Assessments Used by Athletic Trainers to Decide Return-to-Activity Readiness in Patients With an Ankle Sprain

METHODS

We used a cross-sectional, web-based survey to identify which types of outcomes ATs measure to determine that a patient recovering from an ankle sprain is ready for return to activity. Survey logic was applied to then explore which specific assessments were chosen and why. Moreover, if ROASTs were not used, we explored the underlying reasons. This study was approved as exempt research by the Old Dominion University Human Subjects Review Committee.

RESULTS

Respondent Demographics and Outcome Domains

A total of 676 ATs accessed the survey, with 574 submitting responses (85% completion rate). A total of 33 respondents did not meet the inclusion criteria and were eliminated from the analyses, bringing our total sample to 541. Respondent demographics are reported in Table 1. Most outcomes were used by >75% of ATs to determine patients’ readiness for return to activity after ankle sprain, but arthrokinematics, physical activity level, and PROs were each assessed by <36% of respondents (Figure). Chi-square analyses revealed that the outcomes assessed by respondents varied depending on their age (χ² = 578.997, P = .03), highest degree earned (χ² = 35.470, P = .02), educational programs completed (χ² = 101.706, P = .01), years of clinical practice (χ² = 94.297, P < .001), current clinical practice setting (χ² = 50.720, P = .01), and familiarity with the IAC ROAST guidelines (χ² = 32.770, P < .001). Distributions of outcome domains evaluated across demographic variables are presented in Table 2. Regarding clinical practice settings, nontraditional included industrial or occupational medicine, rehabilitation clinics, physicians’ practices, hospitals, and military settings.

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Table 1. Patient Characteristics (N = 541)

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Table 2. Demographic Influences of Selected Outcomes

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Assessment Methods

For respondents who indicated they assessed a given outcome, frequencies of specific evaluation methods are provided in Table 3.

Table 3. Rates of Assessment Method Selection for Each Outcome

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Ankle-Joint Pain

Specific methods of ankle-joint pain evaluation varied based on ATs’ educational programs completed (χ² = 44.766, P = .002), current practice setting (χ² = 31.406, P < .001), and familiarity with the IAC ROAST guidelines (χ² = 18.746, P < .001). Distributions of pain assessments selected across demographic variables are shown in Appendix Table 1.

Ankle-Joint Swelling

Methods selected for ankle-joint swelling differed based on ATs’ age (χ² = 22.089, P = .04), years of clinical practice (χ² = 42.758, P < .001), current practice setting (χ² = 23.232, P = .01), and familiarity with the IAC ROAST guidelines (χ² = 8.470, P = .04). Distributions of ankle-joint swelling assessments selected across demographic variables are given in Appendix Table 2.

Ankle-Joint ROM

Athletic trainers’ choices of ankle-joint ROM tests were influenced by their highest degree earned (χ² = 17.880, P = .02), educational programs completed (χ² = 49.400, P = .01), years of clinical practice (χ² = 38.683, P = .01), current practice setting (χ² = 35.938, P < .001), and familiarity with the IAC ROAST guidelines (χ² = 26.515, P < .001). Distributions of ankle-joint ROM assessments selected across demographic variables are presented in Appendix Table 3.

Ankle-Joint Arthrokinematics

Influences on ankle-joint arthrokinematics tests used by ATs’ included age (χ² = 16.086, P = .04), educational programs completed (χ² = 29.657, P < .001), and years of clinical practice (χ² = 25.584, P = .03). Distributions of ankle-joint arthrokinematic assessments selected across demographic variables are reported in Appendix Table 4.

Ankle-Joint Strength

Selection of ankle-joint strength assessment methods was affected by ATs’ age (χ² = 23.721, P = .02) and current practice setting (χ² = 20.348, P = .02). Distributions of ankle-joint strength assessments selected across demographic variables are shown in Appendix Table 5.

Balance

Specific methods of balance assessment varied based on ATs’ age (χ² = 45.449, P < .001), highest degree earned (χ² = 32.495, P < .001), educational programs completed (χ² = 60.799, P = .003), years of clinical practice (χ² = 38.119, P = .01), current practice setting (χ² = 29.542, P = .003), whether they acted as an athletic training student preceptor (χ² = 10.514, P = .03), and familiarity with the IAC ROAST guidelines (χ² = 15.716, P = .003). Distributions of balance assessments selected across demographic variables are presented in Appendix Table 6.

Gait

Athletic trainers’ methods of gait evaluation differed by current practice setting (χ² = 23.239, P < .001). Distributions of gait assessments selected across demographic variables are illustrated in Appendix Table 7.

Physical Activity Level

Athletic trainers’ methods of evaluating physical activity level varied depending on their highest degree earned (χ² = 25.092, P < .001) and familiarity with the IAC ROAST guidelines (χ² = 8.403, P = .02). Distributions of physical activity level assessments selected across demographic variables are provided in Appendix Table 8.

Functional Capacity

Methods of testing functional capacity were influenced by ATs’ familiarity with the IAC ROAST guidelines (χ² = 13.450, P = .01). Distributions of functional capacity assessments selected across demographic variables are shown in Appendix Table 9.

Patient-Reported Outcomes

Selection of PROs was influenced by ATs’ age (χ² = 49.294, P = .01), highest degree earned (χ² = 32.840, P = .003), educational programs completed (χ² = 88.720, P < .001), and familiarity with the IAC ROAST guidelines (χ² = 27.288, P < .001). Distributions of PROs selected across demographic variables are depicted in Appendix Table 10.

DISCUSSION

To our knowledge, this is the first large-scale study to identify which outcomes ATs use for determining the return-to-activity readiness of patients with ankle sprains. Seven of the 10 studied outcomes (pain, swelling, ROM, strength, balance, gait, and functional capacity) were assessed by most (75.2%–96.5%) ATs, but the remaining 3 outcomes (arthrokinematics, physical activity level, and PROs) were evaluated by smaller proportions (25.3%–35.1%) of ATs. Although 9 of 10 of these outcomes are recommended for evaluation under the IAC ROAST guidelines,¹⁵ our data suggested that many ATs neglected to assess arthrokinematics, physical activity level, and PROs before clearing patients for return to activity. These findings support our preliminary study,¹⁶ in which ATs varied in their assessment of recommended outcomes. The low frequency of PRO use further agrees with the results of a recent report¹⁸ in which 78% of ATs did not include PROs in patient evaluations. Similar to ATs, physicians often did not evaluate all relevant outcomes when making return-to-activity decisions for patients with ankle sprains.¹⁹ This trend across professional disciplines should be further studied as a potential contributor to persistent impairments and CAI arising after an ankle sprain.

For ATs who evaluated a given outcome domain, we further inquired about their selection of specific assessment methods, including ROASTs and non-ROASTs. For pain assessment, ATs preferred a numeric rating scale vastly more than the Foot and Ankle Disability Index (FADI) and other methods. Both options are recommended for pain assessment,¹⁵ but the single-item numeric rating scale might be more attractive than the FADI, which is a multi-item questionnaire with a broader scope focusing on pain and self-reported function. When asked about PRO assessments, only 24% of ATs reported using the highly similar FADI and Foot and Ankle Ability Measure (FAAM) instruments. As we expected, athletes who return to activity after an ankle sprain have exhibited self-reported function consistent with individuals with CAI.^10,11 Despite low rates of FAAM and FADI use, some ATs selected other generic (Patient-Specific Functional Scale), region-specific (Lower Extremity Functional Scale), or single-item (Global Rate of Change) PROs, all of which can be used to effectively gauge patient perceptions regarding recovery from an ankle sprain.¹⁸

Along with PROs, arthrokinematics and physical activity level were the least often assessed outcomes by ATs. Of the few who did evaluate arthrokinematics, most selected the posterior talar glide test to detect restricted posterior translation and, possibly, anterior positional faults of the talus.^20,21 Conversely, most ATs gauging physical activity level deviated from the recommended Tegner Activity Scale, which is a valuable method for establishing a patient’s preinjury activity level and setting goals for rehabilitation. Instead, ATs favored other methods, some of which were objective measures of preinjury and postinjury exercise loads and intensity. Spikes in the acute workload relative to chronic workload were related to an increased risk for injury,²² and thus, objective measurements of physical activity level might be needed throughout rehabilitation to ensure that patients progressively increase physical activity and experience a lower risk for recurrent injury on return to activity.

A large majority of ATs who assessed ankle-joint swelling and ROM used visual inspection. Visual assessment of these outcomes is generally not favorable to ROASTs because of a lack of established validity and reliability and increased measurement error compared with quantifiable assessments.^16,23 The figure-of-8 girth measurement is a simple, valid, and reliable circumferential measurement of the subtalar and midtarsal regions, but it was used by <30% of ATs who evaluated swelling.^24,25 A larger proportion of ATs assessed dorsiflexion ROM using the weight-bearing lunge test (WBLT), recommended for its ability to quantify dorsiflexion ROM in a closed kinetic chain position.¹⁵ Although not a recommended ROAST, goniometry is also a valid, reliable ROM assessment that was used by nearly half of ATs.²⁶ In addition to being viable, goniometry is clearly a popular alternative to the WBLT and has the added benefit of measuring motions beyond dorsiflexion.

Ankle-joint strength evaluations were conducted almost entirely via manual muscle testing, a non-ROAST technique. Manual muscle testing remains a valuable tool for rapidly identifying gross motor deficits during the acute and subacute stages of recovery. However, manual muscle testing lacks the sensitivity to detect subtle strength deficits that are captured using a quantifiable strength measurement.^27,28 Aiken et al²⁷ demonstrated that 30 days after an acute lateral ankle sprain, patients exhibited 5 of 5 on manual muscle testing but quantifiable strength deficits remained. Handheld dynamometry is the simplest method by which ATs can quantify isometric muscular strength and is thus recommended by experts.¹⁵ Isokinetic dynamometers are also a viable option for quantifying muscular strength, but their feasibility is limited by large relative size and high cost.

Most ATs who assessed balance performance used at least 1 of the 3 recommended ROASTs. Balance deficiencies are typical after an acute ankle sprain and often persist for weeks or longer.⁷ Although the Balance Error Scoring System and foot-lift test differ from the Star Excursion Balance Test by evaluating static as opposed to dynamic balance, all 3 tests have exhibited the ability to discriminate between individuals with and those without a previous ankle sprain.²⁹ Despite a tendency to choose recommended balance assessments, 16% of ATs reported they did not gauge balance. This might explain why athletes with an ankle sprain often exhibit residual balance deficits at return to activity.¹⁰

Aside from balance, we surveyed ATs about their use of other dynamic weight-bearing tests. Most ATs characterized gait via visual inspection, a technique recommended by the IAC ROAST guidelines. However, the specific aspects of gait that ATs evaluated remains unclear. Functional capacity was the outcome most used by ATs, although it was not a domain included in the ROAST guidelines. Nearly all ATs observed their patients performing progressive jumping, agility, or sport-specific tasks, but, as with gait, we did not obtain specific details about the evaluation methods.

We conducted further analyses to identify demographic determinants of the outcome domains and specific assessment methods used by ATs. Generally, ATs with more advanced degrees, practicing in nontraditional settings, with more years of clinical experience, and familiar with the IAC ROAST guidelines were most likely to evaluate the recommended outcome domains. Others have reported that ATs with doctorates, more clinical experience, and employment in nontraditional settings placed greater emphasis on educating patients with ankle sprains.³⁰ In our study, these subpopulations of ATs were particularly more apt to use PROs. Familiarity with the ROAST guidelines facilitated use of the recommended FAAM and FADI. Specific PROs selected by ATs were also influenced by the degree earned, educational programs completed, and age, but these factors affected only non-ROASTs such as the Global Rate of Change. Regardless, identifying factors that facilitate PRO use is highly important because most ATs reportedly did not use PROs.¹⁸

Familiarity with the IAC ROAST guidelines affected the choice of assessment methods in 7 of 10 outcome domains (pain, swelling, ROM, balance, physical activity level, functional capacity, and PROs). Although exposure to the IAC ROAST guidelines appeared to positively influence selected measures, fewer than half of ATs were familiar with the publication.¹⁵ Similarly, nearly 40% of ATs described being unaware of the NATA position statement on ankle sprains.^2,30 Practice setting also affected ATs’ evaluations of 6 of 10 outcomes (pain, swelling, ROM, strength, balance, and gait). Of note, employment in nontraditional settings was associated with greater use of the ROASTs for pain and balance assessment and reduced use of non-ROAST assessments such as visual inspection of swelling. Highest degree earned influenced several assessment choices (ROM, balance, physical activity level, and PROs), but a higher degree did not always equate to closer agreement with the ROAST guidelines. Similarly, ATs with greater clinical experience were less likely to use visual determination of swelling but also less likely to use the WBLT to characterize ROM. Completion of more advanced educational programs was associated with a greater likelihood of selecting ROASTs, particularly for pain and balance, as well as non-ROAST PROs.

LIMITATIONS AND FUTURE DIRECTIONS

This study was not without limitations. First, we invited only members of the NATA to participate, which restricted the study’s representation of ATs who are nonmembers. Second, although we surveyed participants about their use of ROASTs, the IAC guidelines were not explicitly intended to be return-to-activity criteria.¹⁵ Given the absence of clear return-to-activity guidelines for patients with ankle sprains at the time of this study,¹⁴ we opted to model our survey on expert consensus recommendations for lateral ankle-sprain evaluation.¹⁵ Since our survey was initiated, an international multidisciplinary consensus of assessments that should and should not be considered for return-to-activity decisions for athletes with a lateral ankle sprain has been published.³¹ In this new PAASS (pain, ankle impairments, athlete perception, sensorimotor control, sport and functional performance) framework, several items that should be included in return-to-activity decisions align with the ROAST guidelines (pain, ankle ROM, ankle strength, perceived confidence, and balance), but others that should not be included in return-to-activity decisions were also in the ROAST guidelines (ankle-joint arthrokinematics, physical activity level represented by aerobic and anaerobic fitness and acute-to-chronic workload ratio).^15,31 Thus, some of the return-to-activity decisions that we identified as deficiencies among ATs actually agree with other experts’ consensus for best practices. Lastly, we obtained valuable information regarding which assessment methods are used by ATs but did not ask ATs how they interpreted test scores to determine return-to-activity readiness. Tassignon et al³² recently published a systematic review aimed at summarizing previously published criteria-based return-to-sport decisions used for patients with lateral ankle sprains. However, the authors found criteria-based evaluations had been used in only 1 study and therefore were unable to provide aggregate criteria-based return-to-sport guidelines.³² Future researchers should examine ATs’ rationale behind assessment-measure selection and the assessment criteria that ATs consider necessary for return to activity.

CONCLUSIONS

Athletic trainers often do not evaluate the full complement of recommended outcomes before determining if patients with ankle sprains are ready for return to activity. The recommended outcomes that ATs most commonly neglected were ankle-joint arthrokinematics, physical activity level, and PROs. When evaluating a given outcome domain, ATs varied in their selection of recommended and nonrecommended assessment methods. Practice in nontraditional settings, completion of more advanced degrees, possession of more clinical experience, and familiarity with expert consensus guidelines appeared to facilitate evaluation of the recommended outcomes and use of the recommended assessment methods for return to activity after an ankle sprain.