Table 2

Protocol for the specific clinical diagnostic tests

	Protocol	Positive findings	Rationale
Dorsiflexion-external rotation test	Leg is stabilised in 90° knee flexion, the ankle in maximal dorsiflexion and an external rotation stress to the injured foot and ankle is applied25 35	Reproduction of anterolateral pain over the syndesmosis area	The test is thought to reproduce pain over the ankle syndesmosis ligaments by mimicking the commonly described mechanism of injury
Dorsiflexion lunge with compression test	Patient performs a lunge forward on the injured leg as far as possible. The lunge is repeated with manual compression provided by the examiner across the ankle syndesmosis25	Increase in the ankle range of motion or decreased pain when compression added	Manual compression is thought to increase stability at the distal tibiofibular joint and so reduces pain during dorsiflexion and/or enables an increase in the ankle range of motion25
Squeeze test	Patient sitting over the side of the bed. Compression of the fibula to the tibia above the midpoint of the calf using one or both hands25 35	Replication of pain in the area of the ankle syndesmosis25 35	Biomechanical analysis confirmed that the test causes separation at the distal tibiofibular joint.20 It is thought to increase tension in the remaining ankle syndesmosis ligament fibres, resulting in pain at the ankle29
Syndesmosis ligament palpation	Palpation AITFL/PITFL-transverse ligament/interosseous ligament/interosseous membrane35 Palpation of the deltoid ligament	Report of pain after pressing the ligament/membrane	The classic feature of ankle syndesmosis injury is thought to be palpatory tenderness over the anterior and posterior tibiofibular ligaments and between the tibia and fibula.35 Tenderness proximally along the interosseous membrane was indicative of a longer time to recovery10 and a more severe injury40

AITFL, anterior inferior tibiofibular ligament; PITFL, posterior inferior tibiofibular ligament.