Anterior Drawer Test av Ankelen

The Anterior Drawer Test of the ankle is a clinical examination used to assess mechanical instability or hypermobility in the sagittal plane of the talocrural joint (ankle joint). It primarily identifies injury to stabilizing structures, especially the anterior talofibular ligament (ATFL), which is the most commonly injured ligament in lateral ankle sprains.

Technique

Patient position

• Supine position with the ankle in ~20° plantarflexion.

• The heel rests in the examiner’s hand, supported against a firm surface to stabilize the calcaneus.

Examiner position

• The examiner stabilizes the tibia and fibula with one hand.

• With the other hand, the calcaneus is drawn anteriorly relative to the tibia.

Observations

• The amount of anterior translation at the lateral ankle.

• The quality of the end-feel: firm ligamentous vs. soft/elastic.

➡ A translation greater than 1 cm compared to the uninjured side, along with a softer end-feel, strongly suggests a partial or complete ATFL rupture.

Grading (0–3 scale)¹:

• 0 = No laxity

• 1 = Humeral head (calcaneus) reaches the glenoid rim equivalent (mild laxity)

• 2 = Clear anterior translation, spontaneous reduction

• 3 = Marked laxity, no spontaneous reduction

Diagnostic Accuracy

Study/Method	Sensitivity	Specificity	Notes
Clinical exam vs. arthrogram²	86%	74%	Strong diagnostic value for inversion ankle injuries
Ultrasound (Croy et al.)³	0.74–0.83	0.38–0.40	Accuracy varied depending on reference standard
Systematic review⁵	Variable	High	Best used with complementary tests (anterolateral drawer, reverse drawer, squeeze test)

Practical Considerations

• Experience level: Less experienced clinicians often detect less translation compared to experts.

• Modified technique: Murahashi et al.⁶ suggested placing the patient’s tibia on an elevated surface (90° hip flexion) to improve interrater reliability.

• Clinical use: Best applied when comparing with the contralateral ankle to detect side-to-side differences in suspected mechanical instability⁴.

Clinical Significance

• The test remains a cornerstone in evaluating lateral ankle sprains, particularly ATFL injury.

• A positive test with significant translation and soft end-feel is strongly indicative of ATFL rupture.

• Limitations: While highly specific, its sensitivity may vary. It should be used in combination with other stress tests and imaging (ultrasound, MRI) for comprehensive evaluation.

References

1. Clinically Relevant Technologies, http://www.youtube.com/watch?v=Z4rvAT3a7OY; Accessed May 2011

2. van Dijk CN, Lim LSL, Bossuyt PMM, Marti RK. Physical Examination is sufficient for the diagnosis of sprained ankles. J Bone Joint Surg. 1996; 78-B: 958-962.

3.  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): 911-9.

4. Wenning M, Gehring D, Lange T, Fuerst-Meroth D, Streicher P, Schmal H, Gollhofer A. Clinical evaluation of manual stress testing, stress ultrasound and 3D stress MRI in chronic mechanical ankle instability. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-3.

5. Beynon, A., Le May, S., & Theroux, J. (2022). Reliability and validity of physical examination tests for the assessment of ankle instability. Chiropractic & manual therapies, 30(1), 58

6. Murahashi, Y., Teramoto, A., Takahashi, K., Okada, Y., Okimura, S., Imamura, R., ... & Yamashita, T. (2023). High reproducibility of a novel supported anterior drawer test for diagnosing ankle instability. BMC Musculoskeletal Disorders, 24(1), 148.