The authors conducted this study to determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury. They conducted an electronic database search (to 6 August 2012) of databases including: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information. Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies involved participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard. The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies studied diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR-1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83-100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was seen in the other tests.
This was the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. They were unable to identify many studies and their findings showed that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. They suggest that additional diagnostic tests, such as MRI, should be considered before arriving at a final diagnosis of syndesmosis injury.