Anterior Drawer of the Ankle
Original Editor - Staci Burns
Lead Editors - Peter Vaes.
Top Contributors - Admin, Kim Jackson, Jennifer Chew, Evan Thomas, Rachael Lowe, Peter Vaes, Laura Ritchie, Tony Lowe, Kai A. Sigel, WikiSysop, Staci Burns, Dan Rhon, Bram Van Steenbergen, Vidya Acharya, Claire Knott, Wanda van Niekerk and Matt Huey
Purpose
The purpose of this test was to determine whether ankle mechanical instability or hypermobility in the sagittal plane of the talocrural joint (or upper ankle joint) is present.
Technique
The patient is supine, the ankle joint is in 20° of flexion, the heel is resting on the palm of the examiner's hand that is resting on the table. thereby stabilizing the calcaneus. The examiner then stabilises the tibia and fibula whilst drawing the calcaneus anteriorly observing the amount of anterior translation at the lateral aspect of the ankle and the change in end feel. The amount of anterior translation and the eventual weakening of the end feel, changing from hard ligamentous to weak elastic, is observed. An anterior translation greater than 1 cm compared to the healthy contralateral ankle and an evident weakening of the end feel are most indicative of a partial rupture or complete rupture of the anterior talofibular ligament. The test is graded on a 4-point scale. 0 represents no laxity and 3 represents gross laxity.
Evidence
Anterior drawer has sensitivity of 86 percent and specificity of 74 percent for a diagnostic test of 160 patients with an inversion ankle sprain when compared to an arthrogram.[2] In a prospective, blinded, diagnostic-accuracy study, Croy et al. measured diagnostic accuracy of the anterior drawer test of the ankle in sixty-six subjects with a history of lateral ankle sprain. Using ultrasound imaging during performance of the anterior drawer test the talofibular interval was measured digitally.[3]
Sensitivity of the the anterior drawer test was 0.74 (95% confidence interval [CI]: 0.58, 0.86) and 0.83 (95% CI: 0.64, 0.93) at the 2.3 mm or greater and 3.7 mm or greater reference standards, respectively. Specificity of the test was 0.38 (95% CI: 0.24, 0.56) and 0.40 (95% CI: 0.27, 0.56), respectively. Positive likelihood ratios were 1.2 and 1.4, whereas the negative likelihood ratios were 0.66 and 0.41, respectively.[3] Croy et al, did find that the test was beneficial when comparing side to side in patients. The recent cross-sectional diagnostic study found out anterior drawer test to be a valuable method of identifying mechanical ankle instabilities[4].
A systematic review did find that the anterior drawer had mixed reliability, validity and sensitivity but the specificity was high when used with the anteriolateral drawer test, the reverse anterior lateral drawer test, tenderness to palpation of the proximal fibula and the squeeze test[5].
There is some descripency that can arise in the amount of movement depending on the experience of the person performing the test. Murahashhi et al, found that less experienced examiners found less translation cmpared to more senior examiners with the traditional set up. But when a modification was performed (the patient's tibia was placed on an elevated surface so the hip was near 90 degrees), the inter-rater reliablity was not significant[6]. This could be beneficial in clinics with multiple clinicians with varying amounts of experience.
Resources
van Dijk et al 1996 Article - Discusses how sensitivity and specificity changes 5 days after injury vs examining within 48 hours.
References
- ↑ Clinically Relevant Technologies, http://www.youtube.com/watch?v=Z4rvAT3a7OY; Accessed May 2011
- ↑ van Dijk CN, Lim LSL, Bossuyt PMM, Marti RK. Physical Examination is sufficient for the diagnosis of sprained ankles. J Bone Joint Surg. 1996; 78-B: 958-962.
- ↑ 3.0 3.1 Croy T, Koppenhaver S, Saliba S, Hertel J. Anterior talocrural joint laxity: Diagnostic accuracy of the anterior drawer test of the ankle. J Orthop Sports Phys Ther. 2013; 43(12): 911-9.
- ↑ Wenning M, Gehring D, Lange T, Fuerst-Meroth D, Streicher P, Schmal H, Gollhofer A. Clinical evaluation of manual stress testing, stress ultrasound and 3D stress MRI in chronic mechanical ankle instability. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-3.
- ↑ Beynon, A., Le May, S., & Theroux, J. (2022). Reliability and validity of physical examination tests for the assessment of ankle instability. Chiropractic & manual therapies, 30(1), 58
- ↑ Murahashi, Y., Teramoto, A., Takahashi, K., Okada, Y., Okimura, S., Imamura, R., ... & Yamashita, T. (2023). High reproducibility of a novel supported anterior drawer test for diagnosing ankle instability. BMC Musculoskeletal Disorders, 24(1), 148.