[RESEARCH] Accuracy of High Ankle Sprain Tests | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

[RESEARCH] Accuracy of High Ankle Sprain Tests

[RESEARCH] Accuracy of High Ankle Sprain Tests - themanualtherapist.com

Accuracy of High Ankle Sprain Tests

A high ankle sprain involves injury to the distal tibiofibular syndesmosis, a fibrous joint stabilized by four ligaments:

Syndesmotic injuries take 2x as long vs. a low ankle sprain to return to sport. Inaccurate or delayed diagnosis can lead to repeated episodes of ankle instability, predisposing to early degenerative changes, and post-traumatic OA. Diagnosis should quantify the degree of instability, as unstable injuries are prioritized for surgery vs. conservative treatment. Arthroscopy, MRI, & diagnostic ultrasound provide high sensitivity and specificity, however, access may be limited.

Physical examination remains a central tenet for diagnosis, including:
  • Squeeze test
  • External rotation test
  • Cotton test
  • Crossed-leg test
  • Heel-thump test
  • Palpation
This systematic review determined the diagnostic accuracy of clinical tests and proposed an algorithm for optimizing test clustering.


  • 6 studies
  • 512 participants
  • 13 clinical tests
No individual test was associated with both high sensitivity and high specificity.

Tests with the highest sensitivity:
  • Palpation 92%
  • Dorsiflexion lunge 75%
Tests with the highest specificity:
  • Squeeze test 85%
  • External rotation 78%


No individual test can both rule in and rule out injury of the ankle syndesmosis accurately.

Optimal diagnostic approach:
  • Initial clustering of tests with high sensitivity (palpation; dorsiflexion lunge)
  • Followed by a test with high specificity (squeeze)
These tests cannot definitively diagnose stable vs unstable.
Decisions on conservative vs surgical management require additional imaging or arthroscopy.


Netterstr€om-Wedin, 2021. Diagnostic accuracy of clinical tests assessing ligamentous injury ofthe ankle syndesmosis: PT in Sport, (49), pp. 214-226.

Dalton Urrutia, MSc PT

Dalton is a Physical Therapist from Oregon, currently living and running the performance physiotherapy clinic he founded in London for Grapplers and Strength & Conditioning athletes. Dalton runs the popular instagram account @physicaltherapyresearch, where he posts easy summaries of current and relevant research on health, fitness, and rehab topics. 
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