SportsHigh ankle sprain: syndesmosis tests
A high ankle sprain injures the syndesmosis, the ligaments that join the tibia and fibula just above the ankle, among them the anterior inferior tibiofibular ligament. It hurts above the ankle joint and can keep an athlete out far longer than a lateral sprain. You recognize the mechanism, palpate and run the special tests.
Free to startScenarios
- The foot was forced into external rotation, eversion and abduction (hyperpronation).
- The ankle was forced into extreme dorsiflexion or plantar flexion.
- Another athlete fell onto the fixed ankle.
The steps
- Suspect a high ankle sprain when the tenderness is above the ankle joint, without signs of fracture or diastasis.
- Ask about the mechanism: hyperpronation, hyperdorsiflexion or hyperplantar flexion, or another athlete falling onto the fixed ankle.
- Palpate above the ankle joint, over the syndesmosis.
- Perform the squeeze test.
- Perform the Cotton test.
- Perform the external-rotation test; the modified Kleiger test, with dorsiflexion and rotation, has the greatest intertester agreement.
- Perform the fibular translation test.
- During each test, watch for symptoms that are provoked or eased: they may indicate a syndesmotic injury.
- Ask about difficulty pushing off or a lack of power.
- Compare the tests with the functional evaluation and refer for radiographs, with MRI if indicated.
Safety rules that stop the station
- The tests cannot grade the injury: compare them with functional and imaging findings.
- A high ankle sprain is treated more conservatively than a lateral sprain: early recognition and immobilization (non-weight bearing, walking boot, cast or brace).
- Widening of the ankle mortise greater than 2 mm or joint incongruity on radiographs: surgical fixation is considered.
To pass
- Mechanism and pain above the ankle joint recognized.
- Squeeze, Cotton, external-rotation and fibular translation tests done.
- Athlete referred for radiographs and the ankle protected.
Official source
National Athletic Trainers' Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes (J Athl Train, 2013)
The National Athletic Trainers' Association position statement on ankle sprains (Journal of Athletic Training, 2013), free on PubMed Central: recommendations 6 and 32 to 34 and its literature review.
Making Synapses is not affiliated with, sponsored by or endorsed by the NATA, the BOC, CAATE, the Ottawa Hospital Research Institute or any university. NATA, BOC and CAATE are trademarks of their respective owners and are named only to describe the content.