Anterior Drawer Test for the Ankle: Assessing the Anterior Talofibular Ligament

The anterior talofibular ligament (ATFL) is, by far, the most commonly injured ligament in classic ankle sprains (the typical inversion sprain, "I rolled my ankle"). The anterior drawer test is the go-to test for assessing its integrity after an injury or when chronic instability is suspected.

What does this test measure?

It assesses the anterior translation of the talus relative to the tibia, which under normal conditions is limited by the ATFL. If this ligament is torn or very lax, the talus can shift forward excessively when an anterior traction force is applied to the foot.

What you'll need

• Nothing essential

Step-by-step protocol

1. Position the subject sitting or lying down, with the knee flexed (to relax the gastrocnemius/soleus) and the ankle in slight plantarflexion (10-20°), the position in which the ATFL is most "aligned" to detect displacement
2. With one hand, stabilize the distal tibia from the front
3. With the other hand, grasp the calcaneus/heel and apply anterior traction, as if trying to "pull" the foot toward you
4. Observe and palpate the degree of forward displacement of the talus, and the quality of the "end-point" (firm vs. soft/absent)
5. Always compare with the contralateral side

Common mistakes

• Not adequately relaxing the calf muscles (a tense gastrocnemius/soleus limits movement and can produce a false negative)
• Performing the test in the very acute phase of a sprain, when pain and protective spasm can mask the result
• Not comparing with the healthy side

How to interpret the result

Result	Interpretation
Negative	Minimal displacement, firm end-point, symmetrical with the healthy side — ATFL likely intact
Mild-to-moderate positive	Increased displacement compared to the healthy side, somewhat softer end-point — suggests partial injury or laxity of the ATFL
Marked positive	Clearly increased displacement, soft or absent end-point — suggests complete rupture of the ATFL

In the acute phase (the first 48-72 hours after a sprain), this test can be hard to interpret due to pain and swelling. If the result is clearly positive, or if instability persists weeks after what seemed like a "normal" sprain, it's worth referring for imaging and considering a stability-focused rehab program.

How it relates to other tests

The anterior drawer is the centerpiece of lateral ankle stability assessment, along with:

• Talar tilt test — assesses the calcaneofibular ligament, complementary to the ATFL
• Ankle motor control test (modified SEBT) — to assess whether any mechanical laxity translates into functional instability during movement

Track and follow up

After an ankle sprain, the risk of re-injury is high if the athlete returns to activity without having regained sufficient stability and motor control. With Movalytics you can record the anterior drawer result at the initial post-injury assessment and repeat it throughout the rehab process, combining it with functional tests to decide when the athlete is truly ready to return to activity with changes of direction.

FAQ

Does the anterior drawer test hurt? It can cause mild discomfort if the ligament is irritated, but it shouldn't be very painful if performed with a relaxed leg and progressively. Can this test be done right after an acute sprain? It can, but pain and muscle spasm in the first 48-72 hours can mask the true degree of laxity, so the assessment is sometimes repeated a few days later. Does laxity detected on this test mean surgery is needed? Not necessarily. Most cases of mild-to-moderate mechanical instability respond well to rehabilitation (strength, proprioception, motor control). Surgery is reserved for cases of severe instability that don't respond to conservative treatment.