Clinical diagnosis of syndesmotic ankle instability: Evaluation of stress tests behind the curtains

Abstract

We studied the feasibility of clinical tests in the diagnosis of syndesmotic injury of the ankle. 9 investigators examined 12 persons twice, including 2 patients with an arthroscopically-confirmed syndesmotic injury. They sat behind a curtain that exposed only the lower legs. We found a statistically significant relation between the final arthroscopic diagnosis and the squeeze, fibula translation, Cotton, and external rotation tests as well as for limited dorsal flexion. None of the syndesmotic tests was uniformly positive in chronic syndesmotic injury. The external rotation test had the fewest false-positive results, the fibula translation test the most. The external rotation test had the smallest inter-observer variance. The physical diagnosis was missed in one fifth of all examinations. When in accordance with medical history and physical examination, positive stress tests should raise a high index of suspicion of syndesmotic instability. The final diagnosis of such instability, however, should be made by additional diagnostic imaging and/or arthroscopy.

National Athletic Trainers' Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes

“…Arthrography and tenography are less accurate than MRI and CT, especially when performed 48 hours after lateral ligamentous injury. 18,19 Evidence Category: B 13. After acute trauma, MRI has high sensitivity, specificity, and accuracy to determine the level of injury to the ankle syndesmotic ligaments.…”

“…Several special tests have been advocated for identifying high ankle sprains, including the squeeze test, Cotton test, external-rotation test, and fibular translation test; however, the diagnostic accuracy of these tests has received little attention. 18 Similarly, the diagnostic accuracy of physical examination immediately after injury in athletes has not been determined. Special tests performed before swelling accumulates in and around the ankle may be of more clinical utility than tests performed later after injury.…”

“…The accuracy of ankle arthrography ranges from 65% to 96%, 18 and the accuracy of peroneal tenography to detect rupture of the CFL ranges from 83% to 95%. 19 Disadvantages of arthrography include reduced accuracy 48 hours after trauma, the invasive nature of the procedure, and the lack of direct visualization of the injured ligaments.…”

Incidence of Ankle Arthritis in Syndesmotic Injuries Even after Operative Intervention

“…Crossed-leg test shows, the patient is seated with the injured leg over the normal knee; the involvement of the syndesmotic injury is identified when the pain is felt (9) . A tibiofibular clear space more than 6 mm located 10 mm above the plafond is indicative of syndesmosis damage, while increase in space between the medial malleolus and the talus indicates syndesmotic and deltoid ligament disruption (10) . Finally all injured ankles were examined the use of intraoperative fluoroscopic external rotation stress assessments.…”

Syndesmosis injuries of the ankle

“…In the crossed-leg test, the patient is seated with the mid-fibula of the injured leg on the knee of the uninvolved leg; the involvement of the syndesmosis is suspected if pain is felt when the knee of the affected leg is pushed toward the ground. Beumer et al assessed the ability of seven examiners to detect syndesmotic injuries using the fibular translation, Cotton, squeeze, and external rotation tests [23]. Three patients with a suspected syndesmotic injury and 9 normal ankles (12 ankles total) were examined.…”