Kleiger Test: Purpose, Procedure, Interpretation, and Clinical Significance

What is the Kleiger test for?

The Kleiger test, also known as the External Rotation Stress Test, is a clinical assessment primarily used to evaluate the integrity of the syndesmotic ligaments of the ankle, helping to detect a high ankle sprain (syndesmotic injury). It can also assist in identifying a deltoid ligament sprain.

Purpose of the Kleiger Test

The primary purpose of the Kleiger test is to assess the stability and integrity of the distal tibiofibular syndesmosis. This syndesmosis is a fibrous joint connecting the tibia and fibula bones just above the ankle joint. Injuries to this area, commonly referred to as "high ankle sprains," are distinct from the more common lateral ankle sprains and often require a longer recovery period due to the critical role these ligaments play in ankle stability.

A secondary, though less common, purpose of the test is to assess the integrity of the deltoid ligament complex on the medial (inner) side of the ankle. This is particularly relevant if there is a suspected eversion injury mechanism.

Anatomy Involved

Understanding the anatomy is crucial for appreciating what the Kleiger test assesses:

• Distal Tibiofibular Syndesmosis: This strong fibrous joint is composed of several key ligaments that bind the distal tibia and fibula together, forming the superior aspect of the ankle mortise. These include:
  • Anterior Inferior Tibiofibular Ligament (AITFL): Located at the front of the syndesmosis.
  • Posterior Inferior Tibiofibular Ligament (PITFL): Located at the back.
  • Interosseous Membrane (IOM): A thick fibrous sheet running between the tibia and fibula along their length.
  • Transverse Tibiofibular Ligament: Often considered part of the PITFL, it runs transversely behind the joint.
• Deltoid Ligament: A strong, fan-shaped ligament complex on the medial side of the ankle. It consists of superficial and deep layers, attaching the medial malleolus of the tibia to the talus, calcaneus, and navicular bones. It resists eversion (outward turning) of the foot.
• Talus: The uppermost bone of the foot, which articulates with the tibia and fibula to form the main ankle joint. Its position within the ankle mortise is highly dependent on syndesmotic integrity.

How the Kleiger Test is Performed

The Kleiger test is typically performed by a healthcare professional following a specific protocol:

1. Patient Positioning: The patient can be seated with their knee flexed to 90 degrees, allowing the foot to hang freely, or positioned supine (lying on their back) with the knee bent.
2. Examiner Positioning: The examiner stabilizes the patient's lower leg (tibia and fibula) just above the ankle with one hand.
3. Application of Stress: With the other hand, the examiner grasps the patient's forefoot. The foot is then gently but firmly dorsiflexed (pulled upwards towards the shin) and simultaneously externally rotated (turned outwards).
4. Observation and Palpation: Throughout the maneuver, the examiner observes the patient's reaction and may palpate the syndesmosis (anteriorly and posteriorly) and the deltoid ligament area for pain, tenderness, or gapping.

Interpreting the Results

The interpretation of the Kleiger test depends on the location of the pain or other findings:

• Positive Test for Syndesmosis Injury (High Ankle Sprain):
  • Pain: The primary indicator is the reproduction of pain over the distal tibiofibular syndesmosis (either anteriorly or posteriorly) during the external rotation maneuver, especially when combined with dorsiflexion.
  • Gapping: In more severe injuries, there may be palpable gapping or widening of the syndesmosis.
• Positive Test for Deltoid Ligament Injury:
  • Pain: If pain is primarily elicited over the medial malleolus and the deltoid ligament complex without significant syndesmotic pain, it suggests a deltoid ligament sprain. This is less common as an isolated finding with this test.
• Negative Test:
  • No pain or discomfort is reproduced over either the syndesmosis or the deltoid ligament during the maneuver.

It's important to compare the findings to the uninjured ankle to establish a baseline and identify subtle differences.

Clinical Significance and Limitations

The Kleiger test is a valuable tool in the differential diagnosis of ankle injuries:

• Clinical Significance:
  • Differentiating Sprains: It helps differentiate a high ankle sprain from the more common lateral ankle sprain, which is crucial because high ankle sprains often require a longer recovery period and may necessitate different treatment approaches (e.g., prolonged immobilization, surgical intervention in severe cases).
  • Guiding Treatment: A positive Kleiger test can guide further diagnostic imaging (such as MRI) and inform the rehabilitation plan.
• Limitations:
  • Sensitivity and Specificity: While useful, the test's sensitivity (ability to correctly identify those with the condition) and specificity (ability to correctly identify those without the condition) can vary. It may not detect all syndesmotic injuries, especially subtle ones.
  • Painful: The maneuver itself can be painful for patients with acute ankle injuries, making cooperation difficult.
  • Not Definitive Alone: The Kleiger test should not be used in isolation. It is one component of a comprehensive physical examination and should be combined with other special tests (e.g., Squeeze Test, Fibular Translation Test) and, often, diagnostic imaging to confirm a diagnosis.
  • False Positives/Negatives: Other conditions can cause pain in the ankle, potentially leading to false positives. Conversely, muscle guarding or patient apprehension might lead to false negatives.

Who Should Perform This Test?

The Kleiger test should only be performed by qualified healthcare professionals, including:

• Orthopedic Surgeons
• Sports Medicine Physicians
• Physical Therapists
• Athletic Trainers
• Other licensed medical practitioners experienced in musculoskeletal assessment.

It is not a test for self-diagnosis by the general public. Proper technique and interpretation require extensive anatomical and clinical knowledge.

Conclusion

The Kleiger test is a fundamental clinical assessment in the evaluation of ankle injuries, particularly for identifying high ankle sprains affecting the distal tibiofibular syndesmosis. By applying a specific external rotation and dorsiflexion stress, it helps clinicians pinpoint pain originating from the syndesmotic ligaments or, less commonly, the deltoid ligament. While a valuable diagnostic tool, it is most effective when integrated into a thorough clinical examination alongside other specialized tests and, when indicated, advanced imaging, ensuring an accurate diagnosis and appropriate management plan for optimal recovery.