Ankle Orthopaedic Test: Squeeze Test

The Squeeze Test is used to assess symptom response at the distal tibiofibular syndesmosis by compressing the tibia and fibula higher up the leg. A positive result may increase suspicion of syndesmosis involvement if it reproduces familiar distal tibiofibular pain. Diagnostic accuracy is limited as a stand-alone test, so it should be interpreted with mechanism, palpation, external rotation stress testing, weight-bearing ability and imaging where appropriate.

Introduction

Syndesmosis injuries may present with pain above the ankle joint, difficulty weight-bearing, pain with dorsiflexion or symptoms after a rotational or eversion ankle mechanism. The Squeeze Test can help assess whether compression through the tibia and fibula reproduces pain at the distal syndesmosis.

A 2022 acute clinical evaluation study found that a positive squeeze test and eversion mechanism were associated with higher odds of syndesmosis injury, but no single clinical variable had enough diagnostic value to completely rule out syndesmosis injury.  

Quick Summary

Test name: Squeeze Test
Also known as: Syndesmosis squeeze test, fibular compression test
Purpose: Assess symptom response related to suspected ankle syndesmosis injury
Body region: Ankle/distal tibiofibular joint
Commonly associated presentation: High ankle sprain, syndesmosis injury
Positive finding: Familiar distal tibiofibular or syndesmosis-region pain during tibia-fibula compression
Negative finding: No familiar distal tibiofibular pain during the test
Best used with: Kleiger’s Test, syndesmosis palpation, dorsiflexion-external rotation test, weight-bearing ability and imaging where indicated
Key limitation: Stand-alone diagnostic accuracy is limited

What Is the Squeeze Test?

The Squeeze Test is an ankle orthopaedic test where the examiner compresses the tibia and fibula together higher up the lower leg to stress the distal tibiofibular syndesmosis indirectly.

A positive response is usually pain at the distal syndesmosis region rather than pain where the calf is squeezed.

Why It Is Used

The test is used when syndesmosis injury is suspected. It may help document symptom response and guide whether further syndesmosis-specific testing or imaging is required.

What It Assesses

The test assesses symptom reproduction in the distal tibiofibular region during proximal tibia-fibula compression.

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

Who It Is Useful For

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

It may not be appropriate in severe acute pain, suspected fracture, marked swelling, deformity or suspected unstable injury.

When to Use This Test

Use the test when the injury mechanism and symptom location suggest possible syndesmosis involvement.

When Not to Use or When to Be Cautious

Use caution with suspected fracture, severe pain, neurological symptoms, obvious deformity, high irritability or symptoms requiring urgent referral.

Equipment Required

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

Step-by-Step Protocol / Practice

Setup

Position the client sitting or lying with the lower leg accessible and relaxed.

Client position

The ankle should be relaxed. The client should be able to report symptom location clearly.

Examiner position

Stand or sit beside the lower leg.

Hand placement

Place both hands around the tibia and fibula at the mid-calf or proximal lower-leg region.

Stabilisation

Support the limb so the client remains relaxed.

Movement or force direction

Compress the tibia and fibula together with controlled pressure.

Instructions

Ask the client to report whether pain is felt at the distal tibiofibular or syndesmosis region.

Positive finding

A positive finding is familiar pain at the distal syndesmosis or distal tibiofibular region during compression.

Negative finding

A negative finding is no familiar distal syndesmosis pain during compression.

Stopping criteria

Stop if symptoms escalate, the client reports sharp pain or the test cannot be tolerated.

Safety notes

Do not use excessive compression. Symptom location matters more than force.

Positive and Negative Test Interpretation

A positive Squeeze Test may increase suspicion of syndesmosis involvement when the client reports familiar distal tibiofibular pain and the history supports a rotational or eversion ankle mechanism.

A negative test may reduce suspicion, but it does not rule out syndesmosis injury. Other findings such as syndesmosis ligament tenderness, external rotation stress response, weight-bearing difficulty and imaging may be more informative in some presentations.

Sensitivity, Specificity and Diagnostic Accuracy

A 2015 multicentre diagnostic accuracy study compared the Squeeze Test and other syndesmosis tests with MRI in 87 acute ankle sprain participants within two weeks of injury. It found that no single test was sufficiently accurate to diagnose syndesmosis injury alone.  

A 2022 acute clinical evaluation study found that a positive squeeze test was associated with higher odds of syndesmosis injury, while also concluding that none of the included clinical variables could completely rule out syndesmosis injury.  

A 2021/2022 diagnostic accuracy review described the squeeze test as having higher specificity and positive likelihood ratio than some other syndesmosis tests, supporting its role as one part of a clustered assessment rather than a stand-alone rule.  

Reliability and Validity

Reliability depends on compression location, force applied, symptom criteria and examiner consistency. A systematic review reported high intra-rater reliability for the squeeze test in some studies, while overall syndesmosis test accuracy and reliability remained limited.  

Validity improves when the Squeeze Test is interpreted alongside other syndesmosis findings rather than in isolation.

Common Errors and Limitations

Common errors include squeezing too distally, interpreting calf discomfort as a positive result, failing to ask symptom location, using excessive force and relying on the test alone.

Limitations include limited sensitivity, subjective force application and overlap with other ankle injuries.

Practical Applications

Use the Squeeze Test as part of a syndesmosis assessment cluster. It can help document symptom response and support decisions about load modification, further testing or referral.

How to Record This in Measurz

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

Related Tests / Internal Links

Kleiger’s Test
Eversion Stress Test
Anterior Drawer Test of the Ankle
Talar Tilt Test
Weight-Bearing Lunge Test
Single-Leg Balance Test
Y-Balance Test

FAQs

What does a positive Squeeze Test mean?

It may increase suspicion of syndesmosis involvement if it reproduces familiar distal tibiofibular pain.

Does the Squeeze Test diagnose a high ankle sprain?

No. It supports clinical reasoning but does not confirm injury alone.

Is the Squeeze Test better for ruling in or ruling out syndesmosis injury?

It may be more useful for increasing suspicion when positive than excluding injury when negative.

Where should symptoms be felt for a positive test?

Symptoms should be reproduced near the distal tibiofibular or syndesmosis region, not just where the calf is squeezed.

Should imaging be considered?

Imaging may be appropriate when clinical suspicion is high, symptoms are severe or management decisions require confirmation.

Key Takeaways

The Squeeze Test assesses symptom response related to the ankle syndesmosis.
A positive test may increase suspicion of syndesmosis injury.
A negative test does not fully exclude injury.
Symptom location is essential.
Record compression location, pain and confidence in Measurz.

References

Baltes, T. P. A., Zwiers, R., Wiegerinck, J. I., et al. (2022). Acute clinical evaluation for syndesmosis injury has high diagnostic value. Knee Surgery, Sports Traumatology, Arthroscopy, 30, 3871–3879. https://doi.org/10.1007/s00167-022-06989-2 

D’Hooghe, P., et al. (2021). Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: A systematic review with meta-analysis. Physical Therapy in Sport, 50, 214–222.

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.