Ankle Orthopaedic Test: Kleiger's Test

Kleiger’s Test, also called the external rotation stress test, assesses pain response when the foot is externally rotated relative to the lower leg. Pain may suggest syndesmosis involvement, deltoid ligament involvement or other ankle injury depending on symptom location. A 2021 systematic review of ankle syndesmosis clinical tests found that no single clinical test is sufficient on its own and recommended interpreting tests in clusters with history and imaging where needed.  

Introduction

A client reports pain above the ankle joint after a twisting injury, tackle, ski fall, landing or forced external rotation mechanism. They may have difficulty pushing off, pain with rotation or tenderness over the syndesmosis.

Kleiger’s Test can help assess whether external rotation stress reproduces familiar pain. It should be used cautiously because syndesmosis injuries can be missed, and some presentations need imaging or medical review.

Quick Summary

Test name: Kleiger’s Test
Also known as: External Rotation Stress Test
Body region: Ankle syndesmosis, distal tibiofibular joint, deltoid ligament region
Purpose: Assess pain response to external rotation stress
Positive finding: Familiar pain over the syndesmosis or medial ankle during external rotation stress
Negative finding: No familiar pain during the test
Best used with: Squeeze Test, syndesmosis palpation, dorsiflexion-external rotation reasoning, weight-bearing tolerance, swelling and imaging/referral when indicated
Key limitation: It does not confirm syndesmosis injury on its own

What Is Kleiger’s Test?

Kleiger’s Test is an ankle external rotation stress test. The lower leg is stabilised while the foot is externally rotated. The test stresses the distal tibiofibular syndesmosis and may also stress the deltoid ligament depending on the position and symptoms.

Why It Is Used

The test is used when high ankle sprain, syndesmosis injury or deltoid ligament involvement is suspected.

It may be relevant after external rotation injuries, contact sport injuries, skiing injuries, cutting, landing, falls or ankle trauma with pain above the ankle joint.

What It Assesses

The test assesses symptom response to external rotation stress. It does not directly identify ligament damage or injury grade.

Pain location matters. Pain over the syndesmosis may support high ankle sprain reasoning, while medial ankle pain may raise concern for deltoid involvement.

Who It Is Useful For

This test may be useful for field-sport athletes, skiers, runners, dancers, court-sport athletes and clients with suspected high ankle sprain or medial ankle symptoms after trauma.

When to Use This Test

Use when syndesmosis or deltoid involvement is clinically relevant and the ankle can tolerate controlled external rotation stress.

When Not to Use or When to Be Cautious

Use caution with suspected fracture, severe swelling, inability to weight bear, severe pain, obvious deformity, acute high-energy trauma, recent surgery or marked instability.

Do not force rotation.

Equipment Required

Treatment table or chair
Pain scale
Measurz recording workflow
Optional comparison-side notes
Optional referral notes

Step-by-Step Protocol / Practice

Setup

Position the client sitting with the knee flexed and foot relaxed.

Client position

The knee is typically flexed to approximately 90 degrees with the ankle in neutral or slight dorsiflexion, depending on the selected method.

Examiner/professional position

Sit or stand facing the foot.

Hand placement

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

Stabilisation

Prevent rotation of the entire leg so that the stress is directed through the ankle.

Movement or force direction

Externally rotate the foot relative to the tibia in a gradual, controlled manner.

Instructions

Ask the client to report pain location, intensity, instability, apprehension and whether symptoms match their usual complaint.

Positive finding

A positive Kleiger’s Test is familiar pain over the syndesmosis, distal tibiofibular region or medial ankle during external rotation stress.

Negative finding

A negative finding is no familiar pain during the test.

Stopping criteria

Stop if pain increases sharply, instability is felt, guarding dominates or symptoms are not tolerated.

Safety notes

Record pain location clearly. Do not force external rotation.

Positive and Negative Test Interpretation

A positive Kleiger’s Test may increase suspicion of syndesmosis injury when pain is felt over the distal tibiofibular region and matches an external rotation mechanism. Medial pain may suggest deltoid ligament involvement or another medial ankle structure.

A positive test does not confirm a high ankle sprain on its own. A negative test does not exclude syndesmosis injury, particularly if the injury is acute, guarded or load-specific.

Interpretation is stronger when combined with squeeze test, syndesmosis palpation, mechanism of injury, dorsiflexion tolerance, weight-bearing ability and imaging/referral when indicated.

Sensitivity, Specificity and Diagnostic Accuracy

A 2021 systematic review of clinical tests for ankle syndesmosis injury found that diagnostic accuracy varies across tests and that clustering history and examination findings is preferable to relying on a single test.  

Condition or presentation: suspected ankle syndesmosis injury/high ankle sprain
Population: people with suspected syndesmotic ligament injury
Test variation: external rotation stress/Kleiger-type testing
Reference standard: arthroscopy, MRI or ultrasound depending on included study
Sensitivity: variable across studies
Specificity: variable across studies
Positive likelihood ratio: not reliable enough to provide one universal value here
Negative likelihood ratio: not reliable enough to provide one universal value here
Key limitations: variable test position, different injury severity, different reference standards and overlap with deltoid ligament symptoms

The same review searched studies up to February 2021 and included clinical tests compared with arthroscopy, MRI or ultrasound, supporting an evidence-based approach using test clusters rather than single-test diagnosis.  

Reliability and Validity

Reliability depends on ankle position, amount of dorsiflexion, external rotation force, stabilisation of the tibia, symptom criteria and comparison side.

Validity improves when pain location is documented precisely and the test is combined with other syndesmosis findings.

Common Errors and Limitations

Common errors include rotating the whole leg instead of the foot, forcing rotation, failing to record pain location, treating medial pain and syndesmosis pain as the same finding and using the test alone to diagnose high ankle sprain.

Limitations include pain guarding, acute swelling, overlap with deltoid injury, variable force and limited stand-alone certainty.

Practical Applications

Use Kleiger’s Test to document external rotation pain response and guide decisions about further syndesmosis testing, weight-bearing progression, referral or imaging.

How to Record This in Measurz

Record test name, side tested, result, pain score, pain location, ankle position, knee position, external rotation force, symptom quality, apprehension, comparison side, swelling, weight-bearing ability, confidence in result and reason for stopping.

Add related squeeze test, syndesmosis palpation, eversion stress, ankle dorsiflexion ROM, weight-bearing tolerance and referral notes.

Related Tests / Internal Links

Squeeze Test
Eversion Stress Test
Anterior Drawer of the Ankle
Talar Tilt Test
Ankle Dorsiflexion Test
Single Leg Calf Raise
Hop Tests
Balance and Proprioception Tests

FAQs

What does Kleiger’s Test assess?

It assesses pain response to external rotation stress at the ankle, commonly in suspected syndesmosis or deltoid ligament injury.

What is a positive Kleiger’s Test?

A positive finding is familiar pain over the syndesmosis or medial ankle during external rotation stress.

Does it diagnose a high ankle sprain?

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

Why does pain location matter?

Syndesmosis pain and medial ankle pain may suggest different structures and require different interpretation.

What should be recorded in Measurz?

Record pain location, ankle position, force direction, pain score, comparison side and related syndesmosis findings.

Key Takeaways

Kleiger’s Test is an external rotation stress test.
Syndesmosis-region pain and medial ankle pain should be recorded separately.
It does not diagnose high ankle sprain alone.
Use it with squeeze test, palpation, history and weight-bearing findings.
Measurz should capture pain location, force direction and comparison findings.

References

Netterström-Wedin, F., & Bleakley, C. (2021). Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis. Physical Therapy in Sport, 49, 214–226.