Diagnostic Accuracy
of the Anterior Drawer Test for the Ankle

T, Koppenhaver S, Saliba S, Hertel J. J Orthop Sports Phys Ther. 2013 Dec;
43(12):911-9. https://www.ncbi.nlm.nih.gov/pubmed/24175608

Take Home Message: The
anterior drawer test for the anterior talocrural joint has a low diagnostic
accuracy, and therefore the results of the test alone should be interpreted
with caution.  Clinicians may want to
consider the use of imaging modalities, such as diagnostic ultrasound, in the
evaluation of the anterior talofibular ligament after an ankle sprain.

anterior drawer test is commonly used to
assess the severity of injury to the anterior talocrural joint (e.g., anterior
talofibular ligament) after an inversion mechanism at the ankle.  Many physical examination techniques,
including the anterior drawer test, have demonstrated low reliability and diagnostic accuracy, which leads
researchers and clinicians to interpret results of the anterior drawer test
with caution.  While the anterior drawer
test has been previously evaluated in existing literature, there have been few
reports about its diagnostic capabilities, especially in combination with the
extent of joint laxity and the clinical usefulness of the test.  The purpose of this study was to evaluate the
diagnostic accuracy of the anterior drawer test, as well as to determine the
extent that the anterior drawer test assists clinicians in determining anterior
talocrural joint laxity.  In the current
study, the authors included 66 participants; each participant was classified as
having: an acute lateral ankle sprain (22 participants); a history of one ankle
sprain with no remaining symptoms (ankle sprain copers, 19 participants); or a
history of recurrent ankle sprains (chronic ankle instability, 25 participants).  To assess the diagnostic accuracy of the
anterior drawer test (graded 0 [hypomobile] to 4 [severe laxity]), the authors manually
applied a standardized anterior drawer force using an arthrometer while visualizing
landmarks on the talus and fibula with diagnostic ultrasound.  The authors investigated the diagnostic
performance of the anterior drawer test compared with two cutoff values for
abnormal laxity (2.3 mm and 3.7 mm; based on healthy controls and previous
research).  The authors demonstrated that
participants with a history of a lateral ankle sprain had greater anterior
talocrural joint laxity (~3.4 mm) compared with healthy participants (~0.2 mm).
Only one healthy control was considered to have abnormal laxity (using either
cutoff).  In contrast, 53% or 36% of participants
with a history of an ankle sprain had abnormal laxity at the anterior
talocrural joint based on the cutoff of 2.7 mm or 3.7 mm; respectively.  Sensitivity of the anterior
drawer test compared with the 2.3 mm cutoff was ~0.74 and specificity was ~0.38 (see definitions
below).  The positive and negative likelihood ratios
were 1.2 and 0.66, respectively at the 2.3 mm reference.  When the authors used the larger laxity cutoff
of 3.7 mm, the sensitivity and specificity of the anterior drawer test were ~0.83
and ~0.40, respectively, with a positive likelihood ratio of 1.4 and a negative
likelihood ratio of 0.41.  Likelihood
ratios of these magnitudes are considered small, which raises concerns about
the diagnostic performance of the anterior drawer test.

this study reported that the anterior drawer test demonstrated low diagnostic
accuracy compared with two reference standards. 
A positive anterior drawer test may lead to small and unimportant
changes in the likelihood of identifying abnormal talocrural joint laxity, and
a negative anterior drawer test may cause small changes in the likelihood that
the patient or participant will not demonstrate abnormal talocrural joint
laxity.  Evaluated by an experienced
clinician, nearly 70% of the participants in this study were classified as
having a positive anterior drawer test. 
According to the results, between 42% and 56% of these participants would
be considered to have a false positive test result, which the authors attribute
to the clinician technique and patient position utilized during the anterior
drawer test.  When using the anterior
drawer test to assess the integrity of the anterior talofibular ligament,
clinicians should continue to interpret subjective results with caution.  Because the anterior drawer test appears to
be a poor predictor of talocrural joint laxity, the authors suggest that if
sophisticated measurement techniques such as diagnostic ultrasound or stress
radiographs are available, clinicians should consider these techniques as more
accurate alternatives. 

Questions for
Discussion: Would you consider modifying your physical exam techniques based on
the results of this study?  Do you have
training and/or access to diagnostic ultrasound in your primary setting?  How important is accurate assessment of
laxity in the overall treatment plan your patients?

by: Kimberly Pritchard
by: Jeffrey Driban



Croy T, Koppenhaver S, Saliba S, & Hertel J (2013). Anterior talocrural joint laxity: diagnostic accuracy of the anterior drawer test of the ankle. The Journal of Orthopaedic and Sports Physical Therapy, 43 (12), 911-9 PMID: 24175608