Which Tests Are Used for the Anterior Talofibular Ligament?

Context

The majority of ankle ligament injuries occur laterally and are the direct result of trauma in plantar flexion with excessive ankle inversion movement (Krueger, Becker, Leemkuil, and Durall, 2015).

This position causes maximal lengthening of the anterior talofibular ligament (ATFL) (Liu et al., 2015), which may explain why it is the ligament most frequently injured during excessive inversion movement.

Due to its anatomical position, this ATFL prevents forward movement of the talus within the tibiofibular mortise. As it is a fairly weak ligament, it tends to lengthen quite easily.

Indeed, it has previously been reported that the anterior talofibular ligament (ATFL) possesses a third of the strength of the calcaneofibular ligament (CFL) (Fallat, Grimm, and Saracco, 1998). As a result, it would take a more severe inversion mechanism of injury for the CFL to also be affected (Waterman et al., 2010). The CFL resists inversion of the calcaneus in relation to the fibula.

In 2016, Miller et al. found that, in 10 cadaver lower limbs, allowing internal rotation of the ankle during the Anterior Drawer Test could enable the clinician to detect more subtle degrees of ankle instability. This is known as the Anterolateral Drawer Test.

Video of the Test

Execution

Traditional Anterior Drawer Test:

To perform the Anterior Drawer Test, the patient lies with the knee slightly bent and the foot protruding from the plane of the table. The therapist holds the ankle at 10°–15° plantar flexion, then grasps the patient’s heel with the contralateral hand. The patient’s foot rests on the therapist’s forearm. Using the base of the other hand, the therapist fixes the tibia as close as possible to the joint line, then applies an anterior force to the calcaneus.

The therapist attempts to perceive visually and manually the extent of talus movement, and will determine whether there is an asymmetry between the involved and uninvolved ankle.

In general, we use a 5-point ordinal scale to classify the degree of laxity in this test:

• 0: hypomobile;
• 1: normal;
• 2: mild increased laxity;
• 3: moderate increased laxity;
• 4: severe increased laxity.

Reverse Anterolateral Drawer Test:

To perform this test, the patient lies with the knee slightly bent to facilitate plantar flexion of the foot. The therapist adjusts plantar flexion to 10°–15°, combined with slight internal rotation without stress. The index and middle fingers are placed on the lateral side of the foot, about 1 cm from the proximal end of the lateral malleolus. The therapist then places the base of the other hand on the distal part of the tibia and applies a push to induce backward displacement of the tibia.

The same ordinal scale as for the Anterior Drawer Test is used to classify the degree of laxity.

Clinical Value

In a 1996 study, Van Dijk et al. assessed the value of the Anterior Drawer Test for diagnosing anterior talofibular ligament (ATFL) rupture. The authors demonstrated that the combination of palpation, the presence of a hematoma, and the Anterior Drawer Test had good diagnostic value 5 days after injury, with a sensitivity of 96% and a specificity of 84%.

This test has also been used to screen for chronic ligament laxity in patients with a history of lateral sprains. However, in their 2013 study, Croy et al. prospectively evaluated the diagnostic accuracy of the Anterior Drawer Test in 60 patients with a history of lateral ankle sprain.

In their study, diagnostic accuracy was assessed for 2 thresholds taken from the literature: the first reference threshold was greater than or equal to 2.3 mm and the second greater than or equal to 3.7 mm. The authors found an Anterior Drawer Test specificity of 0.38 and 0.40 and a sensitivity of 0.74 and 0.83 for the 2.3 mm and 3.7 mm thresholds respectively. This test is therefore limited in its ability to diagnose chronic ligament laxity. Nevertheless, the authors point out that it may be interesting to use the test on both sides in order to compare the results obtained.

In 2019, Melanson and Shuman (2019) found that a translation of 1 cm on the Anterior Drawer Test would indicate ligament laxity. However, a more recent study in healthy subjects performed the Anterior Drawer Test under ultrasound until there was no further anterior translation of the talus and no further lengthening was obtained visually (Sillevis et al., 2020). The authors found a difference of 18 mm between the relaxed position and maximum anterior translation of the talus.

It is currently difficult to say precisely at what point the ligament exceeds normal length.

The new guidelines for ankle sprain management in 2021 advise therapists to use the Reverse Anterolateral Drawer Test combined with palpation (Martin et al., 2021). Indeed, this test has stronger evidence than the traditional Anterior Drawer Test to support its use in the diagnosis of chronic ATFL lesions after lateral ankle sprain.

In a prospective double-blind trial in 2019, Li et al. compared the diagnostic properties of the Anterior Drawer Test, the Anterolateral Drawer Test (ALDT), and the Reverse Anterolateral Drawer Test. All three tests were performed on patients with chronic ATFL lesions. The results indicated that the Reverse Anterolateral Drawer Test was superior to the other two in almost all categories.

Anterior Drawer Test:

• Sensitivity: 0.224
• Specificity: ≈ 1

Anterolateral Drawer Test:

• Sensitivity: 0.473
• Specificity: ≈ 1

Reverse Anterolateral Drawer Test:

• Sensitivity: 0.894
• Specificity: 0.897