Ankle Sprains: How To Evaluate An Athlete's Ability To Return To Play

Author(s): 
By Douglas Richie Jr., DPM

   One of the biggest challenges in a sports medicine practice is deciding when an athlete has sufficiently recovered from an injury and can return to his or her sport. Often, the podiatric physician is under pressure from various sources to return the athlete back to play quickly after injury. More often than not, it is not the athlete who puts the pressure on the doctor. Rather, it is a coach or parent who wants the athlete back in action as soon as possible.    If an athlete returns to play before an injury has adequately healed, there is a risk of re-injury, which could add significantly to the time already lost from the sport. A worse possibility is the occurrence of a new injury due to compensation for a previous unhealed injury.    In the case of a fracture, the treating physician can use fairly objective criteria via imaging studies to determine the extent of healing. For soft tissue injuries such as an ankle sprain, there are not a lot of reliable objective criteria and clinical tests that one can use to determine whether the athlete has fully recovered. This may be one reason why up to 40 percent of all athletes who suffer a grade II or III lateral ankle sprain will go on to long-term sequelae from the original injury.    Over the past 15 years, there has been more insight into monitoring the recovery of athletes who have suffered an ankle sprain and this knowledge can be quite useful to the podiatric physician. In our office, we have modified the protocols of several excellent studies of outcome measures of lateral ankle sprain treatment in order to provide a more accurate assessment of our own patients. Essentially, we have learned that information received from the patient via a questionnaire can be more important than clinical tests in determining the overall level of recovery.

Key Insights From The Literature

   Kaikkonen, et. al., reported on a simple test protocol to evaluate patients after a Grade III ankle sprain.1 They asked three simple questions of the patient: Can you walk normally? Can you run normally? Has your ankle fully recovered?    They performed the following testing:    • an anterior drawer stress test and testing for ankle joint dorsiflexion;    • a functional test with the patient running down stairs;    • one balance test with the patient doing a one-legged stance on a square beam; and    • two strength tests with the patient rising on the toes and rising on the heels.    In comparison to 11 other clinical tests and numerous other subjective interview questions, the aforementioned protocol was the best overall predictor of functional recovery, according to the researchers.    Williams, et. al., proposed the Sports Ankle Rating System to assess functional outcomes of athletes with ankle injuries.2 This system has three major components: a quality of life measure, a clinical rating score and a single numeric evaluation. One can quickly adapt the elements of this rating system to podiatric practice.    Patient-based questionnaires are essential when it comes to evaluating treatment outcomes and determining the patient’s suitability to return to sport. Give the patient the questionnaire to complete before he or she enters the treatment room. The patient should complete it without the influence of others. Questionnaires should be brief and should use a numeric scale from 1 to 5, or employ a visual analog scale (VAS). One should use the numeric scale for quality of life measures such as symptoms and use the VAS for the patient’s clinical rating for pain, swelling, stiffness, the ankle giving way and function. One can then obtain a single overall numeric assessment by the patient for ankle function on a scale of 1 to 100.

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