Acute clinical evaluation for syndesmosis injury has high diagnostic value

Abstract

Purpose To determine the diagnostic value of injury history, physical examination, six syndesmosis tests and overall clinical suspicion for syndesmosis injury. Methods All athletes (> 18 yrs) with an acute ankle injury presenting within 7 days post-injury were assessed for eligibility. Acute ankle injuries were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Standardized injury history was recorded, and physical examination was performed by an Orthopaedic Surgeon or Sports Medicine Physician. Overall clinical suspicion was documented prior to MRI. Multivariate logistic regression was used to determine the association between independent predictors and syndesmosis injury. Results Between September 2016 and July 2019, a total of 150 acute ankle injuries were included. The median time from injury to acute clinical evaluation was 2 days (IQR 2). Prior to clinical evaluation, the median patient reported Visual Analog Scale for pain was 8/10 (IQR 2). Syndesmosis injury was present in 26 acute ankle injuries. An eversion mechanism of injury had a positive LR 3.47 (CI 95% 1.55–7.77). The squeeze tests had a positive LR of 2.20 (CI 95% 1.29–3.77) and a negative LR of 0.68 (CI 95% 0.48–0.98). Overall clinical suspicion had a sensitivity of 73% (CI 95% 52–88) and negative predictive value of 89% (CI 95% 78–95). Multivariate regression analyses demonstrated significant association for eversion mechanism of injury (OR 4.99; CI 95% 1.56–16.01) and a positive squeeze test (OR 3.25; CI 95% 1.24–8.51). Conclusions In an acute clinical setting with patients reporting high levels of ankle pain, a negative overall clinical suspicion reduces the probability of syndesmosis injury. Eversion mechanism of injury and a positive squeeze test are associated with higher odds of syndesmosis injury. Level of evidence Level III.

Modified Stabilization Test to Diagnose Chronic Syndesmotic Injuries Based on Posture Control

“…MRI provides a more accurate diagnosis of acute syndesmotic injuries and can detect aberrant edema signals and ligament misalignment. 3 However, MRI is less accurate in patients with chronic injuries. 26 One study showed that CAI accompanied by chronic synovitis also resulted in localized strong signals in the syndesmotic region, which may compromise the λ sign’s ability to identify combined injuries in CAI patients.…”

Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings

“…A total of seven injury history variables were recorded during acute and delayed clinical evaluation using a previously described form [3]: (1) Injury [new/recurrent], (2) Occasion [game/training/non‐sports injury], (3) Contact [contact/non‐contact], (4) Mechanism of injury [inversion/eversion/external‐rotation/internal‐rotation], (5) Perceived presence of swelling [yes/no], (6) Perceived ankle instability [yes/no] and (7) Sensation of pain radiating up the leg [yes/no].…”

“…Nine standardized clinical tests were recorded during acute and delayed physical examination using a previously described standardized form [3]: (1) Presence of haematoma [yes/no], (2) Tenderness to palpation [lateral/medial/anterior/posterior], (3) Ability to walk normally [yes/no], (4) Ability to walk on toes [yes/no], Ability to walk on heels [yes/no], (5) Passive range of motion in dorsal flexion, plantar flexion, inversion and eversion [full/restricted/painful], (6) Presence of swelling [yes/no], (7) Swelling site [laterally/medially/anterior/posterior/syndesmosis], (8) anterior drawer test [Grades 0–2] and (9) talar tilt test [Grades 0–2]. The anterior drawer test and the talar tilt test were graded as Grade 0: normal; Grade 1: mild laxity; and Grade 2: moderate to gross laxity [5].…”

“…Variables obtained during injury history and physical examination were dichotomized as previously described [3]. Injury occasion [game/training/non‐sports injury] was dichotomized to [game/other].…”

“…A total of seven injury history variables were recorded during acute and delayed clinical evaluation using a previously described form [3]…”