A patient reports significant ankle pain after sustaining an injury in which the foot twisted while in a weight-bearing position. The physical therapist performed a Kleiger (lateral rotation) stress test that reproduced the patient's pain. Which of the following injuries has this patient MOST likely sustained?

1. Anterior talofibular ligament sprain
2. Fibularis (peroneal) tendon subluxation
3. High ankle (syndesmosis) sprain
4. Medial tibial stress syndrome

Welcome back to the Scorebuilders’ Question and Answer Podcast! This podcast provides members of the Scorebuilders’ team with the opportunity to explore challenging multiple-choice examination questions with students actively preparing for the licensing examination. My name is Scott Giles and I will be your host for today’s journey.

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A patient reports significant ankle pain after sustaining an injury in which the foot twisted while in a weight-bearing position. The physical therapist performed a Kleiger (lateral rotation) stress test that reproduced the patient's pain. Which of the following injuries has this patient MOST likely sustained?

1. Anterior talofibular ligament sprain
2. Fibularis (peroneal) tendon subluxation
3. High ankle (syndesmosis) sprain
4. Medial tibial stress syndrome

There are two pieces of critical information presented in the question stem.

1. Mechanism of injury – foot twisted while in weight bearing

2. Special test – Kleiger (lateral rotation) stress test

The question is specifically asking the student to identify the likely injury.

The best case scenario when answering this question is that you are familiar with the Kleiger stress test. If this is the case, there is a tremendous probability that you already have enough information to identify the best option.

The challenge with this question is that the Kleiger stress test is a bit off the beaten path. In fact, I would estimate that approximately half of the students answering this question are unfamiliar with the test. If I had asked a similar question about a more mainstream special test like the Thomas test, anterior drawer test, Tinel’s sign, or Phalen’s test, your mood would likely be much improved.

Let’s review the Kleiger (lateral rotation) stress test.

Kleiger (lateral rotation) Stress Test
Patient Position: The patient is seated at the edge of a table with their knee in 90 degrees of flexion.

Procedure: The therapist stabilizes the patient’s lower leg with one hand, holds the patient’s foot in neutral with their other hand, and then applies a lateral rotation force to the foot.

Positive Sign: If the patient experiences pain over the anterior or posterior tibiofibular ligaments and the interosseous membrane, then the test is positive for a high ankle (syndesmosis) sprain.

Boom! Please stop by and pick up your license!

Let’s explore each of the options and in the process, we will consider the mechanism of injury and special tests, if applicable.

Option 1 - Anterior talofibular ligament sprain
The anterior drawer test for the ankle specifically assesses the integrity of the anterior talofibular ligament (ATFL) during anterior translation of the talus on the tibia. The ATFL resists inversion of the talus and calcaneus as well as anterior translation of the talus on the tibia. The ATFL becomes taut during plantar flexion and is most commonly injured with a combination of end-range plantar flexion and inversion.

This option was likely tempting if you were unfamiliar with the Kleiger stress test. The mechanism of injury (i.e., foot twisted while in weight bearing) was sufficiently vague to be tempting for an anterior talofibular ligament sprain, but would have been more compelling with end-range plantar flexion and inversion. The bottom line is that the Kleiger stress test is not utilized to identify an anterior talofibular ligament sprain.

Option 2 - Fibularis (peroneal) tendon subluxation
Fibularis tendon subluxation is typically provoked by forceful ankle dorsiflexion combined with eversion of the foot. This condition may be misdiagnosed as a lateral ankle sprain due to the proximity of the tendons to the lateral ankle ligaments and the presence of pain, swelling, and ecchymosis at the posterior distal fibula.

Fibularis tendon subluxation typically presents with pain and popping in the posterior lateral ankle. The mechanism of injury (i.e., foot twisted while in weight bearing) again was sufficiently vague to be tempting but the Kleiger stress test is not utilized to identify a fibularis tendon subluxation.

Option 3 - High ankle (syndesmosis) sprain
The most common mechanism of injury for a high ankle (syndesmosis) sprain occurs with forced ankle dorsiflexion and rotation with the foot in a weight-bearing position. Special tests for identifying a high ankle sprain include the Kleiger (lateral rotation) stress test and the squeeze (distal tibiofibular compression) test, as well as various forms of diagnostic imaging.

The mechanism of injury in this scenario combined with a positive Kleiger test makes a high ankle (syndesmosis) sprain the most likely sustained injury.

Option 4 - Medial tibial stress syndrome
Medial tibial stress syndrome, historically referred to as “shin splints,” is an overuse injury of the lower leg.

Periosteal irritation is thought to cause the pain and tenderness associated with medial tibial stress syndrome.

The onset of the condition is gradual, often with exercise, and there is typically not a definitive mechanism of injury. Differential diagnosis should include stress fractures of the tibia and fibula, ischemic disorders, and compartment syndromes of the lower leg. The Kleiger stress test is not utilized to identify medial tibial stress syndrome.

The correct answer is Option 3

Let’s explore the all student data:
26% of students selected Option 1, anterior talofibular ligament sprain
5% of students selected Option 2, fibularis (peroneal) tendon subluxation
56% of students selected Option 3, high ankle (syndesmosis) sprain -the correct response
13% of students selected Option 4, medial tibial stress syndrome

System Classification
This question is a Musculoskeletal System question which represents approximately 27% of all exam items.

Content Outline Classification
This question is a Foundations for Evaluation, Differential Diagnosis, and Prognosis question which represents approximately 33% of all exam items.

Level Classification
This question is a Level 1 question since the question requires students to possess basic foundational academic knowledge. Remediation of Level 1 questions occurs through academic review of entry-level content using textbooks, review books, Basecamp, and flash cards.

Thanks for joining us on the Scorebuilders Q and A podcast! See you next week!

Watch the video version of this Q&A episode on YouTube - https://youtu.be/TBLSnfCv1QI