Ankle Sprains: How To Evaluate An Athlete's Ability To Return To Play
What Clinical Testing Methods Can Reveal
In terms of clinical tests administered by the podiatric physician, the following tests appear to be the most valid and easiest to perform in the office setting.
Lateral hop test. Patients stand on the “uninjured” leg and hop as far as possible in a lateral direction with three continuous hops. They then stand on the “injured” leg and hop back to where they started, using three continuous hops. Patients must make it back to where they started, showing that their injured leg is of equal strength and stability as the uninjured leg.
Single leg stance (Modified Rhomberg Test). The patient stands and balances on the good leg with his or her arms crossed over the chest. Compare the duration that the patient stands on the single leg, without touching the other foot to the ground, to the duration that he or she stands on the injured leg.
Heel rocker test. The patient leans backward against a wall and pulls the toes and forefoot areas of both feet off the ground while rocking backward on his or her heels. The patient raises the toes repeatedly off the ground until full exhaustion. Check for any asymmetry in fatigue between the two ankles.
Ankle joint dorsiflexion. With a goniometer, measure the patient’s range of motion with the knee extended and flexed. Check for symmetry.
Test for joint laxity. Check for symmetry. Apply a manual anterior drawer stress test to the injured and contralateral ankle.
Stair run. Observe the patient running down stairs without holding on to the handrail. Many times, the patient will refuse to do this when the ankle is unstable.
Pertinent Insights In Assessing Athletes On The Playing Field
The office setting has definite limitations for a full assessment of an athlete who is recovering from injury. It is often essential to observe the athlete on a playing field where one can perform further tests. It may not always be feasible for the podiatric physician to follow each and every patient to the playing field. Therefore, it is critical to have a good relationship with the certified athletic trainer and/or the coach of the athlete, who can set up specific drills and then report their observations.
After an ankle sprain, it is important to assess the athlete in straight ahead running and sprinting over a distance of at least 40 meters. Look for any signs of limping or asymmetry of lower leg function. Proceed to put the athlete through an exercise of running a figure eight around cones. The patient should perform multiple laps both clockwise and counterclockwise, and one should look for weakness, favoring or asymmetry. Finally, the patient should perform sport specific drills to be sure he or she is ready. Soccer players should perform kicking drills. Volleyball players should perform vertical jumping and diving drills.
Even with newer insights into subjective and objective evaluations of athletes recovering from soft tissue injury, there is still considerable opportunity for bias and error on the part of the treating physician. In sports medicine, there is a need for the clinician to rely on experience and instinct over objective clinical measures.
The lesson we have learned over the past 10 years is the fact that the patient may know his or her level of recovery better than the doctor. Accordingly, one should give patients every opportunity to express their assessment via written questionnaire without the influence of the coach or parent.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is the Immediate Past President of the American Academy of Podiatric Sports Medicine.
Dr. Caselli (shown in the photo) is a staff podiatrist at the VA Hudson Valley Health Care System in Montrose, N.Y. He is also an Adjunct Professor at the New York College of Podiatric Medicine and a Fellow of the American College of Sports Medicine.