Following injures such as an ACL rupture or repair, we follow extensive return to play protocols. There has until recently been a paucity of such protocols for a return to play following a lateral ankle sprain (LAS). In reviewing some of the recent literature, there are some helpful themes that run through each paper.
Ankle injuries are among the most frequent sports injuries, with a risk of a second injury to the same ankle as high as between 40-70% depending on the sport and may result in up to 40% of patients developing chronic ankle instability, especially in syndesmotic injuries (high ankle sprains). Suggestions have been made that the rate of recurrence could be linked to poor rehabilitation after the first injury and a premature return to sport.
Several recent studies have therefore highlighted the importance of establishing robust criterion-based principles when determining when an athlete is ready to return to sport (RTS) following a LAS to ensure athletes are fully prepared for the demands of their sport.
In a recent international consensus paper “Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework” by Smith et al (2021) the authors gathered the responses of multiple healthcare practitioners experienced in returning athletes to sport post lateral ligament sprain. They determined 16 agreed items to include in the return to sport decision-making process – the ‘PAASS’ framework: an acronym standing for: Pain, Ankle impairments, Athlete perception, Sensorimotor control and Sport/functional performance. However, whilst they highlighted the areas that should be included, they did not in this paper indicate which tests should be used.
In line with recommendations for return to sport criteria in patients following an ACL injury, emphasis has been placed on using a battery of tests to inform decision making rather than a specific test in isolation. These should include subjective and objective criteria (quantitative and qualitative), a series of functional testing and tools to identify psychological readiness for a return to play based on confidence in the limb.
The criteria for determining the timing of a safe RTS have therefore been reliant on clinical reasoning and the experience of the health professional.
Athlete perception and confidence is a key indicator for RTS. The use of self-reported outcome measures at the onset of an injury has been highlighted in the knee to determine those patients who might be most at risk of developing longer term more chronic symptoms or be at risk of a recurrence. For injuries to the foot and ankle, several measures have been implemented including the Injury-Psychological Readiness to Return to Sport Scale (I-PRRS Scale) and the Foot and Ankle Disability Index Sport Items (FADI Sport) and the Foot and Ankle Ability Measure (FAAM) including sport subscale. There are also some sports specific measures such as in dance the Dance Functional Outcome Survey. These scores can then be used at intervals along the rehabilitation journey to assess the self-confidence of the athlete in mental readiness to return to sport, however, the threshold at which a RTS is indicated has yet to be established with conflict in the literature. Hertel and Corbett (2019) suggested that a threshold of 95% should be used in the FAAM questionnaire.
Objective measures
The type of objective assessment tools in the research included:
Balance – The Star Excursion Balance Test including adding neurocognitive skills during testing
Strength:
- Heel Rise Test at a cadence of approximately 1 per second
- Single Leg Squat
- Ankle Evertor strength – handheld dynamometer
Peroneal muscle activation limits uncontrolled inversion, however, this does not activate fast enough in real time to be the main mechanism of defense against a LAS. Training and participation in sport build up an anticipatory learned defense over time which is lost after an LAS. This must be retrained during rehabilitation so static tests of strength and balance will not give an accurate predictive picture of whether an athlete is ready to RTS and more dynamic tests much be incorporated such as hop testing and agility testing.
Hop tests:
- Single-Leg Drop Jump
- Single Hop for Distance (SHD)
- 6m Timed Hop (6MTH)
- Triple Hop for Distance (THD)
- Triple Crossover Hop for Distance (TCHD)
- Single Medial Hop for Distance (MHD)
- Single Lateral Hop for Distance (LHD)
- Single Limb Countermovement Jump for Height (SLCMJ)
- Timed Speedy Hop Test (TSHT)
- Figure of 8 Hop Side Test
- Lateral Hop Test to fatigue at a rate of 1 to 2 per second
- Front-to-back hop test (FB) to fatigue at a rate of 1 to 2 per second
- Functional hop (FH) test – crossover hops forwards and back over a 8m line x 5 repetitions
- 180’ rotational jump (RJ) – jump from both feet rotating 180’ to land facing the opposite direction and back x 10 repetitions (20 full jumps)
Agility test such as Modified T Test
There are many different hop tests reported in the literature. In a recent study, a series of different hop tests were assessed in patients who had undergone a primary Anterior Cruciate Ligament repair. The traditional hop test battery of Single Hop for Distance, Triple Hop for Distance and the Triple Crossover Hop for Distance and the 6m Timed Hop gave higher limb symmetry index scores than the Lateral Hop for Distance, The Medial Hop for Distance and the Timed Speedy Hop Test. The traditional hop tests would have all cleared the player to return to sport with LSI > 90% + but the latter 3 tests reported scores of <90%. Lateral hop and multidirectional hop tests potentially add greater demands on the injured limb than doing straight line hop tests and may have the potential to highlight any residual deficits. Given that most LAS occur when changing direction and turning, the latter tests may be more appropriate for this population group. Consideration should also be given to the requirements of each athlete regarding the demands of their sport and their own unique injury risks.
To date, there is very little evidence regarding what percentage of limb symmetry indices (LSI) are needed prior to RTS following a LAS. A ratio of the injured to non-injured ankle can be calculated as an estimate of the performance of the injured limb against the uninjured limb values. However, as with the use of LSI in ACL protocols, the accuracy of these metrics is influenced by deconditioning of the uninjured limb during rehabilitation, and therefore, the earlier these measurements can be established in the rehabilitation journey the more accurate these will be. In addition, care must be taken to account for the asymmetrical requirements of certain sports and limb dominance in calculating readiness to play.
Phased return to sport
There are multiple levels of a return to sport protocol which varies across authors. They all essentially start at the rehabilitation phase moving towards light non-contact training towards adding more demands on the athlete as they prepare for a return to sport then competition.
- Return to participation (RTPa) – return to training but at a level lower than his or her RTS goal.
- Return to sport
- Return to performance (RTPf) – performing at or above his or her pre-injury level.
The overwhelming theme that comes through in the research is that each athlete must be treated as an individual. Patients may be considered as complex adaptive systems (CAS) where different variables and systems do not act in a predictable and linear manner and occur at different time frames. An athlete may have full muscle strength and power around the ankle but still lack confidence in the limb, whilst another athlete may have total confidence in the limb yet be more limited in range or strength. As such, all athletes should have an individualised return to sport protocol and readiness should not be determined by normative data for their sport or their age but based on their own individual needs and risk factors.
References on request – email info@angelajacksonphysio.com
If you would like to learn about how to implement return to sport protocols and develop confidence in knowing when an athlete is ready to return to sport, then email me for more details on my practical day course From Assessment to Return to Play in the Junior Athlete or learn online with Active Kids Are Not Mini Adults
