Ankle sprain is diagnosed through physical examinations.

When excluding the ankle

rules present, there are three general methods of making diagnostics for ankle sprain. Firstly,
there is inspection and palpation. This method is generally used by detecting pain in certain areas
when palpated and is used for acute lateral ankle sprain. There are also functional methods that
are using manual tests to diagnose ankle sprain. The first functional method is called anterior
drawer test. This particular test examines the integrity of the anterior talofibular ligament which
connects os talus to os fibula, anterior glide of the calcaneus, and talus on the stabilized tibia.
Ankle sprain is diagnosed using a comparison of the results of this test being performed on
healthy ankle. Abnormality is detected when an excessive translation on the injured side of
extremity is present or the inability of the patient to stay still during examination. Validity of this
test is doubted due to unknown previous history such as untreated previous sprains or not
optimum recoveries.
In the anterior drawer test, an ankle meter which are plastic scales placed on the heel and
os tibia to quantify measurements. This method is performed four to seven days after the trauma
to reduce the amount of biased down to moderate bias as suggested by The Royal Dutch Society
if Physical Therapy. The aim is to increase validity of the test. However, it is still can not be
determined whether this method can best diagnose ankle sprain. Below is the imaging of ankle
sprain diagnosed from excessive translation of the talus through anterior drawer test (left) in
comparison with normal ankle imaging (right).

left image source : https://www.researchgate.net/figure/Anterior-translation-of-the-talus-during-

the-anterior-drawer-stress-test-is-measured-as_fig3_331077376
right image source : https://www.imageinterpretation.co.uk/ankle.php
 The next functional method is called the talar tilt test. This method involves inversion
stress test which also known as varus or inward angulation stress test. The talar tilt test assesses
the integrity of the calcaneofibular and the anterior talofibular ligaments. When there is more
than 23o angulation or more that 10o difference between two ankles, the ankle with the bigger
angulation can be concluded as sprained. However, this test needs comparison to the normal
ankle condition which used the physician’s interpretation, thus making its accuracy and validity
questioned. Below are images of talar tilt test examinations. The first image shows how the talar
tilt test may be performed while the second image on the right shows the ligaments involved in
ankle sprain as viewed from the talar tilt test. A rupture on both anterior talofibular ligament and
calcaneofibular ligament can be seen in the illustration.

left image source : https://www.aafp.org/afp/2001/0101/p93.html

right image source : https://us.humankinetics.com/blogs/excerpt/injury-recognition-ankle-tests
Tests are recommended to be performed later, approximately four days for reevaluation if
preceded by an early or immediate examination and five days for examination because
sensitivity increased by 18-25% and specificity increased by 37-52% from examinations done
immediately after the trauma. The delay is required because immediate examinations are often
misguided by swelling and pain present. The result of expert consensus stated that the anterior
drawer test is not as recommended as the talar tilt test due to the low level of validity and high
potential of subjectivity.
When including the present ankle rules, there are also several methods. The most
common rule used is the Ottawa Ankle Rules. The research for this method begun in 1992 on
adult patients with acute injuries that involved foot and ankle. The purpose of implementing
Ottawa Ankle Rules is to decide whether an X-ray is needed to diagnose ankle sprain or the
injury can be diagnosed just by doing palpation according to the rules present. There are several
things that should be noticed during examination using the Ottawa Ankle Rules which are bone
tenderness, especially malleolar tenderness and the patient’s inability to walk as much as four
steps immediately and when delay is given. If these things occur, a foot X-ray series is required.
The Ottawa Ankle Rules can only be performed on patients who are 18 years old and
above. In making diagnoses, six centimeters of the distal part of both os fibula and os tibia must
be palpated. This distance is measured from lateral malleolus and medial malleolus. If medial
malleolar tenderness occurs, more intensive attention should be given.
image source : http://www.ohri.ca/emerg/cdr/ankle.html
Compared to other diagnostic methods, the Ottawa Ankle Rules classified as one of the
most valid methods. The tuning fork test, for example, it is not used commonly in practice, thus
making it a less preferable procedure. As for the Bernese Ankle Rule which avoids palpation on
injured regions, sensitivity is measured up to 100% and specificity up to 91%. Application of
indirect forces using the entire palm of the hand to the fibula about ten centimeters measured
proximally to the tip of the fibula and direct forces to the medial malleolus using the entire
thumb are the examples of Bernese Ankle Rule implementations. The other two known methods,
the Leiden Ankle Rules and Utrecht Ankle Rules have higher risk of bias and inaccuracy,
making them also less preferable than Ottawa Ankle Rules and Bernese Ankle Rules.
For imaging methods, the most common method used is radiography which involves a
series of X-ray assessment. An ultrasonography (USG) is not as recommended as radiography
but is used under considerations of waiting time and unavailability of professional radiologist.
Still, the two methods are used under the same circumstance, that is when tests based on the
Ottawa Ankle Rules show positive results. When the results are negative, X-ray or any imaging
methods should not be included in the series of ankle sprain initial assessment. Images below
show the radiography or X-ray examination result (left) and the ultrasonography (USG) result
(middle and right) of normal ankle.1
left image source : https://www.imageinterpretation.co.uk/ankle.php
right image source : https://www.e-ultrasonography.org/journal/view.php?
viewtype=pubreader&number=177#!po=1.92308

1. Roosen P, Willems T, De Ridder R, San Miguel L, Holdt Henningsen K, Paulus D, De

Sutter A, Jonckheer P. Ankle sprains: diagnosis and therapy. Good Clinical Practice
(GCP) Brussels: Belgian Health Care Knowledge Centre (KCE). 2013. KCE Reports
197C. D/2013/10.273/4.