Br J Sports Med 47:620-628 doi:10.1136/bjsports-2012-091702
  • Review

Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review

Editor's Choice
  1. Kathryn M Refshauge
  1. Faculty of Health Sciences, Discipline of Physiotherapy, University of Sydney, Lidcombe, New South Wales, Australia
  1. Correspondence to Amy D Sman, Cumberland Campus C42, University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia; asma6205{at}
  • Received 3 September 2012
  • Accepted 9 November 2012
  • Published Online First 6 December 2012


Objectives To determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury.

Design Systematic review.

Data sources An electronic database search was conducted (to 6 August 2012) of databases such as: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information.

Study selection Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies included participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard.

Results The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies investigated diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR−1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83–100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was found for other tests.

Conclusions This is the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. Few studies were identified and our findings show that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. Additional diagnostic tests, such as MRI, should be considered before making a final diagnosis of syndesmosis injury.

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