Kleiger's Test: Indications, Interpretation, and Clinical Significance

What indicates a positive Kleiger's test?

A positive Kleiger's test primarily indicates an injury to the distal tibiofibular syndesmosis, commonly known as a "high ankle sprain," or potentially a deltoid ligament sprain, depending on the specific location of pain and presence of joint gapping.

Understanding the Kleiger's Test

The Kleiger's test, also known as the External Rotation Stress Test, is a specialized orthopedic assessment used to evaluate the integrity of the distal tibiofibular syndesmosis and, to a lesser extent, the deltoid ligament. The distal tibiofibular syndesmosis is a complex fibrous joint composed of several key ligaments: the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the interosseous membrane (IOM). These structures are crucial for maintaining the stability of the ankle mortise, preventing excessive separation of the tibia and fibula, which is vital for proper ankle function and weight-bearing. Injuries to this area, often referred to as "high ankle sprains," are distinct from more common lateral ankle sprains and typically require longer recovery periods.

How the Test is Performed

To perform the Kleiger's test, the patient is typically seated with their knee flexed to 90 degrees, allowing the lower leg to hang freely. The examiner stabilizes the patient's lower leg (tibia and fibula) just above the ankle. The examiner then grasps the patient's foot, ensuring a firm grip around the forefoot and hindfoot. The ankle is gently dorsiflexed to a neutral or slightly dorsiflexed position, and then a controlled external rotation force is applied to the foot. This maneuver applies a rotational stress to the ankle mortise, specifically stressing the syndesmotic ligaments and potentially the deltoid ligament.

Interpreting a Positive Kleiger's Test

The interpretation of a positive Kleiger's test relies on the patient's reported symptoms and any observable physical changes during the maneuver.

• Primary Indicator: Pain at the Syndesmosis The most common and significant indicator of a positive Kleiger's test for a syndesmotic injury is the reproduction of pain over the distal tibiofibular syndesmosis. This pain is typically localized to the anterolateral aspect of the ankle, specifically the area between the distal tibia and fibula, where the AITFL is located. The pain should be sharp, localized, and directly reproduced by the external rotation stress. If pain is reported elsewhere (e.g., medial ankle), it may indicate a different pathology.

• Secondary Indicator: Visible or Palpable Diastasis (Gapping) A more severe indication of a positive test is the visible or palpable widening (diastasis) of the distal tibiofibular joint during the external rotation maneuver. This gapping suggests significant disruption of the syndesmotic ligaments, indicating marked instability. While less common to observe overtly without imaging, a subtle sense of movement or "giving" compared to the uninjured ankle can also be a key finding for an experienced clinician.

• Differentiating Pain Location for Deltoid Ligament Injury It's important to note that the Kleiger's test can also stress the deltoid ligament on the medial side of the ankle. If the primary pain is localized to the medial aspect of the ankle during the external rotation, it may indicate a sprain of the deltoid ligament rather than, or in addition to, a syndesmotic injury. Therefore, precise pain localization is crucial for accurate diagnosis.

Clinical Significance and Implications

A positive Kleiger's test has significant clinical implications:

• Diagnosis of High Ankle Sprain: It is a primary clinical indicator for diagnosing a syndesmotic injury (high ankle sprain), differentiating it from more common lateral ankle sprains.
• Assessment of Ankle Stability: A positive test, especially with observed diastasis, points to ankle instability, which can have long-term consequences if not properly managed.
• Guidance for Treatment: High ankle sprains typically require a longer recovery period and often more conservative management (e.g., prolonged immobilization, non-weight bearing) compared to lateral sprains. In cases of significant instability or persistent diastasis, surgical intervention (e.g., syndesmotic screw fixation) may be necessary.
• Pre-Surgical Evaluation: For athletes or individuals with severe ankle trauma, a positive Kleiger's test guides further diagnostic imaging (e.g., stress X-rays, MRI) to confirm the extent of injury and plan appropriate treatment.

Limitations and Considerations

While valuable, the Kleiger's test is not without limitations:

• Subjectivity: The test relies on patient reporting of pain and examiner's subjective assessment of gapping, which can vary.
• False Positives/Negatives: It is not 100% sensitive or specific. A patient might have a syndesmotic injury but not exhibit a strongly positive test, or conversely, pain from other sources might be misinterpreted.
• Need for Confirmation: A positive Kleiger's test should ideally be corroborated with other clinical findings and, often, diagnostic imaging (e.g., stress radiographs to visualize diastasis, MRI to assess ligamentous integrity).
• Acute vs. Chronic: The test is most reliable in the acute phase of an injury. Chronic syndesmotic instability may present differently.

Conclusion

The Kleiger's test is a foundational clinical tool for assessing the integrity of the distal tibiofibular syndesmosis. A positive result, marked by localized pain over the anterolateral ankle during external rotation and/or visible gapping, strongly indicates a high ankle sprain. Understanding the nuances of pain location is essential to differentiate between syndesmotic and deltoid ligament injuries. While a powerful diagnostic aid, its findings should always be integrated with a comprehensive clinical examination and, when necessary, advanced imaging to ensure an accurate diagnosis and appropriate treatment plan for optimal patient outcomes.