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

Netterstrom-Wedin F, Bleakley C

Physical Therapy in Sport 2021 May;49:214-226

systematic review

OBJECTIVE: To summarise and evaluate research on the diagnostic accuracy of clinical tests for ligamentous injury of the ankle syndesmosis. METHODS: CINAHL, Embase, and Medline were searched from inception to February 12, 2021. Studies comparing clinical examination to arthroscopy, magnetic resonance imaging, or ultrasound were considered eligible. Meta-analysis was based on random effect modelling and limited to studies fulfilling all QUADAS-2 criteria. Sensitivity (SN), specificity (SP) and likelihood ratios determined diagnostic accuracy, all with 95% confidence intervals (CI). RESULTS: Six studies were included (512 participants; 13 clinical tests; 29% median prevalence). No individual test was associated with both high sensitivity and high specificity. Tests with the highest sensitivity were: Palpation (SN 92% (95% CI 79 to 98)) and Dorsiflexion Lunge (SN 75% (95% CI 64 to 84%); n = 2 studies). Tests with the highest specificity were: Squeeze Test (SP 85% (95% CI 81 to 89%); n = 4 studies) and External Rotation (SP 78% (95% CI 73 to 82%); n = 4 studies). CONCLUSIONS: Clinical examination should involve initial clustering of tests with high sensitivity (Palpation; Dorsiflexion Lunge), followed by a test with high specificity (Squeeze). However, as these tests cannot definitively stratify syndesmotic injuries into stable versus unstable, decisions on optimal management (conservative versus surgery) require additional imaging or arthroscopy.

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