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.
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.
1. Kaikkonen A, Kannus P, Jarvinen M: A performance test protocol and scoring scale for the evaluation of ankle injuries. Am J Sports Med 22: 462-469, 1994.
2. Williams GN, Molloy JM, DeBerardino TM et al: Evaluation of the sports ankle rating system in young, athletic individuals with acute lateral ankle sprains. Foot Ankle Int 24: 274-282, 2003.