Practical, in which he outlines how and why to assess flexor hallucis longus strength:
When assessing plantarflexion strength in athletes, it is ideal to use a force plate due to the high force capacity of the calf complex. Single leg heel raises can provide a measure of strength endurance, however, this doesn’t measure maximal muscle strength.
For higher level patients, balance training should extend beyond just static balance. The star excursion balance test is a useful tool, as it assesses strength, dynamic balance, and mobility in anterior, posteromedial, and posterolateral planes of movement.
Hop testing provides a gauge of loading tolerance, power and neuromuscular control. Testing begins with bilateral hopping in place and then unilateral hopping in place for about 20-30 reps; it is important to assess the patient’s ability to hop continuously, their symmetric gross speed, and the use of compensatory strategies (e.g. g. excessive arm swing).
If the patient can perform hopping in place adequately, higher-level hop tests can be used, such as:
- Single hop for distance
- Triple crossover hop for distance
- Side hop test
An important note with these tests is to get your patient to cross their arms in order to minimize use of the upper body. Additionally, each test should be performed three times, and measurements should consistently be taken from the back of the heel.
A thorough ankle sprain assessment will set you and your patients up for a rock solid management plan. First, an in-depth subjective assessment must be completed to understand which structures are likely involved, the patient’s current functional capacity, and their goals. Objective assessment should include:
- Weight bearing assessments including the squat, single leg balance, and dorsiflexion
- Ligamentous stress testing
- Muscular strength assessment
- Dynamic balance testing
- Hop tests
With a rigorous assessment, you can be confident in guiding your patient back to the activities they care most about.
For an in-depth understanding on how to master your assessment of ankle sprains, check out expert physiotherapist David Hillard’s Practical here.
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