Accuracy of Clinical Tests for Ankle Syndesmosis Injury

Sman AD, Hiller CE, Rae K, Linklater
J, Black DB, Nicholson LL, Burns J, & Refshauge K. British Journal of Sports Medicine. Published Online First November
19, 2013 doi:10.1136/bjsports-2013-092787

Take Home Message:  There is no one perfect test for high ankle
sprain evaluation.  However, there are a
few things that you can assess to help rule in or out the diagnosis.   

High ankle sprain injuries can be
difficult to differentiate from a lateral ankle sprain or an anterior tibialis
strain when a person suffers an ankle injury; however, it is important to
identify a high ankle sprain early to appropriately manage.  If we could identify a battery of accurate special
tests for diagnosing high ankle sprains (like the Ottawa ankle rules for
fractures), this may help clinicians improve our patients’ outcomes. The authors
compared commonly-used assessments to diagnose high ankle sprains (e.g., syndesmotic
point tenderness, dorsiflexion with external rotation test, dorsiflexion lunge
test with compression, the squeeze test) with magnetic resonance imaging (MRI)
– the gold standard for diagnosis.  Thirteen
clinicians evaluated a total of 87 participants (78% male, average age 25 years)
who had an acute ankle injury and an MRI within 2 weeks of the injury. Thirty-eight
participants had a high ankle sprain based on MRI. The clinicians assessed the
patients with the 4 previously mentioned clinical diagnostic tests and 7
clinical presentations (e.g., pain/dysfunction out of proportion to the injury,
pain felt in the leg and/or knee, single leg hop test). Diagnostic accuracy of
the 4 clinical diagnostic tests ranged from 53.7 (dorsiflexion with
compression) to 66.7% (dorsiflexion with external rotation).  Sensitivity (ability to yield positive test
result in a group that has the condition) ranged from 26 to 92% with the
highest values being with syndesmotic point tenderness (92%) and the
dorsiflexion with external rotation test (71%). 
Specificity (ability to yield negative test result in a group that does
not have the condition) ranged from 29 to 88% with the highest values being
found with the squeeze test (88%) and the dorsiflexion with external rotation
test (63%).  Diagnostic accuracy values
were also calculated on a variety of clinical presentation symptoms, with the
highest sensitivity being found for inability to perform a single leg hop,
inability to walk (both 89%) and mechanism of injury (83%).  The authors found that highest specificity
with pain out of proportion (79%) and pain felt in lower leg or knee during
injury (70%).     

Clinicians should not rely on a single
test to diagnose high ankle sprains, but can use this information to help
determine which tests may be best in interpreting a clinical case.  The authors suggested that clinicians should
combine some sensitive and specific assessments when we evaluate the ankle:
1) inability to
hop, 2) inability to walk, 3) tenderness of the syndesmosis ligament, 3) dorsiflexion-external
rotation stress test, 4) pain out of proportion to the apparent injury, and 5)
the squeeze test. Unfortunately, these five assessments may not always lead to
the same result, which means that clinicians need to use their experience to
make the final decision.   Hopefully
clinicians can use this information to more accurately diagnose and
appropriately treat high ankle sprains. 
Oftentimes, lingering pain is a result of an undiagnosed high ankle
sprain.  As clinicians, we need to conduct
a thorough clinical examination, and be informed as to the value of certain
findings for ruling things in or out.

Questions for Discussion:  Are
there any other tests that you think may be valuable in evaluating high ankle
sprains?  Are there any other clinical
presentations that you have found to be helpful in diagnosing high ankle
by: Nicole Cattano
by: Jeffrey Driban

Related Posts:

Sman AD, Hiller CE, Rae K, Linklater J, Black DA, Nicholson LL, Burns J, & Refshauge KM (2013). Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine PMID: 24255766