Anterior Talocrural Joint Laxity: Diagnostic Accuracy of the Anterior Drawer Test of the Ankle

Abstract

Study Design Prospective, blinded, diagnostic-accuracy study. Objectives To investigate the diagnostic accuracy of the ankle anterior drawer test (ADT) to detect anterior talocrural joint laxity in adults with a history of lateral ankle sprain. Background The ADT is used to manually detect anterior talocrural joint laxity following lateral ankle sprain injury; however, the diagnostic accuracy of this test has not been established. Methods Sixty-six subjects with a history of lateral ankle sprain were examined with the ADT. Anterior talocrural joint laxity was measured digitally from ultrasound images of the talofibular interval during performance of the ADT. In addition, anterior talocrural joint laxity was measured digitally in 20 control subjects to establish a reference standard. ADT results were defined as “positive” or “negative,” based on this and a second reference standard established from the literature. Results The group with a history of lateral ankle sprain had a mean ± SD anterior talocrural joint laxity of 3.36 ± 3.25 mm, compared with 0.17 ± 1.87 mm in the control group. Thirty-five of 66 (53%) subjects demonstrated anterior talocrural joint laxity at a reference standard of 2.3 mm or greater, and 24 (36%) at a reference standard of 3.7 mm or greater. Sensitivity of the ADT 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. Conclusion The ADT provides limited ability to detect excessive anterior talocrural joint laxity; however, it may provide useful information when used in side-to-side ankle comparisons and in conjunction with other physical exam procedures, such as palpation. Level of Evidence Diagnosis, level 3b. J Orthop Sports Phys Ther 2013;43(12):911–919. Epub 30 October 2013. doi:10.2519/jospt.2013.4679

Diagnostic accuracy of instrumented and manual talar tilt tests in chronic ankle instability populations

“…Previous studies have attempted to identify alterations in mechanical laxity between those with and without CAI, with some indicating increased laxity in CAI participants compared with healthy controls (Cordova et al, 2010;Croy et al, 2012) and increased ligament lengthening in copers compared with controls (Croy et al, 2012). A previous study using a population similar to this study reported low diagnostic accuracy for the anterior drawer test (Croy et al, 2013). The values were relatively similar to ours even with this different manual test (Croy et al, 2013).…”

“…A previous study using a population similar to this study reported low diagnostic accuracy for the anterior drawer test (Croy et al, 2013). The values were relatively similar to ours even with this different manual test (Croy et al, 2013). A previous study using talar tilt indicated sensitivity 0.5, specificity 0.88, +LR 4 and -LR 0.57 (Hertel et al, 1999;Schwieterman et al, 2013).…”

“…Clinicians require manual tests with adequate diagnostic accuracy to determine injury severity and establish prognoses, plan treatments, and document clinical outcomes. At the ankle, tests for syndesmosis injury (Sman et al, 2013), anterior talocrural laxity (Croy et al, 2013), and our inversion laxity demonstrate poor to moderate diagnostic accuracy and do not appear to be adequate in and of themselves to guide clinical decision making in a CAI population. This may be due to the difficulty in isolating and evaluating the subtalar joint (Hertel, 2002).…”

“…Instrumented arthrometry has been used more often in research settings, and has been demonstrated to be reliable; however, the diagnostic criteria for mechanical laxity in CAI are still unclear (Kovaleski et al, 1999;Hirai et al, 2009). A model for classifying CAI indicated that mechanical ankle instability may be a relevant factor (Hiller et al, 2011a), and previous work focused on the diagnostic accuracy of the anterior drawer test for laxity in this population (Croy et al, 2013). A talar tilt test may also be relevant for indicating talocrural and subtalar joint laxity and its diagnostic accuracy should be established (Fujii et al, 2000;Phisitkul et al, 2009).…”

Operative treatment of lateral ligament instability

“…The talar tilt test also helps determine CFL competence. The sensitivity of these tests is variable and ranges from 74 to 96% [33][34][35][36][37]. Regardless, performing a manual physical exam is an important part of assessing a patient presenting with ankle instability.…”