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Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus
  1. Michelle D Smith1,
  2. Bill Vicenzino1,
  3. Roald Bahr2,3,
  4. Thomas Bandholm4,5,
  5. Rosalyn Cooke6,
  6. Luciana De Michelis Mendonça7,8,
  7. François Fourchet9,10,
  8. Philip Glasgow11,12,
  9. Phillip A Gribble13,
  10. Lee Herrington6,14,
  11. Claire E Hiller15,
  12. Sae Yong Lee16,17,
  13. Andrea Macaluso18,19,
  14. Romain Meeusen20,
  15. Oluwatoyosi B A Owoeye21,22,
  16. Duncan Reid23,
  17. Bruno Tassignon20,
  18. Masafumi Terada24,
  19. Kristian Thorborg25,26,
  20. Evert Verhagen27,
  21. Jo Verschueren20,
  22. Dan Wang28,
  23. Rod Whiteley3,29,
  24. Erik A Wikstrom30,
  25. Eamonn Delahunt31,32
  1. 1School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
  2. 2Oslo Sports Trauma Research Centre, Norwegian School of Sports Sciences, Oslo, Norway
  3. 3Aspetar, Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  4. 4Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy and Department of Clinical Research, Copenhagen University Hospital, Copenhagen, Denmark
  5. 5Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
  6. 6English Institute of Sport, Manchester Institute for Health and Performance, Manchester, UK
  7. 7Physical Therapy Department, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Minas Gerais, Brazil
  8. 8Graduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Minas Gerais, Brazil
  9. 9Physiotherapy Department, Hôpital de La Tour, Meyrin, Switzerland
  10. 10Laboratoire Interuniversitaire de Biologie de la Motricité, UJM-Saint-Etienne, University of Lyon, Lyon, France
  11. 11High Performance Unit, Irish Rugby Football Union, Dublin, Ireland
  12. 12School of Sport, Ulster University, Jordanstown, UK
  13. 13Department of Athletic Training and Clinical Nutrition, University of Kentucky, Lexington, Kentucky, USA
  14. 14Centre for Health, Sport and Rehabilitation Sciences, University of Salford, Salford, UK
  15. 15Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
  16. 16Department of Physical Education, Yonsei University, Seoul, South Korea
  17. 17Yonsei Institute of Sports Science and Exercise Medicine, Yonsei University, Seoul, South Korea
  18. 18Department of Movement, Human and Health Sciences, University of Rome 'Foro Italico', Roma, Italy
  19. 19Villa Stuart Sport Clinic, FIFA Medical Centre of Excellence, Roma, Italy
  20. 20Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
  21. 21Department of Physical Therapy and Athletic Training, Doisy College of Health Sciences, Saint Louis University, Saint Louis, Missouri, USA
  22. 22Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  23. 23Faculty of Health and Environmental Sciences, School of Clinical Sciences, AUT University, Auckland, New Zealand
  24. 24College of Sport and Health Science, Ritsumeikan University, Kusatsu, Shiga, Japan
  25. 25Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Amager-Hvidovre University Hospital, Copenhagen, Denmark
  26. 26Physical Medicine Rehabilitation Research-Copenhagen (PMR-C), Amager-Hvidovre University Hospital, Copenhagen, Denmark
  27. 27Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam UMC, VUmc site, Amsterdam, Netherlands
  28. 28School of Physical Education and Sport Training, Shanghai University of Sport, Shanghai, China
  29. 29School of Human Movement & Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
  30. 30Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  31. 31School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
  32. 32Institute for Sport and Health, University College Dublin, Dublin, Ireland
  1. Correspondence to Dr Michelle D Smith, The University of Queensland, Brisbane, QLD 4072, Australia; m.smith5{at}


Background Despite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap.

Methods We used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses.

Results Sixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement—PAASS: Pain (during sport participation and over the last 24 hours), Ankle impairments (range of motion; muscle strength, endurance and power), Athlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), Sensorimotor control (proprioception; dynamic postural control/balance), Sport/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session).

Conclusion Expert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury.

Trial registration number ACTRN12619000522112.

  • consensus
  • ankle
  • athletes
  • sport
  • sprains and strains

Data availability statement

Data are available upon reasonable request.

Statistics from

Data availability statement

Data are available upon reasonable request.

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  • Twitter @MichelleD_Smith, @Bill_Vicenzino, @RoaldBahr, @TBandholm, @luludemichelis, @gribblepa, @AndreaMacaluso3, @owoeye_oba, @TassignonBruno, @KThorborg, @Evertverhagen, @RodWhiteley, @ea_wikstrom, @EamonnDelahunt

  • Contributors MDS, BV and ED were responsible for the conception of the study, drafting of the surveys for data collection and qualitative analysis of free text data. All authors were responsible for recruitment and communication with participants (ie, panellists), reviewing surveys and qualitative analysis, and contributing to mapping of RTS outcomes to domains. Data analysis was undertaken by MDS, BV and ED and presented to the authorship team for feedback. All authors contributed to the interpretation of findings and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests KT, TB, OBAO, ED and EV are on the BJSM Editorial Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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