Squeeze Test: how to detect an ankle syndesmosis injury

Not all ankle sprains are the same. There's one type that tends to drag on much longer than expected and, if not identified, can lead to a frustrating recovery: the syndesmosis sprain, or "high ankle sprain." The squeeze test is one of the key tests for raising suspicion of this injury.

What does this test measure?

It assesses the integrity of the distal tibiofibular syndesmosis, the set of ligaments connecting the tibia and fibula just above the ankle. By compressing the tibia and fibula together at the middle of the leg, if the syndesmosis is damaged, pain is reproduced in the distal region (near the ankle), because the compression slightly separates the distal ends of both bones.

Equipment needed

• Nothing required

Step-by-step protocol

1. Position the person seated or lying down, with the leg relaxed
2. Locate the midpoint of the lower leg (between knee and ankle)
3. Using both hands, firmly compress the tibia and fibula together, squeezing them at the level of the mid-calf
4. Hold the compression for a few seconds and ask whether pain appears in the distal ankle region, around the syndesmosis area (between the malleoli, on the front of the ankle)
5. Compare the response with the contralateral side if possible

Common mistakes

• Compressing too far distally (near the ankle) instead of at the middle of the leg, which can confuse the source of the pain
• Not asking specifically about the location of the pain (it should be distal, not at the point of compression)
• Overlooking this test in "normal" sprains that aren't improving at the expected rate

How to interpret the result

Result	Interpretation
Negative	No distal pain appears with compression — syndesmosis likely intact
Positive	Pain reproduced in the distal ankle region (between the malleoli) — suggests tibiofibular syndesmosis injury ("high ankle sprain")

A syndesmosis injury usually requires significantly longer recovery times than a typical lateral ankle sprain, and in cases of significant instability may require immobilization or even surgery. A positive squeeze test, especially combined with pain that isn't improving at the expected rate, justifies referral for imaging assessment.

Related tests

The squeeze test makes more sense when combined with other ankle stability tests:

• External rotation ankle test (Kleiger) — explores the syndesmosis from a different angle (external rotation), increasing combined sensitivity
• Anterior drawer test of the ankle — to differentiate between a lateral ligament injury and syndesmosis involvement

Track and follow up

A syndesmosis sprain that's missed is one of the most typical causes of "back to sport too soon, setback, start over." In Movalytics you can log the squeeze test result at the initial assessment and track pain and ankle function over the recovery weeks, helping you make more informed decisions about when to progress the load.

Frequently asked questions

Is the squeeze test itself painful? The compression itself shouldn't hurt in a healthy leg. If pain appears locally at the point of compression without distal radiation, it's not considered a positive result for syndesmosis. Why do syndesmosis sprains take longer to heal? Because they affect a structure that stabilizes the tibia and fibula against each other, supporting constant rotational loads while walking, running, or changing direction, and its healing and mechanical integration require more time. Can I keep training the upper body while a syndesmosis injury heals? Generally yes, as long as it doesn't involve loading the affected ankle, but the final decision should be made by the medical professional/physical therapist overseeing the recovery.