Ankle Sprain Return to Play Recommendations
***Special thanks to Mithe Berends, Annika Colon, Saige Gomez, and Jesse Tierno (DPT Class of 2023) for their contributions to this post.
Ankle sprains are one of the most common musculoskeletal injuries. Ankle sprains account for 16%-40% of all injuries in sports. For athletic participation, the body demands motion, strength, agility, and power of the ankle joint and the surrounding soft tissue. There are a wide variety of successful rehabilitation protocols. However, the current literature lacks formal criteria for return to play (RTP) for lateral ankle sprains. The following are functional tests that have been used for clinical decision making.
The tests selected for RTP assessment are designed to address motion, balance/proprioception, strength, agility, and power. When able the performance on the injured ankle should be compared to that of the uninjured ankle. Generally, an athlete should achieve at least 90% of the uninjured side.
The first task is the Weightbearing Dorsiflexion Lunge Test. This test is performed using a wall and a tape measure. The athlete faces the wall with the foot perpendicular to the wall and the toes about 3-4cm from the wall. The athlete must keep his/her heel on the ground and lunge forward to touch the knee to the wall. If the athlete can perform this motion, back the foot away from the wall and try again. The goal is to determine the furthest distance the foot can be from the wall and still touch the knee to the wall without lifting the heel. When that placement is determined, the distance from the tip of the big toe to the wall is measured. Each centimeter corresponds to approximately 3.6° of ankle dorsiflexion. Measures less than 9 or 10 cm is considered restricted. The inter-rater and intra-rater reliability for this test is 0.99 and 0.98 – 0.99, respectively.
Balance and proprioception are critical tasks for the ankle of an athlete. Two of the options to assess these tasks can also be used as part of the rehabilitation program. The Star Excursion Test and the Y-Balance Test examine unilateral balance and dynamic neuromuscular control.
First, set-up of the Star Excursion Test takes a couple of minutes. Four strips of tape cut to 6-8 feet each are placed on the floor in the pattern displayed to the right. Two pieces of tape form a ‘+’ and two pieces of tape form an ‘x’ with the result being a star shape where all lines are at a 45° angle to each other. To perform the test, the athlete balances on one leg, while reaching as far as possible into each of the 8 different directions: anterior, anteromedial, medial, posteromedial, posterior, posterolateral, lateral and anterolateral. The distance covered by the reaching limb is measured with further distance equating better control. Data on athletes suggests the reach values for each direction should exceed the athlete’s leg length. It has been reported the anterior, posteromedial and posterolateral directions deficits may identify chronic ankle instability and athletes at greater risk of lower extremity injury. Plisky et al (2009) reported the intra-rater reliability as moderate to good (ICC 0.67- 0.97) and inter-rater reliability as poor to good (0.35-0.93).
The Y-Balance Test is an alternative to the Start Excursion Test. It utilizes a commercially available kit to test excursions of movement in 6 directions: Right Anterior, Left Anterior, Right Posteromedial, Left Posteromedial, Right Posterolateral, and Left Posterolateral. To perform the task, the athlete places hands on the hips and standing on the right leg. The athlete reaches in each of the 3 directions as far as possible with the left leg and the distance is recorded. The test is repeated while standing on the left leg. Failed attempts include loss of balance or kicking the reach indicator forward. Interpretation is similar to the Star Excursion Test – distance in each direction should equal or exceed leg length and be within 4 cm of the contralateral leg in order to return to play. More details of normative values can be found at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4713819/
Athletes are frequently required to perform quick changes of direction. A weak, unstable ankle is at risk of repeat injury. The Agility T-Test can be used to assess neuromuscular control, injury reduction, and overall physical capabilities needed for an athlete to return to sport. The set up for this test requires a tape measure and 4 target markers as displayed in the figure to the left. To perform this test the athlete is timed while they sprint forward 10 yards to tap a cone, then turn left and shuffle 5 yards to touch a cone. They 
then shuffle to the right 10 yards to touch a cone and back left 5 yards to where they first tapped. Then, they perform a backward shuffle back 10 yards to where they began. Quick explosive movements and cutting are needed for safe RTP. Ideally, a pre-season assessment is available, but if it was not normative values are available by gender.
Explosive power is also an important component of athletic performance. Tests such as the Cross-over Triple Hop and 6-meter Timed Hop can both be used to assess power. To perform the Cross-over Triple Hop begins with marking a straight line on the floor. The athlete starts on 1-side of the line and perform 3 hops with the same leg with each hop landing on the other side of the line. The task is repeated with the other leg. The criteria is the involved distance being 90% of the uninvolved leg. Likewise, the 90% criteria applies to the 6-meter Timed Hop Test. A 6-meter long line is identified and the athlete is instructed to hop on 1 leg as quickly as possible to traverse the 6-meter distance. The task is repeated on the contralateral leg.
In summary, there is no single or combination of tests proven to be the optimal return to play criteria. However, sampling from the components required of the sport the athlete is returning to will provide the best opportunity for success and lower the risk of re-injury. Collectively the tasks identified above are a good representation of the components needed for athletic success.
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References
• Agility T-test. Physiopedia. (n.d.). Retrieved September 18, 2022 from https://www.physio-
pedia.com/Agility_T-
Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal
• Clanton TO, Matheny LM, Jarvis HC, Jeronimus AB. Return to play in athletes following ankle injuries. Sports Health. 2012 Nov;4(6):471-474.
• D’Hooghe P, Cruz F, Alkhelaifi K. Return to Play After a Lateral Ligament Ankle
Sprain. Curr Rev Musculoskelet Med. 2020 Jun;13(3):281-288.
• 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. J Athl Train. 2012;47(3):339-357.
• Heyward V. Advanced fitness assessment and exercise prescription. Human kinetics, 6th edition: 303(5)
• Hop Test. Physiopedia (n.d.) Retrieved September 13, 2022 from
https://www.physio-pedia.com/Hop_Test
• Knee to wall test. Physiopedia. (n.d.). Retrieved September 18, 2022, from Physiopedia. (n.d.). Retrieved September 13, 2022 from https://www.physiopedia.com/Y_Balance_Test
• Miller T. National Strength and Conditioning Association. Test and Assessment. Human Kinetics. Champagne, IL. 2021
• Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. Journal of Orthopaedic & Sports Physical Therapy. 2006 Dec;36(12):911-919.
• Wood R. Agility T-test. Topend Sports. https://www.topendsports.com/testing/tests/t-test.htm. Published 2008. Accessed September 18, 2022.