Research Review By Dr. Jeff Muir©


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Date Posted:

March 2022

Study Title:

Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework – an international multidisciplinary consensus


Smith MD, Vicenzino B, Bahr R, Bandholm T, Cooke R et al.

Author's Affiliations:

School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia; Oslo Sports Trauma Research Centre, Norwegian School of Sports Sciences, Oslo, Norway; Aspetar, Orthopaedic and Sports Medicine Hospital, Doha, Qatar; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy and Department of Clinical Research, Copenhagen University Hospital, Copenhagen, Denmark; additional academic and research centers...

Publication Information:

British Journal of Sports Medicine 2021; 55: 1270–1276.

Background Information:

Lateral ankle sprains are among the most common sports-related injuries, although they are often thought to be relatively minor and quick to heal with minimal intervention (1). Perhaps owing to this perception, evidence indicates that over 50% of those suffering a lateral ankle sprain do not seek treatment and many return to sport (RTS) prematurely, before their injury has fully healed (2). One study showed that up to 75% of US high school athletes returned within 3 days of injury and 95% returned within 10 days (3). This could be too soon for some athletes!

No criterion-based guidelines informing treatment decisions following lateral ankle sprain exist, with a recent systematic review unable to identify any studies providing RTS guidance (4) and a review of expert opinion unable to define consensus on assessments or cut-off thresholds for RTS (5).

The lack of treatment guidelines is thought to contribute to premature RTS, which itself is thought to precipitate recurrent ankle problems (6). The goal of the current study was to develop a consensus for assessment items that should inform RTS decisions.

Pertinent Results:

Expert Panel Participants:
250 invitations to participate were distributed; 198 (79.2%) responses were received (that’s pretty good!). Completed responses for Round 1 numbered 155 (78.2%), while for Rounds 2 (137, 88.4%) and 3 (119, 76.8%) saw lower, but still satisfactory, response rates. Demographics of respondents across the different rounds were similar and not significantly different.

Of 35 assessment items presented to panelists, 16 reached consensus (> 70% agreement) to be included in the RTS decision-making process, while 17 reached consensus not to be included.

Consensus Items for Inclusion:
  • Sport-specific activities
  • Pain severity during sport participation
  • Ankle range of motion
  • Ankle muscle strength
  • Hopping
  • Agility
  • Completion of a full training session
  • Jumping
  • Pain severity over the last 24 hours
  • Perceived ankle reassurance/confidence
  • Proprioception
  • Perceived ankle stability
  • Psychological readiness
  • Ankle muscle endurance
  • Dynamic postural control/balance
  • Ankle (and lower limb) muscle power
Consensus Items Not for Inclusion
  • Structural integrity of the ligaments on imaging
  • Pain severity over the last week
  • Pain severity on palpation
  • Health-related quality of life
  • Hip and knee muscle endurance
  • Ankle muscle length
  • The Functional Movement Screen
  • Aerobic fitness
  • Anaerobic fitness
  • Ligamentous laxity
  • Ankle joint arthrokinematics
  • Acute chronic workload
  • Lower limb and/or trunk kinematics
  • Hip and knee muscle strength
  • Foot biomechanics
  • Straight-line running speed
Based on the assessment items reaching consensus to be included in RTS assessment, five domains were established: Pain, Ankle impairments, Athlete perception, Sensorimotor control and Sport//functional performance (“PAASS”). 99% of panelists agreed with these domains.

Comments on PAASS Domains and Items:
Regarding items to be included in the assessment, panelists felt items that directly influenced sport-specific function and/or contributed to risk of injury recurrence were most important. The athlete’s perception of their readiness to RTS and perception of their ankle status were also deemed to be very important. Items not reaching consensus were excluded if they were considered not to influence RTS ability (ex. ligament integrity or laxity and pain severity). Foot and lower limb biomechanics and patient-reported foot and ankle function scores were also deemed not sufficiently sensitive to properly assess RTS. Items involving a longer timeframe or time away from sport were not deemed necessary and, finally, items that would be highlighted or assessed in other included PAASS items (ex. ankle muscle length or joint kinematics) would be appropriately evaluated when assessing ankle range of motion.

Clinical Application & Conclusions:

Based on the responses of expert panelists, the authors concluded that RTS for acute lateral ankle sprain should be assessed based on pain severity during sport participation, ankle impairments, athlete perception, psychological readiness, sensorimotor control and sport/functional performance. Interestingly, ligament laxity and pain severity on palpation were not included in the list – these two factors are commonly used in clinical practice!

EDITOR’S NOTE: This was an appropriate methodology for investigating this topic, drawing on the expertise and experience of a global, multidisciplinary team of experts who are frequently involved in this decision-making process. In the absence of a sufficient amount of high-level evidence on which to base such recommendations, this paper certainly adds useful information to the literature on a topic that is so full of nuance and individual circumstances.

Study Methods:

A three-round Delphi approach was used to canvas a panel of experts. Items not reaching consensus after 3 rounds were left undecided.

Delphi Panel Participants:
Panelists included: health and/or exercise professionals proficient in English and working with top tier athletes (Division I, English Premier League, etc.), those working in field/court sports where acute lateral ankle sprain injuries are common and/or involved in RTS decisions for athletes. Individuals covered a wide variety of sports and geographic areas in order to draw panelists and expertise from worldwide practitioners and sporting activities.

Online Surveys:
Data collection consisted of online surveys with closed- and open-response questions. Panelists provided “Yes”, “No” or “Unsure/I don’t know” responses to the inclusion of an assessment item and provided reasons for their choices. Consensus was deemed to be reached if > 70% agreement (“Yes” or “No”) was achieved.

Panelists were given 4 weeks to return responses in each round. Panelists were informed of items that did not reach consensus and the proportion of respondents that responded “Yes”, “No” or “Unsure/I don’t know”. Following the second survey, consensus items were mapped to domains provisionally and then presented to the authorship team for consideration and agreement.

Data Analysis:
Level of agreement was calculated for each item. Content analysis was performed on themes from the open-response questions. Themes were categorized following discussion among 3 researchers (one female and two male physiotherapists).

Study Strengths / Weaknesses:

  • Diverse geographical, sporting and professional representation on the panel of experts.
  • Three-round Delphi survey process allowed for greater likelihood of consensus.
  • This was a clinically relevant study in an area lacking such a document.
  • No athletes were included as panelists, thus the study lacked the athletes’ perspective.
  • Items for assessment are recommended but no methods (i.e. tests) for assessing those items were suggested.
  • While many professions were represented, the majority of respondents were physiotherapists, potentially skewing the results.

Additional References:

  1. Delahunt E, Gribble PA. Structured clinical assessment: a brake to stop the ankle joint ’rolling’. Br J Sports Med 2018; 52: 1294.
  2. McCann R, Kosik K, Terada M, et al. Residual impairments and activity limitations at return to play from a lateral ankle sprain. International Journal of Athletic Therapy and Training 2018; 23: 83–8.
  3. Medina McKeon JM, Bush HM, Reed A, et al. Return-to-play probabilities following new versus recurrent ankle sprains in high school athletes. J Sci Med Sport 2014; 17: 23–8.
  4. Tassignon B, Verschueren J, Delahunt E, et al. Criteria-Based return to sport decision-making following lateral ankle sprain injury: a systematic review and narrative synthesis. Sports Med 2019; 49: 601–19.
  5. Wikstrom EA, Mueller C, Cain MS. Lack of consensus on Return-to-Sport Criteria following lateral ankle sprain: a systematic review of expert opinions. J Sport Rehabil 2019; 29: 231–7.
  6. Konradsen L, Bech L, Ehrenbjerg M, et al. Seven years follow-up after ankle inversion trauma. Scand J Med Sci Sports 2002; 12: 129–35.

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