Ankle Orthopaedic Test: Kleiger's Test

Kleiger’s Test, also known as the external rotation stress test or dorsiflexion-external rotation test, is used to assess symptom response during syndesmosis loading. A positive result may increase suspicion of syndesmosis involvement when it reproduces distal tibiofibular or anterolateral ankle pain. Diagnostic accuracy is limited, so it should be interpreted with mechanism, palpation, squeeze testing, weight-bearing ability and imaging where relevant.

Introduction

A client may present after a rotational ankle injury with pain above the ankle joint, difficulty weight-bearing and symptoms that do not behave like a simple lateral ankle sprain. Kleiger’s Test can help assess whether external rotation stress reproduces symptoms associated with syndesmosis involvement.

Syndesmosis injuries can be difficult to identify clinically. A multicentre diagnostic study of 87 acute ankle sprain participants compared several clinical tests with MRI and reported that no single test was sufficient on its own.  

Quick Summary

Test name: Kleiger’s Test
Also known as: External rotation stress test, dorsiflexion-external rotation stress test
Purpose: Assess symptom response to syndesmosis loading
Body region: Ankle
Commonly associated presentation: High ankle sprain, syndesmosis injury
Positive finding: Reproduction of familiar distal tibiofibular, syndesmosis or anterolateral ankle pain during external rotation stress
Negative finding: No familiar syndesmosis-region symptoms during the test
Best used with: Squeeze Test, syndesmosis palpation, dorsiflexion lunge, weight-bearing assessment and imaging where indicated
Key limitation: Diagnostic accuracy is limited when used alone

What Is Kleiger’s Test?

Kleiger’s Test is an ankle orthopaedic test that applies an external rotation force to the foot and ankle while the lower leg is stabilised. It is commonly used to assess syndesmosis-related symptom reproduction.

The test may also stress medial ankle structures depending on position and force direction, so symptom location is important.

Why It Is Used

The test is used when syndesmosis injury is suspected after a rotational ankle mechanism or when symptoms are located around the distal tibiofibular region.

It can help guide further assessment and support decisions about whether additional testing, imaging or referral may be needed.

What It Assesses

Kleiger’s Test assesses symptom reproduction during external rotation loading of the ankle and distal tibiofibular region.

It does not directly visualise the syndesmotic ligaments, grade instability or confirm injury.

Who It Is Useful For

This test may be useful for clients with rotational ankle injuries, pain above the ankle joint, suspected high ankle sprain, pain with weight-bearing dorsiflexion or persistent symptoms after ankle sprain.

It may not be appropriate when fracture, severe acute pain, deformity or unstable injury is suspected.

When to Use This Test

Use the test when the mechanism, symptom location and functional presentation suggest possible syndesmosis involvement.

When Not to Use or When to Be Cautious

Use caution when the client has severe pain, marked swelling, inability to weight bear, suspected fracture or symptoms that require urgent referral.

Equipment Required

Chair or treatment table
Pain scale
Measurz for recording
Optional comparison notes
Optional referral/imaging notes

Step-by-Step Protocol / Practice

Setup

Position the client sitting with the knee flexed and the lower leg relaxed.

Client position

The client sits with the ankle in neutral or slight dorsiflexion, depending on the selected version.

Examiner position

Stand or sit facing the client’s foot.

Hand placement

Stabilise the distal tibia and fibula with one hand. Hold the foot with the other hand.

Stabilisation

Prevent excessive tibial rotation while applying stress through the foot.

Movement or force direction

Apply an external rotation force to the foot and ankle. The test may be performed in neutral or dorsiflexion.

Instructions

Ask the client to report the location and quality of symptoms.

Positive finding

A positive finding is reproduction of familiar syndesmosis-region pain, distal tibiofibular pain or anterolateral ankle pain.

Negative finding

A negative finding is no familiar syndesmosis-region pain during the test.

Stopping criteria

Stop if symptoms escalate sharply, the client guards strongly or the test cannot be performed safely.

Safety notes

Apply controlled force only. Do not force the ankle into painful external rotation.

Positive and Negative Test Interpretation

A positive Kleiger’s Test may increase suspicion of syndesmosis involvement when it matches a rotational mechanism, distal tibiofibular tenderness, difficulty weight-bearing and related test findings. It does not confirm syndesmosis injury on its own.

A negative test may reduce suspicion when the overall presentation is low risk, but it does not exclude syndesmosis injury, especially when history and palpation remain strongly suggestive.

Interpretation is stronger when combined with squeeze test findings, ligament palpation, weight-bearing ability, dorsiflexion tolerance and imaging where appropriate.

Sensitivity, Specificity and Diagnostic Accuracy

A multicentre diagnostic study of acute ankle sprain participants compared syndesmosis clinical tests with MRI as the reference standard. The dorsiflexion-external rotation stress test showed limited diagnostic utility when used alone, with values reported around 71% sensitivity and 63% specificity in this acute population.  

Earlier evidence reported variable values depending on ankle position, test variation and reference standard. Reviews of ankle syndesmosis tests have concluded that no single clinical test is sufficient to identify syndesmosis injury with high certainty.  

A positive result may increase suspicion, but likelihood ratios are generally not strong enough to confirm injury. A negative result may reduce suspicion but does not exclude injury when clinical suspicion remains high.

Reliability and Validity

Reliability varies with ankle position, examiner force, client guarding and symptom interpretation. A broader ankle orthopaedic test review found that reliability and validity evidence for ankle tests is limited overall.  

Validity is improved when the test is interpreted alongside other syndesmosis findings rather than in isolation.

Common Errors and Limitations

Common errors include failing to stabilise the tibia, applying force too quickly, not recording symptom location, interpreting medial ankle pain as syndesmosis pain without context and relying on the test alone.

Limitations include variable test descriptions, overlap with deltoid ligament stress, pain inhibition and limited stand-alone diagnostic value.

Practical Applications

Use Kleiger’s Test as part of a syndesmosis assessment battery. It can help document symptom response to external rotation stress and guide whether further testing, modified loading or imaging referral may be appropriate.

How to Record This in Measurz

Record test name, side tested, result as positive, negative, unclear or unable to test, pain score, symptom location, symptom quality, ankle position, force direction, comparison side, irritability, confidence in result, reason for stopping and related findings.

Include whether the test was performed in neutral or dorsiflexion.

Related Tests / Internal Links

Squeeze Test
Eversion Stress Test
Anterior Drawer Test of the Ankle
Talar Tilt Test
Weight-Bearing Lunge Test
Ankle Dorsiflexion Test
Single-Leg Balance Test

FAQs

What does Kleiger’s Test assess?

It assesses symptom response to external rotation stress at the ankle and syndesmosis region.

Is Kleiger’s Test the same as the external rotation stress test?

Yes, it is commonly referred to as the external rotation stress test or dorsiflexion-external rotation stress test.

Does a positive test diagnose a syndesmosis injury?

No. It may increase suspicion but does not confirm injury on its own.

What symptom location matters most?

Pain around the distal tibiofibular or syndesmosis region is more relevant than vague ankle discomfort.

Should imaging be considered?

Imaging may be appropriate when syndesmosis injury is suspected or symptoms are severe, persistent or functionally limiting.

Key Takeaways

Kleiger’s Test applies external rotation stress to the ankle.
A positive result may increase suspicion of syndesmosis involvement.
Diagnostic accuracy is limited as a stand-alone test.
Symptom location is essential.
Record ankle position, pain location and confidence in Measurz.

References

Beynon, A., Le May, S., & Theroux, J. (2022). Reliability and validity of physical examination tests for the assessment of ankle instability. Chiropractic & Manual Therapies, 30, 58. doi:10.1186/s12998-022-00470-0

Sman, A. D., Hiller, C. E., Rae, K., Linklater, J., Black, D. A., Nicholson, L. L., et al. (2015). Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine, 49(5), 323–329.

Sman, A. D., Hiller, C. E., & Refshauge, K. M. (2013). Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: A systematic review. British Journal of Sports Medicine, 47(10), 620–628.

Netterström-Wedin, F., Matthews, M., & Bleakley, C. (2022). Diagnostic accuracy of clinical tests assessing ligamentous injury of the talocrural and subtalar joints: A systematic review with meta-analysis. Sports Health, 14(3), 336–347. doi:10.1177/19417381211029953