Anterior Drawer Test of the Ankle for Instability

The anterior drawer test of the ankle is to test for instability in the ankle by looking at the laxity of the anterior talocrual joint.This test is used very often with people after an acute ankle sprain or even someone with chronic ankle instability.

I could not find any exact data on when this test was developed but based upon an article in 1975 (Carl-Axel Cedell (1975) Ankle Lesions, Acta Orthopaedica Scandinavica, 46:3, 425-445, DOI: 10.1080/17453682.1975.12288954), there is discussion about the history of understanding that the ATFL is important in ankle stability and that the anterior drawer test was a good test to identify ankle instability. There is mention from a study in 1952 that 20 degrees of plantar flexion allowed more anterior translation of the talus, so I could see how the testing came about.

How to perform it
-Have the patient supine with their foot/lower leg off the table
-Start with the non-affected side
-Make sure the person is relaxed
-Stabilize the distal tibia with one hand and the other hand holds the calcaneus (heel)
-Plantar flex their foot to around 20 degrees
-Pull forward with the hand around the calcaneus
-Look and feel for the amount of movement of the ankle
-Compare to the affected side

When it comes to the evidence for reliability, validity, sensitivity and specificity. It does seem to be a tad bit mixed. Beynon et al (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.) did find that evidence was limited for the reliability and validity but it did have a high specificity (if there wasn’t laxity the ankle was stable). Croy et al (Croy, T., Koppenhaver, S., Saliba, S., & Hertel, J. (2013). Anterior talocrural joint laxity: diagnostic accuracy of the anterior drawer test of the ankle. Journal of orthopaedic & sports physical therapy, 43(12), 911-919.) did find that finding the amount of mobility limited but says that it could be beneficial when comparing side to side.

There could also be an issue with determining the amount of motion based upon experience. Murahashi et al (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. ) did find more of a difference between junior examiners and seniors with the more traditional assessment set up. But when there was a modification of having the leg elevated and supported, there was less of a difference, so this may be useful with a mixed group of clinicians.

One thing the overall evidence says, is to utilize this test as apart of your history taking along with things like palpation of the ATFL, additional tests and a good assessment can be much more beneficial overall in diagnosing instability in the ankle

What do you think of this test? Do you utilize it? How beneficial do you find it?