Medical Engineering & Physics 22 (2000) 723731 www.elsevier.

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Technical note

A new ankle laxity tester and its use in the measurement of the effectiveness of taping
Trent Kirk a, Subrata Saha
a

a,*

, Larry S. Bowman

R.W. Christensen Biomechanics Laboratory, Department of Bioengineering, Clemson University, Clemson, SC 29634, USA b Blue Ridge Orthopaedics, Clemson, SC 29631, USA Received 20 July 2000; received in revised form 14 December 2000; accepted 19 January 2001

Abstract Damage to the lateral ligaments of the ankle, namely the anterior talobular (ATFL) and the calcaneobular (CFL) ligaments, is a frequently reported sports injury. The anterior drawer test is generally used to evaluate whether the ATFL has been torn, while the talar tilt test is used to determine if the CFL has been injured. Although these two manual tests are often utilized for quick diagnosis, they have been criticized because of their subjective nature and their inability to produce quantitative and reproducible results. A prototype ankle tester was manufactured that could measure the input force and torque, as well as the linear and angular deprivations for the anterior drawer test and the talar tilt test, respectively. This device was used to take readings on 10 human volunteers of a mean age of 21.6 years. This device was X-ray compatible, adjustable for varying patient sizes, relatively small, portable, and easy to operate. Testing was performed to determine how the stiffness of the ankle would respond to taping, and the effect of walking on the taped ankle. The overall mean anterior drawer was 5.93 mm and the mean talar tilt was 51.6 for bare ankles using a force of 111 N (25 lbs) for the drawer and a torque of 16 N m for the tilt. Taping provided an average increase in stiffness of 11.3%, demonstrating that it did provide increased stability. However, statistically signicant (P 0.05) decreases in the stiffness subsequent to taping were observed between the initially taped ankles and after 20 min of walking, when it was shown that talar tilt had increased. The prototype ankle tester produced repeatable measurements, and results show that the increase in stiffness due to taping did decrease after a short period of time. 2001 IPEM. Published by Elsevier Science Ltd. All rights reserved.

1. Introduction 1.1. Anatomy of the ankle Damage to the lateral ligaments of the ankle is the most commonly reported injury in sports activities. In a two-year study of almost 3000 high school athletes, 14% of all injuries were of the ankle [1]. This study also found a six per 100 rate of ankle injury per season, and 85% of these ankle injuries were sprains. These sprains were most common in basketball, football and womens cross-country racing. Injury usually occurs due to an inversion, internal rotational force, or combination of the two, applied to the foot when the ankle is in plantar
This paper was presented in part at the 19th Southern Bioengineering Conference, Virginia Tech, Blacksburg, VA, 1416 April 2000. * Corresponding author. Address for correspondence: 501 Rhodes Research Center, Clemson University, Clemson, SC 29634, USA. Tel.: +1-864-656-7603; fax: +1-864-656-4466. E-mail address: ssaha@clemson.edu (S. Saha).

exion [2]. Specically, the anterior talobular (ATFL), the calcaneobular (CFL) and, rarely, the posterior talobular ligaments (PTFL) are the lateral ligaments normally injured in an ankle sprain (Fig. 1). The ankle is like a hinge joint with the talus, tibia and bula making up the bony contributions. The subtalar joint is made up of the calcaneus and the talus; the calcaneus articulates on three surfaces of the talus and distally with the cuboid. Connecting the foot to the lower leg is the talus, which articulates with the tibia and bula by the ankle mortise. The lateral malleolus and the lateral portion of the mortise are made up by the distal bula. The distal tibia makes up the medial malleolus and mortise. The ATFL, PTFL and interosseous ligament connect the distal bula and tibia, which form the interior tibiobular joint [3]. The ATFL is approximately 20 mm long, 10 mm wide and 2 mm thick. The ATFL makes about a 75 angle with the oor from its bular insertion to talar insertion. The CFL is roughly 20 mm long, 5 mm wide and 3 mm thick; it crosses the talocrural and subtalar joints and is connected to the peroneal

1350-4533/01/$20.00 2001 IPEM. Published by Elsevier Science Ltd. All rights reserved. PII: S 1 3 5 0 - 4 5 3 3 ( 0 1 ) 0 0 0 0 8 - X

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Fig. 2.

Stress radiograph of anterior drawer test.

Fig. 1. Anatomy of the lateral ankle.

sheath. Also, the CFL lies inferior and posterior from the interior tip of the bula to the calcaneus. The approximate angle between the ATFL and CFL is 104 [4]. 1.2. Ankle sprains As mentioned previously, ankle sprains normally occur in inversion along with some plantar exion. Lateral ankle sprains are found to be more common than medial ankle sprains due to the fact that the lateral malleolus extends more distally than the medial malleolus, creating less bony obstruction to inversion than eversion [5], and the ATFL is much weaker than the detoid ligament [6]. There are generally three grades of ankle sprain. Grade I sprains are painful, but have no swelling or instability. An athlete can normally return to his or her sport in about one to two weeks. Grade II sprains involve partial tearing of the ATFL and CFL and produce swelling, pain and slight instability. There is usually an eight to 12 week period for recovery with athletes with these injuries. Lastly, Grade III sprains demonstrate gross instability, swelling and pain. These injuries may require surgical intervention [7]. 1.3. Ankle evaluation and injury There are several methods of evaluating the sprained ankle, but two of the most common methods are the anterior drawer and talar tilt tests. These tests can be difcult to perform in the case of recent injuries because of the patients pain. These tests require a comparison of the injured side versus the uninjured side to determine the variability of laxity exhibited by the patient. The anterior drawer test is generally performed by stabilizing the tibia with one hand and grasping the calcaneous with the other hand; anterior force is then applied to the cal-

caneous to displace the talus forward. When the laxity of the uninjured ankle is compared with that of the injured ankle, it is often possible to determine whether the ATFL has been torn or injured. Normally, when the anterior drawer and talar tilt tests are performed, stress radiographs of the ankle are taken. These are X-rays of the injured area while the ankle is being stressed, so that actual measurements can be made on the X-ray. As shown in Fig. 2, the anterior drawer measurement is the horizontal distance from the bula to the tip of the talar dome [4]. It has been reported that 45 mm displacement between the talus and tibia is most likely normal, while 810 mm would indicate an ATFL tear, and 1015 mm displacement would suggest a ATFL, PTFL and CFL tear [3]. The talar tilt test is performed by stabilizing the tibia and applying an inversion stress on the ankle. This test provides information as to whether the CFL has been torn when laxity is compared with that of the uninjured ankle [3]. The talar tilt angle is formed between the inferior articular surface of the tibia and the superior surface of the talus (Fig. 3) [4]. Stress radiographs for talar tilts can give accurate angular measurements for laxity comparison. A study by Cox and Hewes, where over 200 stress radiograph subjects were studied, proposed that a talar tilt greater than 5 indicated a high possibility that one or more of the lateral ligaments were torn [8]. One study found that a talar tilt of about 10 normally signi-

Fig. 3. Stress radiograph of talar tilt test.

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es an isolated ATFL tear, while a talar tilt greater than 20 usually indicates a tear of both the ATFL and CFL. For the range between 10 and 20, it is usually difcult to distinguish between a single and double ligament tear [9]. A few general guidelines should be followed when one is performing these two tests. First, the patient should be seated and have his or her leg in a comfortable position to relax the leg muscles. Also, the patients amount of pain should be limited, so that the patient is not resisting motion and thereby distorting the laxity measurements. A study by Becker et al. showed that anterior drawer tests without anesthesia on injured ankles showed almost no or less laxity than the uninjured ankle with a load of 15 kg [10]. Becker et al. went on to recommend that anterior drawer tests without anesthesia (peroneal block) be evaluated carefully and that an underevaluation rate of about 20% is possible [10]. Another guideline is related to the exion and ankle positioning during the testing. For the anterior drawer test, it is ideal to have the foot placed in approximately 15 plantar exion [11]. Positioning the foot in this manner allows the ATFL to be isolated and creates the largest neutral zone laxity restraint to the motion of the joint under small magnitudes of force at 10 and 20 plantar exion [12]. Also, for the talar tilt test, it is recommended that the ankle be placed in about 20 internal rotation but in a neutral position. This ensures that the CFL is isolated, but also that radiographs will be perpendicular to the mortise [11]. Most studies recommend testing the ankle at a variety of exion angles to determine the maximum amount of laxity [13], but the most important factor to practise would be consistency so that proper comparisons can be made. This leads to the nal requirement for both tests: consistent force and torque application from patient to patient [14]. This is difcult to achieve for the physician who performs the testing manually. However, with the use of a mechanical device or other means, the magnitude of force and torque applied for each test can be controlled so that meaningful comparisons can be made. 1.4. Objective Currently there is no device on the market that can quantitatively measure the anterior drawer and the talar tilt tests at the time of examination, as well as being stress-radiograph compatible. The goal of this project was to design a new ankle laxity tester to accurately and reproducibly make these measurements. The device was designed to have the capability of following all of the guidelines for the anterior drawer and the talar tilt tests that were mentioned previously. The device was used to determine the effects of moderate activity on the stiffness of taped ankles and bare ankles for human volunteers. We plan to use this device in future studies to offer

new evidence as to which method of ankle support is more effective in maintaining stability for prolonged periods.

2. Literature review 2.1. Arthrography Arthrography is a method that has been used to evaluate the lateral ankle ligament damage. Arthrography involves injecting a radio-opague medium into the ankle joint, then taking a radiograph. This procedure should be performed within 24 h of injury but no later than 5 days after injury. If the test is performed long after injury, the tear in the joint capsule may have closed with blood clots or brin tissue [15]. There is a relationship between the ATFL with the lateral aspect of the capsule; leakage normally demonstrates a tear of this ligament. Finding contrast medium in the peroneal tendon sheath signies a tear of the CFL [2]. If the dye remains in the peroneal sheath and does not extravasate, then the test result is negative [15]. Sometimes the ligament tear is so severe that there is insufcient pressure to force contrast into the sheath, while at other times the dye will not enter because of a small sheath disruption. This is why there are sometimes false negative evaluations of CFL injury [15]. Arthrography is recommended more for CFL damage than the talar tilt test [15], but contrast medium tests are rarely performed due to the few indications for primary operative repair of acute tears of the lateral ligaments [2]. One study of 192 patients with lateral ligament damage found that arthrography was more reliable compared with the anterior drawer test [16]. Another study by Black et al. discovered that arthrography was reliable when diagnosing ATFL tears, while detection of tears of the CFL was generally not as accurate [17]. 2.2. Magnetic resonance imaging (MRI) A reliable means of testing the ankle for ligament damage is through the use of magnetic resonance imaging (MRI). A study by Gaebler et al. found that, when compared with the talar tilt test, MRI was a very reliable means of determining the amount of stability of the ankle in lateral ligament injuries [18]. Even though MRI evaluation is expensive, the test is often accurate and reliable. MRIs can replace invasive arthrography, and can help a physician to determine if surgical intervention is necessary for highly competitive athletes with acute double ligament ruptures [3]. On the other hand, treatment is often based on the amount of instability of the ankle, and MRI has limited usefulness in the everyday assessment of injured ankle ligaments [2].

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2.3. Telos ankle stress apparatus The Telos ankle stress apparatus (Telos Corp., Fallston, MA) is a device currently on the market (Fig. 4). The Telos device is designed to perform stress radiographs through inversion, eversion and anterior drawer tests. The U-shaped device can be adjusted to varying leg sizes with the patient in the supine position. For the talar tilt testing, the patients leg is placed in 18 internal rotation with the foot in a neutral position. Pressure is applied 2 cm above the ankle joint and is increased slowly by turning a handle on a threaded shaft. Pressure is displayed in kiloponds (kgf) by using a force transducer until the pressure reaches 15 kp. Then an X-ray can be taken. The patient is placed on his or her side for the anterior drawer test. The foot is placed in a plantar exed position, and the pressure bar is again placed 2 cm above the ankle joint. Pressure is applied anteriorly until 15 kp is reached and a stress radiograph can be taken [11]. The device is quite useful because of its reproducibility of the force application and patient positioning. Because of the success of the Telos apparatus, the device has been used in numerous ankle studies [14,16,1922]. However, the device is not equipped to take linear and angular measurements.

torque wrench for applying known torque for talar tilt measurement; dial gage for measuring the changes in linear displacement; gage for measuring angular changes in the talar tilt test; allow the foot to be placed in neutral and 20 internal rotation for talar tilt test; allow foot to be placed in 15 plantar exion for anterior drawer test; allow the device to be applicable to persons of all shapes and sizes with adjustable foot width; bearing blocks for smooth movement and transition between the tests; allow the device to be used in any examiner setting from the sitting position; provide quick transition between anterior drawer and talar tilt tests; and limit the size and weight of the device to ensure portability. AutoCAD Version 14 software was used to create the initial prototype drawings. Once the drawings were made, a wood model was fabricated to determine if any major design changes and improvements needed to be made. 3.2. Testing Ten subjects with normal ankles volunteered for the study. The subjects had no prior existence of ankle injury, and were within the age range 2023 years. The ankles were tested at a set force and torque to maintain consistent input. To determine the amount of pressure applied, different values of force and torque were used on the control subjects until no signicant differences were noticed when either was increased. Pain was also taken into account; the amount of force and torque were increased until almost being uncomfortable, so that the maximum amount of pressure could be reached. The value of pressure for the air compressor was determined to be 6.9 kPa (25 psi) for the anterior drawer test. Similarly, the maximum torque for the talar tilt test was found to be 16 N m. A load cell was then used to determine the amount of actual force applied for the anterior drawer test, and this was found to be approximately 111 N (25 lbs). For each subject, the ankle laxity was measured for both the anterior drawer test and the talar tilt test. Both ankles were tested so that the stiffness of each ankle could be compared. The ankle was placed in 15 plantar exion for anterior drawer, and in the neutral position for talar tilt, while the patient was seated with the knee at 90 exion. First, the initial laxity was measured before the taping began. The taping method used was the basket weave

3. Methods 3.1. Prototype design The following design criteria were developed for the proposed ankle laxity tester: Lexan (polycarbonate) was to be used for the foot base assembly to allow for X-rays; aluminum was to be used for the base, and some other parts of the device; use of an air compressor and air cylinder for repeatable force application;

Fig. 4.

Telos stress testing device.

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[23], which was performed by an experienced certied physical therapist. Standard athletic tape and pre-wrap were used. One ankle was taped and anterior drawer and talar tilt measurements were taken, and then the subject participated in walking on a treadmill at 0.45 m/s (3.7 mph) and 0% grade. After 10 min, the anterior drawer and talar tilt were again measured for both the ankles. Then, the subject walked for another 10 min, and the measurements were repeated. Finally, the tape was removed, and the anterior drawer and talar tilt measurements were taken again. All measurements were conducted by the same individual to maintain consistency. The testing plan was approved by the Institutional Review Board (IRB) of Clemson University for human testing. All statistical calculations were performed using SAS Statistical software.

Fig. 6.

Foot placement for anterior drawer.

4. Results 4.1. Prototype Subsequent to fabrication of the wooden model an actual prototype was manufactured using aluminum and Lexan parts. The nal prototype with main design components labeled is shown in Fig. 5. Figs. 6 and 7 show how the foot is placed for the drawer and tilt tests, and Figs. 8 and 9 show a closer view of the mechanical

components for the anterior drawer (air compressor, etc.) and the talar tilt (torque wrench) tests, respectively. Since AutoCAD drawings and pictures cannot always provide insight into how the tests are actually performed, a owchart of both tests with procedures is given in Fig. 10. 4.2. Testing results Ten volunteers were tested to determine: (1) the repeatability of the laxity measurements when the device was used and (2) the impact of activity on the effective-

Fig. 5.

Final prototype.

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Fig. 7.

Foot placement for talar tilt.

Fig. 8.

Mechanical components for drawer.

ness of taping in maintaining ankle stability. For the taped ankle, averages for each stage and measurements of each individual can be found in Table 1. Overall means with 95% condence intervals for the left and the right ankles combined for initial and nal values of testing for anterior drawer were 5.97 mm (1.53 mm), (5.566.38 mm), and for talar tilt were 51.6 (3.9), (50.552.6). A dependent single-tailed t-test was performed for both the anterior drawer and the talar tilt by rst averaging the initial and nal measurements. Both tests showed no signicant statistical difference between the left- and right-side measurements (P 0.05). The average values of the anterior drawer and the talar tilt for the right side were 6.01 mm (1.57 mm) and 51.6 (4.1), and for the left side, 5.93 mm (1.53 mm) and 51.6 (3.9), respectively. Dependent t-tests were also performed to compare the difference between values before and after taping, and between taping and after 20 min of activity. The taping provided an increased stiffness of 22.9% for the anterior drawer and 11.3% for the talar tilt, and these increases were statistically signicant (P=0.0003 and P=0.0001). After 20 min of walking there were decreases of 22% and 3.7% in stiffness for the taping compared with initially taped for the anterior drawer and the talar tilt, and these decreases were statistically signicant (P=0.0348 and P=0.0029). Analysis of variance (ANOVA) was also performed for both laxity tests to examine more closely the effect of taping on the ankle. Using a repeated measures design, more sensitive comparisons can be made. ANOVA results showed that at least one of the means was different for both the anterior drawer test and talar tilt test (P=0.0001) when comparing stiffness before taping, after taping and after activity. A general linear models table was also prepared to show individual comparisons between stiffness for the taped ankle to determine which means were different. For talar tilt, these results showed that the stiffness of the ankle increased between bare ankles and after taping (P=0.0001), and there was a signicant increase in talar tilt for the taped ankle after 20 min of activity (P=0.0238). For the anterior drawer, there was a statistical difference in stiffness for anterior drawer after taping of the bare ankle (P=0.0009). There was also a signicant decrease in the stability of the taped ankle after 20 min of activity (P=0.0001).

5. Discussion This device is different from other commercially available ankle testing devices because it is capable of taking quantitative measurements at the time of examination, as well as being stress-radiograph compatible. Results from this study may not fully agree with other

Fig. 9. Mechanical components for tilt.

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Fig. 10. Flowchart for anterior drawer and talar tilt tests.

Table 1 Mean values for anterior drawer and talar tilt for the taped ankle for 10 subjects (N=10) Initial After tape After 20 min

Anterior drawer (taped ankle, mm) Mean 5.37 4.16 Standard 1.15 1.29 deviation Talar tilt (taped ankle, ) Mean 53 46 Standard 4.6 2.6 deviation

4.92 1.33 48 2.3

ankle testing studies because different values of force and torque were used for each test. Also, a majority of other the studies were based only on stress radiographs. Differences in these results from our study may also be attributed to positioning of the foot for laxity testing and the differing amounts of manual force applied. The second objective of our study was to determine the effectiveness of ankle taping in maintaining stability after activity. Talar tilt is the test of most importance since the ankle sprain often occurs in severe inversion.

Therefore, we shall mainly focus on the measurement of talar tilt. Results from this study showed a signicant difference between the stiffness of untaped and taped ankles, and between initially taped and after 20 min of activity. There were only slight increases in inversion after activity (3.7% after 20 min). The fact that inversion increased after activity agrees with the results of several studies [2426]. Results of our taping study agreed with similar investigations by other authors who also showed that the effectiveness of taping decreases after vigorous activity for a prolonged period [24,26]. It is expected that the measured value of talar tilt will depend on the amount of torque used for each study. For example, the study by Fumich et al. did not use a constant force or torque for their testing [24]. They mentioned that, the athlete was asked to exert maximal effort for the motion to be recorded. The study by Paris et al. mentioned using a 9 kg mass to produce the torque, but did not mention the actual value of the torque applied [25]. The study by Greene and Hillman used a lesser torque value but obtained higher values of inversion [26]. This raises the question as to what value of torque should be used for proper ankle testing. Paris et al. even went on to say that the 9 kg mass used in their study

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was most likely much less than the actual pressures encountered in a normal ankle sprain [25]. It is possible that the higher torque used (16 N m) for this study was much closer to the forces imparted during spraining. This, however, does not explain the differences in the inversion values and the decreases in tape stiffness when compared with this study. Again, foot placement is also very important when comparing inversion results. Also, the taping method is an extremely important variable, which is likely to have caused large differences in the measured values of talar tilt. This ankle tester offers several advantages clinically and experimentally. This device can quantify normally subjective anterior drawer and talar tilt tests. By quantifying the drawer and tilt, the device can be used as a screening device for athletes to determine if there is excessive laxity present so that preventive measures can be taken. Also, when considering clinical applications, laxity measurements before surgical intervention and after surgery would be benecial to determine if improvements were made following reconstruction. The device also permits the examiner to avoid excessive radiation exposure when taking stress radiographs. Finally, the ankle tester would be helpful for further ankle studies when making multiple comparisons for various treatment modalities. One of the limitations of this study was that the amount of pressure applied to the Velcro straps when tightening them appeared to play an important role in how much displacement was recorded. Perhaps this can be avoided by using a scale under tension to tighten the Velcro straps to ensure consistent strapping [27].

References
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6. Conclusion Ankle sprains are such a common occurrence that there is a need for a new device to test for ankle sprains. The purpose of this study was to develop a new device to perform the anterior drawer and talar tilt tests. The device was to be able to take quantitative measurements at the time of examination and was stress-radiograph compatible. This made the device valuable for clinical and experimental applications. The design proved to be successful after the nal prototype and testing was completed. This device also allowed us to test the level of support provided by taping the ankles after walking. Results showed statistically signicant decreases in stiffness when the talar tilt was measured immediately after taping versus after 20 min of activity. This is most likely due to the loosening of the tape, but may also be partly due to changes in the soft tissues. Our results suggest that taping may not be a reliable means of ankle support, which has also been reported by other studies.

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[25] Paris DL, Vardaxis V, Kokkaliaris J. Ankle ranges of motion during extended activity periods while taped and braced. J Athl Train 1995;30:2238. [26] Greene TA, Hillman SK. Comparison of support provided by a semirigid orthosis and adhesive ankle taping before, during, and after exercise. Am J Sports Med 1990;18:498506.

[27] Shapiro MS, Kabo JM, Mitchell PW et al. Ankle sprain prophylaxis: an analysis of the stabilizing effects of braces and tape. Am J Sports Med 1994;22:7882.