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Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: a systematic review with meta-analysis

The short answer

How accurately do clinical examination tests diagnose ligamentous injury of the ankle syndesmosis (high ankle sprain)?

This systematic review of 6 studies (512 participants) evaluated how accurately bedside clinical tests detect ligament injury of the ankle syndesmosis (high ankle sprain), compared against arthroscopy, MRI, or ultrasound. No single test could both rule a syndesmotic injury in and rule it out. The authors recommend clustering highly sensitive tests (palpation and dorsiflexion lunge) first, then a highly specific test (squeeze), but caution that imaging or arthroscopy is still needed to decide management.

DescriptiveRead paper
Meta-analysis512 ParticipantsLimited evidence

Key points

  1. The ankle syndesmosis is the fibrous joint between the tibia and fibula; injuring it is known as a high ankle sprain.
  2. Sensitivity is how well a test catches true injuries; specificity is how well it correctly clears uninjured ankles.
  3. Palpation (SN 92%) and the dorsiflexion lunge (SN 75%) were the most sensitive tests, useful for ruling injury out.
  4. The squeeze test (SP 85%) and external rotation test (SP 78%) were the most specific tests, better for ruling injury in.
  5. No single test was both highly sensitive and highly specific, so the authors propose a sequenced cluster of tests.

How it was conducted

Design
Systematic review with meta-analysis of diagnostic accuracy studies (PRISMA and SEDATE, PROSPERO registered)
Search
CINAHL, Embase, and MEDLINE from inception to 12 February 2021; 6 of 5,286 records included
Participants
512 participants across 6 studies (4 prospective, 2 case-control), with 29% median injury prevalence; 13 clinical tests
Intervention
Clinical examination tests (squeeze, external rotation, palpation, dorsiflexion lunge, and others) as index tests
Outcomes
Sensitivity, specificity, and likelihood ratios versus arthroscopy, MRI, or ultrasound reference standards
Analysis
Random-effects univariate model (Meta-DiSc); meta-analysis limited to 4 studies meeting all QUADAS-2 criteria

What they found

  • Palpation had the highest sensitivity: SN 92% (95% CI 79 to 98).
  • Dorsiflexion lunge: pooled SN 75% (95% CI 64 to 84), SP 84% (95% CI 78 to 89), 2 studies, 271 participants.
  • Squeeze test: pooled SN 32% (95% CI 23 to 42), SP 85% (95% CI 81 to 89), 4 studies, 428 participants; LR+ 3.16, LR- 0.77.
  • External rotation test: pooled SN 70% (95% CI 60 to 78), SP 78% (95% CI 73 to 82), 4 studies; LR+ 3.02, LR- 0.51.
  • At a 20% pretest probability, a positive squeeze test raised post-test probability to 44% and a positive external rotation test to 43%.
  • Specificity estimates showed high heterogeneity (squeeze I2 = 95.6%, external rotation I2 = 96.7%).

Limitations

  • Only 6 studies were included and just 4 entered the meta-analysis; two were excluded for high risk of bias.
  • Pooled estimates showed high statistical heterogeneity, especially for specificity.
  • Analysis used a univariate (rather than bivariate) model due to the small number of studies.
  • Studies with concomitant fractures were excluded, so findings do not generalize to mixed fracture cases, and the test cluster algorithm is unvalidated.

Why it matters

For patients
No single ankle exam test is definitive for a high ankle sprain, so your clinician may use several tests together and sometimes a scan.
For clinicians
Cluster sensitive tests (palpation, dorsiflexion lunge) to rule out, then a specific test (squeeze) to rule in, but use imaging or arthroscopy to decide on surgery.
For readers
Clinical tests for high ankle sprain are individually imperfect and work best sequenced into a cluster.

Source

doi:10.1016/j.ptsp.2021.03.005

Read the original paper
Clinically assessing this area? See the ankle & foot special tests.

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