Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework - an international multidisciplinary consensus

Key points

1. 01The PAASS framework covers 5 domains: Pain, Ankle impairments, Athlete perception, Sensorimotor control, and Sport/functional performance
2. 0216 assessment items reached >70% consensus for inclusion; 17 items were excluded by consensus
3. 03Athlete perception items (perceived ankle confidence, stability, and psychological readiness) were recognised as essential alongside physical tests
4. 04Structural imaging, ligamentous laxity, aerobic fitness, and general foot-ankle questionnaires were excluded by consensus
5. 05No specific tests or cut-off thresholds were defined - only the domains and items to assess

How it was conducted

Design

Three-round Delphi consensus survey

Participants

155 health and exercise professionals (78.7% male; mean age 41.3 years; mean clinical experience 16.1 years) from 19 countries, 6 professions, and 15 sports

Professions

Physiotherapists (52.9%), athletic trainers (18.1%), sports medicine physicians (17.4%), and others

Consensus threshold

A priori defined as >70% agree or disagree responses

Survey rounds

Round 1: 155 panellists; Round 2: 137 panellists (88.4%); Round 3: 119 panellists (76.8%)

Primary outcome

Consensus on assessment items and domains for return-to-sport decision-making after acute lateral ankle sprain

What they found

• 16 of 35 assessment items reached >70% consensus for inclusion in the return-to-sport decision
• 17 assessment items reached >70% consensus for exclusion
• 2 items did not reach consensus after 3 rounds: intra-articular swelling and static postural control/balance
• 99% of panellists agreed with the 5 proposed PAASS domains
• 98% of panellists agreed with the mapping of assessment items to the domains
• 198 of 250 invited individuals (79.2%) accepted the invitation and were sent the first survey link

Limitations

• No specific clinical tests or measurement cut-off thresholds were identified - the framework tells clinicians what to assess but not how
• Athletes were not included as panellists, so the athlete perspective on return-to-sport readiness is absent
• The panel was predominantly physiotherapists (52.9%), which may limit perspective breadth
• Sport-specific assessment items that may be relevant to individual sports may not have been identified due to the generic cross-sport approach

Why it matters

For patients

Athletes recovering from an ankle sprain should expect to be assessed on pain levels, ankle movement and strength, their own confidence and readiness, balance, and sport-specific functional tasks before being cleared to return to play - not just on how quickly swelling resolves.

For clinicians

The PAASS framework provides a structured, internationally validated checklist of 16 items across 5 domains to guide return-to-sport decisions; clinicians still need to select appropriate tests and thresholds for each item based on clinical judgment and context.

For readers

This consensus paper fills a recognised gap by establishing expert agreement on what to assess before return to sport after ankle sprain, but prospective validation studies are needed to confirm whether adherence to PAASS actually reduces reinjury rates.