Ankle Lateral Ligament Injury Assessment

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Tarina van der Stockt and Jess Bell

Introduction[edit | edit source]

Lateral ankle ligament injury is a common MSK condition representing 85% of ankle injuries[1] and has a high recurrence rate (up to 70%).[1] Persisting post-injury symptoms such as swelling, impaired strength, instability (occasional giving way), and impaired balance responses for more than 12 months following the initial injury is defined as '' Chronic Ankle Instability-CAI''[2]. Up to 40% of patients report developing chronic ankle instability.[3]

It is thought that patients who experience a lateral ankle sprain, but do not develop instability, may adopt different neuromuscular control strategies post-injury compared to patients who do develop ankle instability.[4]

Limited dorsiflexion[5], reduced proprioception, reduced isometric abductor hip strength[6], postural control deficiencies on SLS [7] were associated with a higher risk of ankle sprain and instability.

The highest incidence of lateral ankle sprains (LAS) was found for aeroball, basketball, indoor volleyball, field sports and climbing.[8]

A systematic review by Hiller et al[9] reported a larger talar curve, reduced concentric inversion strength, greater sway when standing on stable surfaces with eyes closed, a more inverted ankle position and decreased foot clearance during gait, and prolonged time to stabilization after a jump.

Assessment[edit | edit source]

Ottawa ankle rules.png

The Ottawa Ankle Rules are used to determine the need for radiography in acute ankle injuries. If these rules are positive, the patient/athlete needs an x-ray to rule out fractures.

The Ottawa Ankle Rules are as follows:

  1. Tenderness on palpation of :
    1. Posterior edge/dip of lateral malleolus
    2. Posterior edge/dip of medial malleolus
    3. Base of 5th metatarsal
    4. Navicular bone
  2. Inability to fully weight-bear for normal 4 steps at the time of injury or on examination

Subjective Assessment[edit | edit source]

  • Mechanism of Injury and WB status. If an athlete was injured during a game, a decision has to be made on return to play based on the MOI and WB status.
  • Mechanical and postural contributing Factors
  • Two weeks after injury assess against Chronic Ankle Instability using the Cumberland Ankle Instability Tool. A cut off of higher than 11.5 is unlikely to progress to CAI. A lower score is more likely associated with a higher risk of developing CAI[10]

Objective Assessment:[edit | edit source]

  • Assessment of ligamentous laxity:
  • Swelling
  • Isometric ankle eversion/abduction

Chronic Ankle Instability Checklist[edit | edit source]

Following LAS, a comprehensive assessment of the factors contributing factors can help predict the prognosis. The following is a set of markers that are associated with CAI:

  • ROM Markers:
    Weight-bearing ankle Dorsiflexion < 34 degrees on knee to wall test[5]
  • Strength Markers:
    Isometric hip abduction strength <34% of body weight[6]
  • Balance-Stability Markers:
    Inability to stand still without getting unsteady/wobbly on the Single-leg balance test for:
    • <10 seconds with feet flat on the floor
    • <5 seconds balancing on toes (heel raise) [6]
      Poor performance on the Star Excursion Balance Test (SEBT)[15]
    • Anterior reach < 54-67% leg length
    • Posterolateral reach < 70-94% leg length
    • Posteromedial reach < 76-91% leg length
  • Performance Markers: Unable to complete single leg drop landing test. (from 40 cm) at 2 weeks[16] Unable to complete 10 lateral hops in < 13-15.5 seconds[17]

References[edit | edit source]

  1. 1.0 1.1 Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wickstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. American journal of sports medicine. 2016.The American Journal of Sports Medicine Vol 45, Issue 1, pp. 201 - 209
  2. Fernández-de-las-Peñas C, editor. Manual therapy for musculoskeletal pain syndromes: An evidence-and clinical-informed approach. Elsevier Health Sciences; 2015 Jun 17
  3. Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports medicine. 2014 Jan 1;44(1):123-40.
  4. Jaber H, Lohman E, Daher N, Bains G, Nagaraj A, Mayekar P et al. Neuromuscular control of ankle and hip during performance of the star excursion balance test in subjects with and without chronic ankle instability. PLoS One. 2018;13(8):e0201479.
  5. 5.0 5.1 Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Australian Journal of Physiotherapy. 1998 Jan 1;44(3):165-72.
  6. 6.0 6.1 6.2 Powers CM, Ghoddosi N, Straub RK, Khayambashi K. Hip strength as a predictor of ankle sprains in male soccer players: a prospective study. Journal of athletic training. 2017 Nov;52(11):1048-55.
  7. Kobayashi T, Yoshida M, Yoshida M, et al. Intrinsic Predictive Factors of Noncontact Lateral Ankle Sprain in Collegiate Athletes: A Case-Control Study. Orthop J SportsMed 2013;1:232596711351816.
  8. Waterman BR, Belmont PJ, Cameron KL, et al. Epidemiology of ankle sprain at the United States Military Academy. Am J Sports Med 2010;38:797–803.
  9. Hiller CE, Nightingale EJ, Lin CW, Coughlan GF, Caulfield B, Delahunt E. Characteristics of people with recurrent ankle sprains: a systematic review with meta-analysis. Br J Sports Med. 2011 Jun 1;45(8):660-72.
  10. Vuurberg G, Kluit L, van Dijk CN. The Cumberland Ankle Instability Tool (CAIT) in the Dutch population with and without complaints of ankle instability. Knee Surgery, Sports Traumatology, Arthroscopy. 2018 Mar 1;26(3):882-91.
  11. Anterior Drawer Test of Ankle . Available from:[last access 26/11/2019]
  12. Talar Tilt Test with Paul Marquis-Postitive on this patient [last access 26/11/2019]
  13. Syndesmosis Squeeze Test .[last access 26/11/2019]
  14. Ankle External Rotation Test[last access 26/11/2019]
  15. Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. Journal of athletic training. 2012 May;47(3):339-57.
  16. Doherty C, Bleakley C, Delahunt E, Holden S. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med. 2017 Jan 1;51(2):113-25.
  17. Linens SW, Ross SE, Arnold BL, Gayle R, Pidcoe P. Postural-stability tests that identify individuals with chronic ankle instability. Journal of athletic training. 2014 Jan;49(1):15-23.
  18. Star Excursion Balance Test . Available from:[last access 26/11/2019]
  19. Mobility Assessment: Ankle & Calf Flexibility. Athletes, Runners, Squats, High Heels . [last access 26/11/2019]
  20. Single Leg Drop. Ohio State Sports Medicine.[last access 26/11/2019]
  21. Lateral Hop Test[last access 26/11/2019]