Kleiger Test: How to Detect Syndesmosis Injuries with External Rotation

When the squeeze test leaves things uncertain, or you want to strengthen your suspicion of a syndesmosis injury (or a deltoid ligament injury, on the inner side of the ankle), the Kleiger test offers another angle of assessment: external rotation of the foot.

What does this test measure?

The Kleiger test evaluates the integrity of the distal tibiofibular syndesmosis and the deltoid ligament (medial ankle) by applying an external rotation force to the foot and ankle while the leg is stabilized. This rotation stresses both structures; if they're damaged, it reproduces pain in the corresponding area.

Equipment needed

• None required

Step-by-step protocol

1. Seat the subject with the knee flexed at 90° and the foot hanging relaxed, unsupported
2. With one hand, firmly stabilize the tibia and fibula just above the ankle
3. With the other hand, hold the foot (by the rear/midfoot) and apply passive external rotation (turning the foot "outward" relative to the leg)
4. Maintain the rotation with moderate pressure and ask where pain appears:

- Pain on the medial side (inner), over the medial malleolus → suggests deltoid ligament involvement - Pain on the anterior side, between the tibia and fibula (syndesmosis area) → suggests syndesmosis injury

1. Compare with the contralateral side

Common mistakes

• Not stabilizing the leg properly, allowing the rotation to be "absorbed" by the knee and reducing actual stress on the ankle
• Applying excessive force from the start, producing diffuse pain that's hard to localize
• Not distinguishing between medial pain (deltoid) and anterior/syndesmosis pain when interpreting the result

How to interpret the result

Result	Interpretation
Negative	External rotation doesn't reproduce significant pain—syndesmosis and deltoid ligament likely intact
Positive (medial pain)	Suggests deltoid ligament involvement
Positive (anterior pain, between tibia and fibula)	Suggests tibiofibular syndesmosis injury

Like the squeeze test, a positive Kleiger test—especially when combined with an external rotation injury mechanism (for example, a fixed foot with the body twisting)—increases suspicion of a "high ankle sprain", which requires different management and recovery timelines than a typical lateral sprain.

Relationship with other tests

The Kleiger test is best interpreted together with:

• Squeeze test (syndesmosis) — explores the same structure via compression, increasing sensitivity if both are positive
• Anterior drawer test for the ankle — helps differentiate a syndesmosis/deltoid injury from a classic lateral ligament complex injury

Record and track progress

Correctly identifying whether a sprain involves the syndesmosis (rather than "just" the lateral ligaments) changes recovery time expectations and loading progression. In Movalytics you can record the Kleiger test result alongside the rest of your ankle assessment, and document the type of sprain to adjust expectations and return-to-activity planning.

Frequently asked questions

Does the Kleiger test replace the squeeze test? No, they're complementary. Both explore the syndesmosis through different mechanisms (compression vs. external rotation), and combining them improves diagnostic sensitivity. What injury mechanism typically causes this type of injury? External rotation mechanisms with the foot fixed on the ground (for example, a sudden change of direction with the foot "planted"), unlike the classic inversion mechanism of lateral sprains. Is an X-ray needed if the Kleiger test is positive? In many cases, imaging is recommended to rule out associated fractures (especially of the fibula) and assess the extent of the ligament injury, so a positive result should be referred for medical evaluation.