High reproducibility of a novel fixed anterior drawer test for diagnosing ankle instability

doi:10.21203/rs.3.rs-1971022/v1

Download PDF

Research Article

High reproducibility of a novel fixed anterior drawer test for diagnosing ankle instability

https://doi.org/10.21203/rs.3.rs-1971022/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 27 Feb, 2023

Read the published version in BMC Musculoskeletal Disorders →

You are reading this latest preprint version

Background

The manual traditional anterior drawer test (ADT) is essential for deciding the treatment for chronic ankle instability, but it has been shown to have a comparatively low reproducibility and accuracy, especially in less experienced hands. To clarify the inter-examiner reproducibility, we compared the actual distance of anterior translation between junior and senior examiners in ADT. We also evaluated the diagnostic abilities of traditional ADT, and a novel modified ADT (fixed ADT).

Methods

Thirty ankles were included in this study, and ankle instability was defined using stress radiography. All subjects underwent two methods of manual ADT by junior and senior examiners, and ankle instability was judged in a blinded fashion. The anterior drawer distance was calculated from the lengthening measured using a capacitance-type sensor device.

Results

The degree of anterior translation determined by the junior examiner was significantly lower than that determined by the senior examiner when traditional ADT was performed (3.3 vs. 4.5 mm, P=0.016), but there was no significant difference in anterior translation between the two examiners when fixed ADT was performed (4.6 vs. 4.1 mm, P=0.168). The inter-examiner reliability of fixed ADT was higher than that of traditional ADT. For the junior examiner, the diagnostic accuracy of fixed ADT was higher than that of traditional ADT (sensitivity, 0.40 vs. 0.80; specificity, 0.75 vs. 0.80).

Conclusion

Fixed ADT may have the advantage of being a simple manual test of ankle instability with less error between examiners.

Ankle sprains

Ankle instability

Anterior talofibular ligament

Anterior drawer test

Capacitance-type sensor device

Ankle sprains involving the lateral ligament are the most frequently occurring injuries in sports and physical activities [1, 2]. Most of them are treated conservatively, but in some cases, there may be residual symptoms, such as pain and instability during exercise and daily activity, which may progress to chronic ankle instability [3-5]. Chronic ankle instability is not only a residual symptom, but can also accelerate the development of osteoarthritis over a long period of time. While physical therapy may be attempted for patients with chronic ankle instability, structural mechanical dysfunction may be compensated for by operative treatment, such as ligament repair and reconstruction. Therefore, it is essential to identify the individual cause of ankle instability, and quantitative assessment of structural mechanical dysfunction is mandatory. Recent studies have demonstrated the quantitative evaluation of lateral ligament injury and ankle instability using MRI and stress ultrasonography [6-10]. Manual physical examination, called the anterior drawer test (ADT), is also an essential evaluation in making treatment decisions because of its convenience, cost, and dynamic nature [10, 11]. However, it has been pointed out that this procedure can be subjective, lacks reproducibility, and can be difficult, especially for less experienced clinicians [12, 13].

To improve diagnostic accuracy, several studies on the optimal ankle joint angle and the magnitude and direction of the force applied in performing the anterior drawer test have been reported [13-17]. Allowing for the internal rotation of the ankle during traditional ADT may make it easy for the examiner to detect more subtle degrees of ankle instability and result in higher diagnostic sensitivity [13, 16]. Li et al. recently showed that the reverse anterolateral drawer test method is more sensitive and accurate in diagnosing chronic anterior talofibular ligament injuries than traditional ADT [10]. Although various techniques and methods have been reported to improve diagnostic accuracy, little consideration has been given to test reproducibility.

The reason for the comparatively low reproducibility and accuracy of traditional ADT, especially in less experienced hands, may be that the test requires two hands for manipulation and relative hand movements make it difficult to perceive ankle instability [10, 12, 13]. Furthermore, it is not easy for less experienced examiners to relieve gastrocnemius muscle spasms. Hence, we evaluated the usefulness of a novel modified ADT, called fixed ADT, in which one hand of the examiner is fixed while stabilizing the distal tibia. We also measured the actual distance of anterior translation in the manual test to clarify the inter-rater reliability of traditional and fixed ADTs. The objective of this study was to compare the reproducibility and accuracy of the two ADTs and to determine the usefulness of fixed ADT. We hypothesize that fixed ADT has higher reproducibility and diagnostic ability than traditional ADT in the diagnosis of ankle instability.

Subjects

The subjects were 30 ankles (24 patients) with or without a history of ankle sprain who complained of instability or pain. First, all patients underwent stress radiography, and ankle instability was defined using stress radiography. Second, all patients underwent manual ADT using two methods; the procedure was performed by a junior resident doctor (junior examiner: orthopedic surgeon with 2 years of experience) and senior foot and ankle surgeon (senior examiner: orthopedic surgeon with 23 years of experience) who were blinded.

Stress radiography

Lateral stress radiographs of the ankles were taken in two projections using the Telos stress device (Telos, Griesheim, Germany). Anterior drawer stress was applied with a magnitude of 150 N of posteriorly directed force to the tibia, which allowed the visualization of changes in the neutral position of the joint ends in the ankle joint under constant stress. The distance of anterior talar translation was measured from the posterior lip of the tibial plafond to the nearest articular surface of the talus (Figure 1). In comparison with the unstressed position, anterior subluxation of the talus of more than 3.5 mm was considered to be indicative of ankle instability [18, 19].

Manual anterior drawer test

To perform traditional ADT, the patient was seated on the edge of the examination bed with the calf hanging over (Figure 2a). The examiner pulled the calcaneus of the subject forward with one hand, while pushing the tibia backward with the other hand to reverse the direction of the forces. The examiner evaluated ankle instability using the sensation of the relative motion between the two hands.

Fixed ADT was performed in the supine position with the lower leg placed on a board with the hip and knee joints in 90-degree flexion and the ankle joint in 10- to 20-degree plantar flexion (Figure 2b). The examiner stabilized the lower leg on the board, pulled the calcaneus forward with one hand, and judged the ankle instability by the sensation of the movement of one hand.

The two methods of ADT were performed by a junior and senior examiner. The examiner graded the amount of posterior displacement of the talus using manual ADT, with a grade of 1 as stable joint, 2 as partially unstable, and 3 as completely unstable. Grades 2 and above were considered positive for excessive instability, whereas grade 1 was considered negative or normal [6].

Anterior drawer displacement measured by the sensor during manual anterior drawer test

To clarify the actual distance of anterior displacement in the manual ADT, we evaluated anterior translation measurements using a capacitance-type sensor device, as previously described [20]. Briefly, braces hold the foot and ankle, and allow freedom of movement between them. The sensor was fixed with a snap button to the lateral malleolus and talar part of the brace, and the anterior drawer distance was calculated from the lengthening measured by the sensor. Traditional and fixed ADTs were also performed by junior and senior examiners, as mentioned above, to measure the anterior drawer displacement.

Statistical analysis

Statistical significance was evaluated using Welch’s t-test for comparison using EZR, a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria) [21]. Pearson’s correlation coefficient was used to determine the linear relationship between the anterior drawer displacement of manual ADT between the senior and junior examiners. To assess the diagnostic performance of the tests, the sensitivity, specificity, and positive and negative predictive values were calculated for each examination. The correlation between junior and senior examiners in terms of the accuracy of each physical examination was assessed using the kappa statistic. Statistical significance was set at P less than 0.05.

Ethics and registration

This study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines. The study was approved by the Institutional Review Board for Clinical Research of our hospital (reference number 29-242), and informed consent was obtained from all study participants after providing patients with written and oral information before inclusion in the study.

Table 1 shows the demographic data and the anterior talar translation distance on stress radiography. The male-to-female ratio of patients was approximately 1:3. The mean age was 32.0 (range, 23-38) years, and body mass index (BMI) was 22.4 (range, 17.1-30.0) kg/m². Ankle instability was defined in 10 cases by anterior drawer stress radiography.

In the manual ADTs, the junior examiner diagnosed 9 cases with instability by traditional ADT and 12 cases with instability by fixed ADT. The senior examiner diagnosed 16 cases with instability by traditional ADT and 10 cases with instability by fixed ADT. For the junior examiner, the diagnostic accuracy of the manual tests for detecting ankle instability defined by stress radiography had a sensitivity of 0.4 and 0.8, with a specificity of 0.75 and 0.8 in traditional and fixed ADTs, respectively (Table 2). For the senior examiner, the diagnostic accuracy had a sensitivity of 0.8 and 0.7 with a specificity of 0.6 and 0.85 in the traditional and fixed ADTs, respectively. The kappa values of the inter-examiner reliability for detecting instability in the traditional ADT and fixed ADT were 0.416 and 0.571, respectively.

The distance of anterior translation determined by the junior examiner using the capacitance-type sensor device was significantly lower than that of the senior examiner in traditional ADT (3.26±2.03 vs. 4.5±1.88, P=0.016), but with the numbers available, there was no significant difference in anterior translation between the examiners in fixed ADT (4.64±2.08 vs. 4.14±1.96, P=0.168) (Figure 3). The correlation coefficient of anterior drawer displacement between examiners was highly significant in fixed ADT (R=0.537 and P=0.002), and with the numbers available, there was no significant correlation in traditional ADT (R=0.067 and P=0.728) (Figure 4).

We demonstrated the reproducibility and accuracy of ADTs using a capacitance-type sensor device and determined the usefulness of fixed ADT. In traditional ADT, the measurements of anterior drawer displacement by the junior examiner were significantly lower than those by the senior examiner, and the sensitivity of traditional ADT performed by the junior examiner was relatively low. However, the distances of anterior displacement between examiners were similar in the fixed ADT, and the test was sensitive, even when performed by the junior examiner.

Several studies have assessed ankle instability using stress radiography and/or ultrasonography. Tarczyńska et al. evaluated 30 patients with chronic ankle instability treated surgically or nonoperatively and showed that stress radiography is a reliable and objective imaging tool for diagnosing ankle instability [1]. Lee et al. suggested that the anterior talofibular ligament length on stress ultrasound could be useful for diagnosing chronic ankle instability in addition to the manual anterior drawer test and stress radiography [9]. However, these diagnostic methods are limited by the availability of the instruments and potential errors from radiography and ultrasonography [13]. Most surgeons rely on the manual anterior drawer test to determine treatment.

Manual ADT is essential in clinical settings, but requires experience to perfect the technique, and low sensitivity of the test may be due to technical variation between individual examiners, especially with less experienced examiners [12, 13]. In the ADT procedure, axial load increases the stability of the ankle joint complex and results in a reduction in the sensitivity of ADT in detecting mechanical ankle instability [22]. In a biomechanical cadaveric study, Tohyama et al. indicated that ADT with an ankle positioned between 10 and 20 degrees of plantar flexion produced the most laxity and least stiffness [17]. They also suggested that an excessive magnitude of anterior load is not necessary to detect disruption of the anterior talofibular ligament during the anterior drawer test [23]. In a study using ultrasonography, ADT of the anterior talofibular ligament-deficient ankle at 20 degrees of plantar flexion induced greater length changes in the anterior talofibular ligament than ADT with the ankle in neutral position [14]. As mentioned above, manual ADT requires certain technical points to be proficient in the procedure. Most studies refer only to the modified technique and diagnostic accuracy of ADT, and there are few reports on verifying its reproducibility or inter-rater reliability. The reason for this is that quantitative measurements of anterior translation in manual ADT are difficult in vivo. In the current study, we were able to quantitatively measure the distance of anterior displacement between examiners using a capacitance-type sensor device and evaluated its reproducibility.

In this study, fixed ADT had high diagnostic accuracy, even with junior examiners, and the distance of anterior translation was similar to that determined by the senior examiner. This may be due to the fact that placing the lower leg on the board with the hip and knee flexed at 90 degrees with the subject in supine position makes it easy for them to relax and relieves gastrocnemius muscle spasm. Kovaleski et al. indicated that ADT with the knee positioned at 90-degree flexion produces more laxity than that with the knee at 0-degree flexion, which may be accounted for by increased tension of the gastrocnemius-Achilles tendon complex when the knee is extended, increasing the ankle complex stiffness during ADT [15]. Furthermore, the examiners perform traditional ADT by applying an anteriorly directed force to the calcaneus with a backward push on the tibia, and evaluate the ankle joint laxity by two-hand manipulation.¹ Thus, examiners need to evaluate ankle instability by the relative movements of both hands, and complex movements and subtle sensations are required, resulting in low sensitivity and reproducibility, especially with less experience. In fixed ADT, examiners may decrease the sensation of relative hand movements by stabilizing the distal tibia with one hand, making it easier to diagnose ankle instability. Fixed ADT is a particularly preferred method for evaluation of ankle instability by inexperienced examiners who are not foot specialists.

This study has several limitations. First, the number of cases in our study was relatively small, which may have affected the statistical analysis. Second, there was no difference in the diagnostic accuracy between traditional and fixed ADTs for senior examiners, and further larger studies are warranted. Finally, the diagnostic accuracy was evaluated based on the instability defined by stress radiography, but not based on the patient's symptoms, such as instability. Despite these limitations, we show that the distance of anterior translation by the junior examiner was significantly lower than that by the senior examiner in traditional ADT and is similar between examiners in fixed ADT. To the best of our knowledge, there are no reports documenting a comparison of the actual distances of anterior displacement in manual anterior drawer test in vivo.

Fixed anterior drawer test has a higher inter-rater reliability than the traditional procedure, and a similar amount of anterior translation was observed between junior and senior examiners when it was performed. Fixed ADT is a simple manual examination, and may be useful for the evaluation of ankle instability as a method with less error between examiners.

MRI, Magnetic Resonance Imaging

ADT, anterior drawer test

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines. The study was approved by the Institutional Review Board of Sapporo Medical University Hospital (reference number 29-242), and informed consent was obtained from all study participants after providing patients with written and oral information before inclusion in the study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ contributions

Coordination of study conduction YM. Study design YM, AT. Data collection YM, KT. Statistical analysis YM. Data interpretation AT, YO. Clinical consultant AT, YO, SO, RI, MK, KW, TY. Manuscript preparation YM. Critical review of the manuscript AT, KW, TY. Approval of the final draft AT, TY. The authors read and approved the final manuscript.

Acknowledgements

We would like to thank Edanz (www.edanz.com) for English language editing.

Tarczyńska M, Sekuła P, Gawęda K, Szubstarski M, Przybylski P, Czekajska-Chehab E. Stress radiography in the diagnosis and assessment of the outcomes of surgical treatment of chronic anterolateral ankle instability. Acta Radiol. 2020; 61(6): 783–788.
Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010; 92(13): 2279–2284.
Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998; 19(10): 653–660.
Malliaropoulos N, Ntessalen M, Papacostas E, Longo UG, Maffulli N. Reinjury after acute lateral ankle sprains in elite track and field athletes. Am J Sports Med. 2009; 37(9): 1755–1761.
O’Loughlin PF, Murawski CD, Egan C, Kennedy JG. Ankle instability in sports. Phys Sportsmed. 2009; 37(2): 93–103.
Cho JH, Lee DH, Song HK, Bang JY, Lee KT, Park YU. Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test, stress radiography, magnetic resonance imaging, and arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2016; 24(4): 1022–1028.
Croy T, Koppenhaver S, Saliba S, Hertel J. Anterior talocrural joint laxity: diagnostic accuracy of the anterior drawer test of the ankle. J Orthop Sports Phys Ther. 2013; 43(12): 911–919.
Gomes JLE, Soares AF, Bastiani CE, de Castro JV. Anterolateral talar palpation: A complementary test for ankle instability. Foot Ankle Surg. 2018; 24(6): 486–489.
Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS. New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound. Knee Surg Sports Traumatol Arthrosc. 2014; 22(7): 1701–1707.
Li Q, Tu Y, Chen J, Shan J, Yung PS, Ling SK, et al. Reverse anterolateral drawer test is more sensitive and accurate for diagnosing chronic anterior talofibular ligament injury. Knee Surg Sports Traumatol Arthrosc. 2020; 28(1): 55–62.
Nyska M, Amir H, Porath A, Dekel S. Radiological assessment of a modified anterior drawer test of the ankle. Foot Ankle. 1992; 13(7): 400–403.
Fujii T, Luo ZP, Kitaoka HB, An KN. The manual stress test may not be sufficient to differentiate ankle ligament injuries. Clin Biomech (Bristol, Avon). 2000; 15(8): 619–623.
Phisitkul P, Chaichankul C, Sripongsai R, Prasitdamrong I, Tengtrakulcharoen P, Suarchawaratana S. Accuracy of anterolateral drawer test in lateral ankle instability: a cadaveric study. Foot Ankle Int. 2009; 30(7): 690–695.
Kikumoto T, Akatsuka K, Nakamura E, Ito W, Hirabayashi R, Edama M. Quantitative evaluation method for clarifying ankle plantar flexion angles using anterior drawer and inversion stress tests: a cross-sectional study. J Foot Ankle Res. 2019; 12: 27.
Kovaleski JE, Norrell PM, Heitman RJ, Hollis JM, Pearsall AW. Knee and ankle position, anterior drawer laxity, and stiffness of the ankle complex. J Athl Train. 2008; 43(3): 242–248.
Miller AG, Myers SH, Parks BG, Guyton GP. Anterolateral Drawer Versus Anterior Drawer Test for Ankle Instability: A Biomechanical Model. Foot Ankle Int. 2016; 37(4): 407–410.
Tohyama H, Beynnon BD, Renström PA, Theis MJ, Fleming BC, Pope MH. Biomechanical analysis of the ankle anterior drawer test for anterior talofibular ligament injuries. J Orthop Res. 1995; 13(4): 609–614.
Anderson KJ, Lecocq JF, Lecocq EA. Recurrent anterior subluxation of the ankle joint; a report of two cases and an experimental study. J Bone Joint Surg Am. 1952; 34 A(4): 853–860.
Cass JR, Morrey BF. Ankle instability: current concepts, diagnosis, and treatment. Mayo Clin Proc. 1984; 59(3): 165–170.
Teramoto A, Iba K, Murahashi Y, Shoji H, Hirota K, Kawai M, et al. Quantitative Evaluation of Ankle Instability Using a Capacitance-Type Strain Sensor. Foot Ankle Int. 2021; 42(8): 1074–1080.
Kanda Y. Investigation of the freely available easy-to-use software 'EZR' for medical statistics. Bone Marrow Transplant. 2013; 48(3): 452–458.
Liu W, Maitland ME, Nigg BM. The effect of axial load on the in vivo anterior drawer test of the ankle joint complex. Foot Ankle Int. 2000; 21(5): 420–426.
Tohyama H, Yasuda K, Ohkoshi Y, Beynnon BD, Renstrom PA. Anterior drawer test for acute anterior talofibular ligament injuries of the ankle. How much load should be applied during the test? Am J Sports Med. 2003; 31(2): 226–232.

Table 1 | Patient demographics and distance of anterior talar translation (ATT)

Sex	Male	6 (8 feet)
	Female	18 (22 feet)
Age (y), mean [range]		32.0	[23–38]
Height, cm [range]		171.1	[154–185]
Body weight, kg [range]		65.9	[46–92]
Side	Rt	20
	Lt	10
ATT distance	<3.5 mm	20
	≥3.5 mm	10

Data are presented as frequencies, unless otherwise indicated.

ATT, anterior talar translation of stress radiography

Table 2 | Diagnostic accuracy of two manual anterior drawer tests by the senior and junior examiners

Sensitivity

(95% CI)

Specificity

(95% CI)

PPV

(95% CI)

NPV

(95% CI)

Traditional ADT

Junior examiner

0.400

(0.122-0.738)

0.750

(0.509-0.913)

0.444

(0.137-0.788)

0.714

(0.478-0.887)

0.416

(0.096-0.735)

Senior examiner

0.800

(0.444-0.975)

0.600

(0.361-0.809)

0.500

(0.247-0.753)

0.857

(0.572-0.982)

Fixed ADT

Junior examiner

0.800

(0.444-0.975)

0.800

(0.563-0.943)

0.667

(0.349-0.901)

0.889

(0.653-0.986)

0.571

(0.265-0.878)

Senior examiner

0.700

(0.348-0.933)

0.850

(0.621-0.968)

0.850

(0.621-0.968)

0.722

(0.465-0.903)

Data are presented as mean (range), unless otherwise noted.

ADT, anterior drawer test; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value

No competing interests reported.

Download PDF

Journal Publication

published 27 Feb, 2023

Read the published version in BMC Musculoskeletal Disorders →

Editorial decision: Major revision
10 Oct, 2022
Reviews received at journal
30 Sep, 2022
Reviewers agreed at journal
14 Sep, 2022
Reviews received at journal
12 Sep, 2022
Reviewers agreed at journal
02 Sep, 2022
Reviewers agreed at journal
25 Aug, 2022
Reviewers invited by journal
22 Aug, 2022
Editor assigned by journal
22 Aug, 2022
Editor invited by journal
22 Aug, 2022
Submission checks completed at journal
22 Aug, 2022
First submitted to journal
17 Aug, 2022

You are reading this latest preprint version

High reproducibility of a novel fixed anterior drawer test for diagnosing ankle instability

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Journal Publication

Version 1