Delayed physical examination at day 4–5 (van Dijk)

How it is done

Examine the ankle again 4–5 days after the injury (5 days in the original study), once the early pain and swelling have settled, rather than relying on an examination in the first 48 hours. Look for bruising (haematoma discolouration), check for pain on pressing over the anterior talofibular ligament (at the front of the outer ankle), and do the anterior drawer test. Positive: a positive anterior drawer test together with bruising and pain on pressing over the anterior talofibular ligament (the original study based its diagnosis on these three findings).

What the studies found

Lateral ankle ligament rupture after an inversion injury. van Dijk et al. 1996 enrolled 160 consecutive patients aged 18–40 and examined them within 2 days and again at 5 days. The delayed examination was the most accurate method compared (the others were arthrography, stress X-rays and ultrasound): sensitivity 96%, specificity 84%. Examiners with limited experience were more accurate at 5 days than within 48 hours. Patients were operated on if the delayed examination or the arthrogram was positive (135 operated, 122 ruptures found); those not operated on were judged by follow-up after at least 6 months. Because the test itself helped decide who had surgery, sensitivity is likely flattered (verification bias). The same patients are reported in two 1996 papers. The Dutch ankle sprain guideline (Vuurberg 2018) states that ligament damage is assessed most reliably by delayed physical examination at 4–5 days.

What the numbers mean

• Positive result: see the caution above before relying on this result.
• Negative result: see the caution above before relying on this result.

The ladder: what a result does to your estimate

Calculated from the likelihood ratios above. Read the caution above before relying on these. For any other starting estimate, use the probability calculator.

Work out what a result means for your patient: probability calculator

Source

van Dijk CN, Mol BW, Lim LS, Marti RK, Bossuyt PM. Diagnosis of ligament rupture of the ankle joint. Physical examination, arthrography, stress radiography and sonography compared in 160 patients after inversion trauma. Acta Orthop Scand. 1996;67(6):566–570. Journal article (DOI) · single study
Also cited: van Dijk CN, Lim LS, Bossuyt PM, Marti RK. Physical examination is sufficient for the diagnosis of sprained ankles. J Bone Joint Surg Br. 1996;78(6):958–962. Journal article (DOI)
Also cited: Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956. Journal article

Website-only test: added to the library on 9 October 2026 and not part of Rule It In, Rule It Out. Figures independently checked against the sources cited above; any note above says where only the abstract could be checked. If a newer or better study changes them, this page will be updated.