Lateral Ankle Sprains - Guiding return to sport decision making

Recommendations and expectations for return to sport (whether athletic or recreational) following lateral ankle sprains has lacked consistency. We're often taught to use the ligament injury grade to set expectations on the time to return, despite up to 92% of ankle sprains also suffering from a secondary tissue injury, that can have a wildly different rehabilitation timeline.

So how do can we navigate this in practice?

I would love to be able to tell you, don't worry, there's a simple, standardised solution. However, not only is each injury different, so is the activity people want to return to. So assessment, rehab and expectations have to be different for each person and athlete.

Getting someone back to recreational running on flat ground following a small sprain stepping off a curb will be different from helping an athlete return to high grade basketball following their third major sprain.

In recognition of this, there's been a shift in rehab generally from purely time-based rehabilitation timelines to frameworks that emphasise reaching minimum requirements in attributes like strength, balance, sport specific skills, as well as psychological readiness.

This approach has been working well in ACL rehab. Now recently in the research, we've not only got a consensus on what to test to guide return to play decision making (the PAASS Framework), we've also got a set of tests which closely follow the framework (the Ankle GO Score) and have been showing promise, with validity in predicting return to sport rates.

Let's dive in.

Introducing the PAASS Framework: A consensus on what to assess pre-return to play

In 2021, Smith et al published an international consensus on what they think are the important attributes to develop titled the PAASS Framework.

The PAASS Framework for return to play from lateral ankle sprains

The framework recognises what we've been figuring out for a while now. That there's unlikely to be one test that'll able to reliably predict whether someone is ready or not to return to sport. It needs to be a battery that tests a range of attributes, alongside consideration such as the person's perception of their own injury and recovery.

It doesn't provide specific guidance on tests and exact benchmarks because in 2021, there was limited research (and there still is a severe lack), on what are the best tests and scores required for each sport or activity.

When I spoke to a colleague working in volleyball and basketball, he and other medical teams were noticing that anterior reach distance on a modified star excursion balance test (mSEBT), was much more important in jumping sports than other field sports. So typically reported guidance of >60-70% limb symmetry index (LSI) was way too low for their sport/athletes.

So in the lack of good evidence, having guidance on how to device and modify your own testing program is helpful.

But what if you don't know where to start?

Putting the PAASS into practice. The Ankle GO Score

The Ankle GO Score is a series of tests, outcome measures and scoring system developed by As Prof Brice Picot and his team at the Savole Mont Blanc University, with the purpose of guiding return to sport post lateral ankle sprain. Each test has differing scores with a total possible score of 25.

The Ankle GO Score

In 2023, they showed that at 2 months post lateral ankle sprain, those with a score of <8 were unlikely to return to sport at the same preinjury level. Then in 2024, they also showed that at the same 2 month post-injury scoring, people with a score of >11 points were significantly more likely to become 'copers', the term for people who don't go on to develop chronic ankle instability following a lateral ankle sprain.

At this stage there's no exact score that we can say can used for a cut-off for return to play. This is because the research to date has focused on validating the scoring system by showing it's predictive of outcomes, as well as the longer time frame required to collect data on people returning to sport.

What I've found interesting about looking at the scoring system itself, it does match closely with findings from the latest clinical practice guideline by Martin et al 2021, on what scores were associated with good and poor outcomes across a range of different tests, sports, activities and conditions (lateral ankle sprains vs chronic ankle instability). What was lacking was a consistent recommendation as none of the studied tests were tested in a way to draw consistent conclusions.

However, in the interim while we're waiting for more research, I still feel comfortable recommending the Ankle GO score as a battery of tests, alongside checking pain severity, ankle range of motion, regaining LSI to >90-95% on objective strength testing of ankle evertors, invertors and plantarflexors, being able to complete sport specific activities with no pain and instability and a successful return to training.

So what benchmarks/cut-offs am I using in clinical practice?

We all love numbers as specific guidance. So at the risk of being corrected, below is the general test battery I use for patients I see in private practice who're returning to recreational sport/physical activity.

• Ankle invertor and evertor strength LSI >90%. Inversion:Eversion strength ratio 1:1 is also desirable, with > evertor strength in those with pes cavus foot types.

• Single leg calf raise, between 1-1.5 x bodyweight (higher end for more intense/higher level sport/activity) + >90% LSI

• mSEBT, anterior reach distance LSI >70% and posterior medial distance LSI >90% of leg length.

• Forward hop test, LSI of >95% with limited to no errors on the quality assessment of a single leg loading (QASLS) tool

• Side hop test, between 25-40 reps in 30 seconds (higher end for more intense/higher level sport/activity)

• A FAAM Sport Subscale Score of >95%

• Able to complete sport specific skills including linear and multi-directional running drills

• Able to return to training with no pain or instability

• Patient feels ready and comfortable to return to play + an ALR-RSI score of >63%

Got a different experience with return to sport decision making? Let me know with a comment below.