title: Diagnostic accuracy of clinical tests for ankle syndesmosis injury.
abstract: OBJECTIVE
  Our aim was to investigate the diagnostic accuracy of the clinical presentation of ankle syndesmosis injury and four common clinical diagnostic tests.
  
  
  METHODS
  Cross-sectional diagnostic accuracy study.
  
  
  METHODS
  9 clinics in two Australian cities.
  
  
  METHODS
  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).
authors.affiliation: Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia.
authors.forename: Amy D
authors.initials: AD
authors.lastname: Sman
authors.affiliation: Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia.
authors.forename: Claire E
authors.initials: CE
authors.lastname: Hiller
authors.affiliation: Sports Clinic, University of Sydney, Camperdown, New South Wales, Australia.
authors.forename: Katherine
authors.initials: K
authors.lastname: Rae
authors.affiliation: Castlereagh Imaging, St Leonards, New South Wales, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Linklater
authors.affiliation: Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Black
authors.affiliation: Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia.
authors.forename: Leslie L
authors.initials: LL
authors.lastname: Nicholson
authors.affiliation: Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia.
authors.forename: Joshua
authors.initials: J
authors.lastname: Burns
authors.affiliation: Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia.
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Refshauge
mesh_terms: D000293:Adolescent; D000328:Adult; D016512:Ankle Injuries / Q000175:diagnosis*; D001265:Athletic Injuries / Q000175:diagnosis*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010808:Physical Examination / Q000379:methods; D012680:Sensitivity and Specificity; D055815:Young Adult
keywords: Ankle Injuries; Foot Injuries; Lower Extremity Injuries; Orthopaedics; Physiotherapy