Ankle Sprain Assessment
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A thorough assessment is essential to properly diagnose an ankle sprain and rule out any other injuries which may also be present.
The following examples are for information purposes only. We recommend seeking professional advice before attempting any rehabilitation.
Aims of assessment
- To assess the degree of instability.
- Grade of ligament damage.
- Identify any reduction in range of motion or reduced strength.
- Identify any other additional or associated injuries such as an avulsion fracture where a piece of bone at the end of a ligament has come away from the main bone itself.
It is important to understand that no single test can give a conclusive answer or diagnosis but can helps to build an overall picture of the problem in the therapists head from where they use professional judgment and experience to make a diagnosis.
As with any sports injury the therapist will usually follow a set procedure to diagnose an injury. The following is one example:
- Read medical records if available or X-rays.
- Previous treatment should be taken into account when diagnosing an injury, even one as simple as an ankle sprain.
- Listening - asking a number of questions to build up a picture of what might have happened. For example:
- How did it happen?
- Was there any pain at the time?
- Was the pain sudden onset or gradual?
- Was there any swelling and was it sudden onset or gradual? - a sudden swelling often indicates a bleeding into the joint rather than a gradual increase in synovial fluid within the joint.
- Did you hear any noises? - this could indicate ligaments tearing or bones breaking!
- Did you apply any emergency procedures such as RICE?
- Is there anything you do which makes it worse / better?
- Is this the first time you have injured the ankle in this way or is it recurrent?
- Observe the patient as they stand and when lying or sitting on a couch with the legs out in front. They will look for any abnormal position, deformity and of course swelling.
The patient moves the foot from plantarflexion to dorsiflexion. The therapist looks for reduction in normal range of movement and any pain in performing these movements. Then this is repeated moving from eversion to inversion.
The therapist moves the ankle and foot from plantar flexion to dorsi flexion and then inversion to eversion looking again at range of movement, comparing one foot with the other and and painful movements. The athlete remains relaxed and does not resist or actively move the foot or ankle. Any pain at the extreme range of inversion may indicate ligament damage as it is the ligament that is being stressed. The anterior drawer test is a special test which assesses the integrity of the ankle ligaments, particularly the anterior talo fibula ligament and the calcaneo fibula ligament.
The therapist gently resists the athlete as they try to move the ankle from inversion to eversion. Pain when performing this test may be an indication of tendon damage or inflammation (possibly peroneal tendons) as it is the tendons connecting muscle to bone that are stressed when performing this test.
These can only be performed if pain allows. A badly injured ankle will not be capable of performing these tests. The lunge test involves the athlete leaning forwards over one knee keeping the heel of the front foot in contact with the ground. It measures dorsi flexion in comparison to the uninjured ankle. Other tests include one leg standing balance (eyes closed) test and hopping tests. Note - hopping on a recently injured ankle is definitely to be avoided but this test may be of benefit much later in the rehabilitation process.
Palpation (touching and feeling)
Finally the therapist will touch or feel certain points of the ankle to identify any specific painful areas. The following are usual points to palpate:
- Distal fibula (bottom of the fibula bone)
- Lateral malleolus (bony bit on the outside of the ankle - peroneal tendon dislocation / inflammation)
- Lateral ligaments (most likely to be painful)
- Talus (bone at the top of the ankle which the tibia or shin bone sits on)
- Peroneal tendon
- Base of 5th metatarsal (where the peroneus brevis attaches to)
- Medial ankle ligaments.
Does it need an X-Ray?
If the sprain is severe and the athlete has trouble weight bearing an X-Ray may be beneficial in identifying possible fractures. However, an experienced sports medicine professional should be capable of palpating to identify if the pain is worse on the bone (lateral or medial malleolus) or on the ligament itself. The therapist should then record any significant signs or symptoms and test results for future reference and as a record of what was found.