Kleiger's Test (External Rotation Test): High Ankle Sprain (Syndesmosis) Guide
In short
High ankle sprains involve tears of the distal tibiofibular syndesmosis and take twice as long to heal as regular inversion sprains. Learn how Kleiger test and the Squeeze test diagnose syndesmotic tears.
In this guide (8 sections)
What is a High Ankle (Syndesmosis) Sprain?
Unlike standard inversion ankle sprains that injure the lateral ATFL, a high ankle sprain involves tearing of the syndesmotic ligament complex: the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and the interosseous membrane.
These ligaments bind the fibula tightly to the tibia, forming the mortise for the talus. High ankle sprains occur when the planted foot is forced into external rotation and dorsiflexion, widening the ankle mortise.
How to Perform Kleiger's External Rotation Test
The patient sits with their lower leg dangling off the edge of the examination plinth:
- Proximal Stabilization: The clinician stabilizes the patient lower leg (tibia and fibula) with one hand, preventing knee and hip rotation.
- Foot Grasp and Neutral Position: The clinician grasps the plantomedial aspect of the foot with the other hand, bringing the ankle into neutral or slight dorsiflexion.
- External Rotation Torque: The clinician applies an external rotation force to the foot, rotating the talus within the mortise.
- Positive Finding: Reproduction of sharp pain anterolaterally over the distal syndesmosis above the ankle joint line confirms a syndesmotic sprain.
The Squeeze Test (Hopkins Test) for Syndesmosis Widening
The Squeeze test is performed by compressing the tibia and fibula together at mid-calf level. In a syndesmotic tear, compression at mid-calf creates a mechanical lever that springs the distal syndesmosis apart, eliciting pain at the distal ankle. Pain reproduction carries 94 percent specificity for high ankle sprains.
Diagnostic Performance Table
| Examination Test | Sensitivity | Specificity | Clinical Role | |
|---|---|---|---|---|
| Kleiger's External Rotation Test | 71 percent | 84 percent | Primary provocative test for syndesmotic widening | |
| Squeeze Test (Mid-Calf) | 30 to 45 percent (Low) | 94 percent (Very High) | Highly specific; confirms extensive interosseous tear | |
| AITFL Palpation Tenderness | 92 percent | 59 percent | Excellent initial screening for anterior syndesmosis tenderness |
Frequently Asked Questions
Why do high ankle sprains take 6 to 12 weeks to heal compared to 2 to 4 weeks for lateral sprains?
Every step taken forces the wedge-shaped talus upward into the mortise, spreading the healing syndesmosis apart. A period of non-weight-bearing in a CAM boot is required to allow fibrous tissue consolidation.
What if Kleiger test reproduces medial pain instead of anterolateral pain?
Medial pain over the deltoid ligament during external rotation indicates a deltoid ligament tear or medial malleolus fracture rather than an isolated syndesmotic injury.
Anatomy of the Distal Syndesmosis and Diastasis
The distal tibiofibular syndesmosis comprises the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), transverse ligament, and interosseous membrane. When the talus is forcefully externally rotated and dorsiflexed, it wedges the fibula away from the tibia, tearing the syndesmotic ligaments.
Rehabilitation Timelines and Delayed Recovery
Unlike lateral ankle sprains that resolve in 2 to 4 weeks, high ankle syndesmotic sprains require 6 to 12 weeks of structured recovery. Early phases require non-weight-bearing boot immobilization to permit ligamentous scar consolidation without mortise widening (diastasis).
High-Traction Society Turf Sports Risks
Playing football or cricket on modern artificial turf with rubber cleated shoes produces high torsional traction. When the foot remains planted while the body rotates inward, a high ankle sprain frequently occurs. Proprioceptive wobble-board training is essential before cleared return to sport.
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