Br J Sports Med 49:323-329 doi:10.1136/bjsports-2013-092787
  • Original article

Diagnostic accuracy of clinical tests for ankle syndesmosis injury

  1. Kathryn M Refshauge1
  1. 1Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia
  2. 2Sports Clinic, University of Sydney, Camperdown, New South Wales, Australia
  3. 3Castlereagh Imaging, St Leonards, New South Wales, Australia
  1. Correspondence to Amy D Sman, Faculty of Health Sciences, University of Sydney, Cumberland Campus C42, PO Box 170, Lidcombe, NSW 1825, Australia; amy.sman{at}
  • Accepted 19 October 2013
  • Published Online First 19 November 2013


Objective Our aim was to investigate the diagnostic accuracy of the clinical presentation of ankle syndesmosis injury and four common clinical diagnostic tests.

Design Cross-sectional diagnostic accuracy study.

Setting 9 clinics in two Australian cities.

Participants 87 participants (78% male) with an ankle sprain injury presenting to participating clinics within 2 weeks of injury were enrolled.

Methods Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were compared with MRI results (read by a blinded radiologist) as a reference standard. Tests were evaluated using diagnostic accuracy, sensitivity, specificity and likelihood ratios (LRs). A backwards stepwise Cox regression model determined the combined value of the clinical tests.

Results The clinical presentation of an inability to perform a single leg hop had the highest sensitivity (89%) with a negative LR of 0.37 (95% CI 0.13 to 1.03). Specificity was highest for pain out of proportion to the apparent injury (79%) with a positive LR of 3.05(95% CI 1.68 to 5.55). Of the clinical tests, the squeeze test had the highest specificity (88%) with a positive LR of 2.15 (95% CI 0.86 to 5.39). Syndesmosis ligament tenderness (92%) and the dorsiflexion-external rotation stress test (71%) had the highest sensitivity values and negative LR of 0.28 (95% CI 0.09 to 0.89) and 0.46 (95% CI 0.27 to 0.79), respectively. Syndesmosis injury was four times more likely to be present with positive syndesmosis ligament tenderness (OR 4.04, p=0.048) or a positive dorsiflexion/external rotation stress test (OR 3.9, p=0.004).

Conclusions Although no single test is sufficiently accurate for diagnosis, we recommend a combination of sensitive and specific signs, symptoms and tests to confirm ankle syndesmosis involvement. An inability to hop, syndesmosis ligament tenderness and the dorsiflexion-external rotation stress test (sensitive) may be combined with pain out of proportion to injury and the squeeze test (specific).

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