Sun et al.

BMC Musculoskeletal Disorders (2024) 25:53 BMC Musculoskeletal

https://doi.org/10.1186/s12891-023-07155-6
Disorders

RESEARCH Open Access

Standing on single foot-binding test yields

satisfactory results as a novel method for the
diagnosis of distal tibiofibular syndesmosis
instability: a prospective, cross-sectional
diagnostic-accuracy study
Shouqi Sun1,2,3†, Tianshi Tang1,2,3†, Pengtao Shi1,2,3, Chen Yang1,2,3, Wenjuan Wang1,2,3*, Lei Chen1,2,3* and Min Wei1,2,3*

Abstract
Background Non-invasive diagnosis of distal tibiofibular syndesmosis instability (DTSI) was a great challenge to
clinicians. We designed a new method, the Standing on single foot-Binding test, and investigated the accuracy of the
test in the diagnosis of distal tibiofibular syndesmosis instability in adults with a history of ankle injury.
Methods 85 participants with ankle injury were subjected to the Standing on single foot-Binding test, MRI and
palpation to detect the distal tibiofibular syndesmosis instability (DTSI) and the findings were compared with ankle
arthroscopic results. Both participants and arthroscopist were blind to the predicted results of the clinical tests.
Sensitivity, specificity, PPV, NPV, LR+, LR − and their 95% CIs were calculated for each of the clinical tests as well as for
the positive clinical diagnosis.
Results The Standing on single foot-Binding test (SOSF-B test) outperformed MRI and palpation, in terms of
sensitivity (87.5%/84.38%), specificity (86.79%/86.79%), PPV (80%/79.41%), NPV (92%/91.2%), LR+ (6.625/6.39), LR-
(0.14/0.18) and diagnostic accuracy (87.06/85.88), among others, in the diagnosis of distal tibiofibular syndesmosis
instability (DTSI). The diagnostic performance of 20° SOSF-B test was virtually identical to that of 0° SOSF-B test.
According to the prevalence (28.7%) of DTSI and LR of four tests, the post-test probability could be used in clinical
practice for the prediction of DTSI.

†
Shouqi Sun and Tianshi Tang contributed equally to this work.
*Correspondence:
Wenjuan Wang
304963211@qq.com
Lei Chen
18501219257@163.com
Min Wei
minwei301@163.com
Full list of author information is available at the end of the article

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Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 2 of 9

Conclusion This prospective and double-blind diagnostic test showed that the SOSF-B test is clinically feasible for
the diagnosis of distal tibiofibular syndesmosis instability (DTSI), and new diagnostic tools for rapid screening of distal
tibiofibular syndesmosis instability (DTSI).
Level of evidence II.
Keywords Arthroscopy, Cross-sectional, Diagnostic-accuracy study, Distal tibiofibular syndesmosis instability (DTSI),
Prospective, Standing on single foot-binding test

Background in diagnosis because it presents no conspicuous signs of

Distal tibiofibular syndesmosis injury, known as the high fracture and separation. Among the radiographic tools,
ankle sprain, represents a common complication of the MRI has been found to possess good specificity and sen-
ankle injury. About 18% of ankle sprains and 23% of the sitivity in the diagnosis of syndesmosis injury. Nonethe-
ankle joint fracture have concomitant distal tibiofibular less, MRI remains relatively costly [19]. A meta-analysis
syndesmosis injury [28]. Distal tibiofibular syndesmo- involving multiple studies on the examination methods
sis includes the anterior inferior tibiofibular ligament for distal tibiofibular syndesmosis injury evaluated the
(AITFL), posterior inferior tibiofibular ligament (PITFL), accuracy of multiple clinical tests and found that no sin-
tibiofibular interosseous ligament (TFIL), and transverse gle clinical trial could convincingly predict the disease
tibiofibular ligament (TTFL) and plays a crucial part in [18]. The physical examination methods currently used
maintaining the stability of the ankle joint [17]. in clinical practice include squeeze test, dorsiflexion-
Distal tibiofibular syndesmosis injury, on the basis of compression test, dorsiflexion-external rotation test,
MRI findings and patients’ motion state, falls into three manual stability test, crossed-leg test, heel thump test
types. With type I, or strain type, MRI shows the injury [10]. Nonetheless, these techniques mainly focus on dis-
of the distal tibiofibular syndesmosis but the patient has tal tibiofibular syndesmosis injury and can’t judge the
no problems walking; With type II (instability type), MRI degree of injury [10]. These tests diagnose distal tibiofib-
exhibits the distal tibiofibular syndesmosis injury and the ular syndesmosis injury by inducing pain and the squeeze
patient has trouble walking, due to susceptibility to twist- test is the only test that yields a clinically relevant result
ing and ankle pain; With type III type (also referred to as [18]. Ankle arthroscopy is the gold standard for the diag-
separation type), MRI reveals complete rupture of the nosis of ankle syndesmosis injury, but in clinical practice,
distal tibiofibular syndesmosis, frequently accompanied caution should be exercised since ankle arthroscopy is an
with fracture. Type II and type III usually require surgical invasive procedure under anesthesia [4, 7, 24, 25].
treatment [16, 26]. Type II (instability type) is much more So far, non-invasive diagnosis of DTSI has been a great
difficult to diagnose since only ligament is injured and challenge to clinicians. At present, elastic fixation for the
ankle symptoms are atypical. In view of this, we designate DTSI can achieve good surgical results [8]. Therefore, we
type II (instability type) as distal tibiofibular syndesmosis assume that a similar effect can be obtained by strength-
instability (DTSI). ening the distal tibiofibular joint with an external device.
We statistically analyzed the 293 patients who had a In this study, we developed a new strategy for diagnosing
history of ankle sprain without fracture and received DTSI: Standing on single foot-Binding test (SOSF-B test)
ankle arthroscopic exploration including checkup of dis- and investigated the accuracy of the test in the diagnosis
tal tibiofibular space, between October 2017 and Decem- of DTSI in adults with a history of ankle injury.
ber 2020, from the Chinese PLA general hospital. The
result showed that 84 cases had DTSI, with an incidence Methods
of 28.7%. Therefore, we were led to believe that DTSI This single-center study was approved by the Ethics Com-
is an important subtype of the high ankle injury, and mittee of Chinese PLA General Hospital (2021 − 637).
improving the diagnostic accuracy is clinically of great
significance. Up till now, there are no generally-accepted Participant selection
diagnostic criteria for DTSI and well-established indica- We selected patients from the orthopaedic department
tions for surgery. from January 1, 2021 to January 31, 2022 according to
The patients with DTSI usually suffer from ankle pain, the established criteria. Included in the study were the
discomfort and easy sprain, but these symptoms are not candidates satisfying the following criteria: (1) patients
specific [10, 27]. The biomechanical study showed that suffering from pain or instability due to ankle sprain; (2)
the distal tibiofibular joint is highly stable [27]. Type II patients scheduled for an ankle arthroscopic procedure.
distal tibiofibular syndesmosis injury (distal tibiofibu- The exclusion criteria included: (1) candidates with ankle
lar syndesmosis instability, DTSI) is easy to be missed deformity; (2) those who had previously received ankle
Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 3 of 9

Fig. 1 Elastic bandage (a), arthroscopic probe (b and c) and pressure index instrument (d)

Fig. 2 SOSF-B test. The patient stands on the affected foot on the 0° flat (a) and 20 ° flat (b); The elastic bandage is tightly wrapped around the affected
ankle in non-weight-bearing position (c); The patient stands on the affected foot wrapped with elastic bandage on the 0° flat (d) and 20 ° flat (e)

surgery; (3) those incapable of standing up; (4) those who Binding method
eventually refused to receive the surgery; (5) those whose The standing on single foot test
distal tibiofibular joint space had not been arthroscopi- The patient was instructed to stand on single foot, with
cally explored (joint arthrodesis). upper limbs dropping naturally, on the 0° flat and 20 ° flat
Ethical approval was obtained from the Ethics Com- for 5 s (Fig. 2a and b) (The Standing time was determined
mittee of Chinese PLA General Hospital (2021 − 637). by pre- experiment). By comparing the standing state on
both sides, standing on single foot test was considered
Binding device and measurement equipment positive if (1) the patient was unable to stand on single
On the basis of our previous experience, normal foot for 5 s; or (2) the patient could stand on single foot
blood pressure of human ankle superficial vein and for 5 s, but had two of the following conditions: (a) The
pre-experimental results, we elected to employ elas- patient’s upper body shook obviously; (b) The patient had
tic bandage (TIANJIN TENAI NEW MEDICAL to adjust the foot position to complete the standing; (c)
SUPPLIES&TEXTILE TECHNIQUE CO., LTD) The patient reported that the contraction of the posterior
(Fig. 1a) to tightly bind the patients’ tibiofibular joint leg muscle group was more obvious on the affected side
in non-weight-bearing position, with pressure index than on the healthy side.
set at 50 ~ 60 g (The pressure was determined by
pre- experiment). The standing on single foot-binding test
An arthroscopic probe (Smith & Nephew) was used According to the pressure setting, the elastic bandage
for measurement and the diameter was1mm (Fig. 1b and was tightly wrapped around the affected ankle (Fig. 2c).
c). The pressure index instrument consisted of a stan- The standing on single foot test was repeated (Fig. 2d
dard pressure sensor and an electronic display module and e). The situations of standing before and after bind-
(Fig. 1d). ing were compared, and the binding test was considered
Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 4 of 9

positive if the positive sign of the affected side disap- data and chi-square test was employed for enumeration
peared or weakened. data. Alpha (α) value was set at 0.05.
In order to determine the diagnostic utility of the clini-
Standing on 0° and 20 ° flat plate cal tests, we compared the physical examination results
The standing state of patients on 0° flat and 20 ° flat plate with the arthroscopic diagnosis. A series of 2 × 2 con-
were recorded respectively. The physical examination tingency tables were generated, using the arthroscopic
was carried out by the same examiner. diagnosis (positive or negative for DTSI) as the reference
standard. Sensitivity, specificity, PPV (positive predic-
Syndesmosis ligament palpation and MRI tive value), NPV (negative predictive value), LR+ (posi-
Syndesmosis ligament palpation and MRI were used for tive likelihood ratio), LR− (negative likelihood ratio) and
checking ankle syndesmosis injury. Syndesmosis liga- their 95% CIs were calculated for each of the clinical tests
ment palpation included the tenderness at projection as well as for the positive clinical diagnosis [6, 12, 19].
point of body surface of AITFL/PITFL-transverse liga- The diagnostic accuracy was calculated as: (True posi-
ment [14]. MRI were evaluated for the presence of syn- tive + True negative)/Total number of cases [13].
desmotic injury [9, 11]. Syndesmosis ligament palpation In this study, prevalence represented the pre-test prob-
was performed by the same examiner and the MRI by ability of a particular diagnosis in all listed cases. Post-
two experienced radiologist who was blind to the results test probability allows for estimation of how much the
of clinical tests and arthroscopic exploration. examiner’s findings influenced the accuracy of the diag-
nosis when the test yielded a negative or a positive result.
Surgical technique Sample size was estimated by PASS 11 and met the sta-
The distal tibiofibular syndesmosis stability was tistical requirements.
arthroscopically probed by checking the distal tibio-
fibular joint gap. Briefly, the probe tip was inserted into Patient and public involvement
the distal tibiofibular joint space (Fig. 3a), with the hook It was not appropriate or possible to involve patients or
being rotated axially. If the probe tip could open the dis- the public in the design, or conduct, or reporting, or dis-
tal tibiofibular joint gap (Fig. 3b and c), the distal tibio- semination plans of our research.
fibular joint space was greater than 1 mm.
The operation was done by a sports medicine doctor Results
with 30 years of clinical experience. All surgical proce- There were 85 cases in our cohort, and all participants
dures were photographed and video-recorded. had a definite history of ankle joint trauma. In terms of
the results of ankle arthroscopic exploration, the partici-
Statistical analysis pants were divided into two groups. Figure 4 outlines the
The statistical analysis was performed by using Statistical exclusion and inclusion of participants throughout the
Package for Social Sciences software, version 26.0 (SPSS). study. Participants’ characteristics, including age, gender,
Measurement data were expressed as mean ± standard laterality, height, weight and BMI, are given in Table 1.
deviation (SD) and were rounded to two decimal places. Ankle arthroscopy revealed that there were three
The independent sample t test was used for measurement main complications in patients with DTSI: synovitis,

Fig. 3 Arthroscopic exploration process. Make the probe tip insert the distal tibiofibular joint space (a); The probe tip opens distal tibiofibular joint space
(b and c)
Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 5 of 9

Fig. 4 Flow chart of participant recruitment

osteochondral lesion of the talus and chronic lateral specificity (86.79%). The 20° SOSF-B test (80%) and 0°
ankle syndesmosis injury (Table 2). SOSF-B test (79.41%) had the higher PPV compared
Overall, the diagnostic accuracy of 20° SOSF-B test with MRI (60.98%) and syndesmosis ligament palpation
(87.06%) and 0° SOSF-B test (85.88%) was virtually (54.76%). What is more, the 20° SOSF-B test (92%) and 0°
identical and was significantly better than that of MRI SOSF-B test (91.2%) had the higher NPV in comparison
(72.94%) and syndesmosis ligament palpation (67.06%). with MRI (84.09%) and syndesmosis ligament palpation
In addition, the 20° SOSF-B test (87.5%) and 0° SOSF- (79.07%). Furthermore, LR + and LR- of the four clinical
B test (84.38%) had the highest sensitivity and same diagnostic methods were of value in clinical practice. The
Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 6 of 9

Table 1 General features of the participants This continuous nature of LR and their implication in
Item Total (N = 85) With DTSI (N = 32) Without DTSI shifting probabilities when the test result is positive or
(N = 53)
negative can be graphically illustrated on a Fagan nomo-
Age(year) 33.77 ± 11.09, 29.91 ± 9.94, 36.38 ± 11.2,
gram, which could also be clinically used. According to
(18 ~ 64) (17 ~ 55) # (19 ~ 64) #
Gender(male: 59:26 18:14* 40:13*
the prevalence (28.7%) of DTSI and LR + of the four tests,
female) the post-test probability of 20° SOSF-B test, 0° SOSF-B
Side(left: right) 37:48 17:15# 26:27# test, MRI and palpation was 72.7%, 72%, 51% and 44.7%.
Height (m) 1.73 ± 0.08, 1.72 ± 0.76, 1.74 ± 0.08, According to the prevalence (28.7%) of DTSI and LR- of
(1.55 ~ 1.87) (1.55 ~ 1.84) * (1.58 ~ 1.87) * the four tests, the post-test probability of 20° SOSF-B
Weight (Kg) 76.04 ± 12.55, 74.05 ± 12.39, 77.4 ± 12.06, test, 0° SOSF-B test, MRI and palpation was 5.3%, 6.8%,
(52 ~ 115) (52 ~ 95) * (53 ~ 115) * 11.1% and 15%, respectively (Fig. 5).
BMI (kg/m²) 25.38 ± 3.43, 25.13 ± 3.94, 25.55 ± 3.07,
(18.87 ~ 34.06) (18.87 ~ 34.06) * (19.83 ~ 33.97) *
Discussion
(mean ± SD). #: P < 0.05; *: P > 0.05
Our research team, from clinical and biomechanical per-
spectives, designed the Standing on Single Foot-Binding
Table 2 Complications of ankle injury using arthroscopic test (SOSF-B test), which used an external bandage to
findings as the reference standard
partially replace the function of the distal tibiofibular
Complications Total With With-
(N = 85) DTSI out
syndesmosis, to diagnose DTSI. Our analysis of the diag-
(N = 32) DTSI nostic performance (Table 3) exhibited that the test had
(N = 53) good sensitivity and specificity in detecting DTSI, as
A 11(13%) 5(16%) 6(11%) compared with palpation and MRI. Han SH believes that
A+B 14(17%) 2(6%) 12(23%) MRI performs well in the diagnosis of ligament injury,
A+C 47(55%) 22(69%) 25(47%) but it is unable to quantitatively determine the degree of
A+B+C 13(15%) 3(9%) 10(19%) joint laxity by dynamic inspection [23]. This study proved
A: synovitis; B: osteochondral lesion of the talus; C: chronic lateral ankle that MRI had poor specificity (69.81%) in the diagnosis
syndesmosis injury
of DTSI when compared with 0° SOSF-B test (86.79%).
The 20 ° SOSF-B test (87.5%) showed marginally better
LR + for 20° SOSF-B test (6.625) and 0° SOSF-B test (6.39) sensitivity than 0° SOSF-B test (84.38%), but it requires
indicated a moderate increase in the likelihood of the a special device and had the same specificity as that of
disease if the test result was positive. The LR + for MRI 0° SOSF-B test (86.79%). The post-test probability of 0°
(2.59) and syndesmosis ligament palpation (2.01) sug- SOSF-B test, derived from the prevalence (28.7%) and LR
gested a small increase in the likelihood of the disease if (+) was 72%, suggesting that the probability of DTSI for
the test result was positive. The LR − for the 20° SOSF-B a person in this hypothetical population increases from
test (0.14) and 0° SOSF-B test (0.18) was indicative of a 28.7 to 72% when he or she has a positive result with the
moderate decrease in the likelihood of the disease with if 0° SOSF-B test. The post-test probability of 0° SOSF-B
the test result was negative. The LR − for MRI (0.31) and test was 6.8%, derived from the prevalence (28.7%) and
syndesmosis ligament palpation (0.44) was suggestive of LR (-), indicating that when the 0° SOSF-B test yields a
a small decrease in the likelihood of the disease if the test negative result, a person’s chance of having DTSI drops
result was negative (Table 3). from 28.7 to 6.8% in this population [3]. We believe that

Table 3 Clinical test results and indices of diagnostic utility in the diagnosis of DTSI using arthroscopic findings as the reference
standard
TEST Arthroscopic Sensitivity (%) Specificity (%) PPV (%) NPV (%) LR+ LR- Diagnostic
diagnosis (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) accuracy (%)
+ -
20° SOSF-B test + 28 7 87.5 86.79 80 92 6.625 0.14 87.06
- 4 46 (70.07–95.92) (74.05–94.09) (62.54–90.94) (79.89–97.41) (3.28–13.37) (0.06–0.36)
0° SOSF-B test + 27 7 84.38 86.79 79.41 91.2 6.39 0.18 85.88
- 5 46 (66.45–94.10) (74.05–94.09) (61.59–90.66) (77.81–96.33) (3.15–12.94) (0.08–0.41)
MRI + 25 16 78.13 69.81 60.98 84.09 2.59 0.31 72.94
- 7 37 (59.56–90.06) (55.49–81.26) (44.54–75.38) (69.33–92.84) (1.65–4.05) (0.16–0.61)
Palpation + 23 19 71.88 64.15 54.76 79.07 2.01 0.44 67.06
- 9 34 (53.02–85.60) (49.75–76.51) (38.83–69.83) (63.52–89.42) (1.32–3.05) (0.25–0.78)
Statistically significant (P < 0.05). PPV, positive predictive value; NPV, negative predictive value; LR+, positive likelihood ratio; LR−, negative likelihood ratio
Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 7 of 9

Fig. 5 The Fagan nomogram predicting post-test probability from prevalence and LR. 20° SOSF-B test (a), 0° SOSF-B test (b), MRI (c) and palpation (d)
respectively represent. The solid line is based on LR (+), and the dash line is based on LR (-)

the 0° SOSF-B test can satisfy the needs of clinical diag- 50 ~ 60 g as the pressure index, because the binding effect
nosis and can serve as a new alternative of physical exam- was the best under this condition. The lower pressure
inations for diagnosing DTSI. index couldn’t play the role of compression, while the
Our aim is to seek a new tool for rapid outpatient patients with the higher pressure felt obvious discomfort
screening of DTSI, and we are pleasantly surprised to find in the lower limbs, which might be related to the fact that
that the SOSF-B test can better diagnose diseases com- too strong pressure will block the blood circulation at the
pared with MRI and palpation. This may be because the ankle; (2) We used 5 s as the standing time basing on the
SOSF-B test is similar to a disease treatment method, that results of the pre-experiment. In the pre-experiment, we
ankle joint binding is often used as a treatment option for used 1 s, 5 and 10 s to detect the impact of the stand-
ankle instability in clinical practice and may have good ing time. It found that 1 s was so short that the observer
therapeutic effects [1], and overcomes the disadvan- and patient did not have enough time to judge the stand-
tage that other diagnostic methods cannot dynamically ing state. And some patients felt increasing pain on the
observe the patient’s movement state. This test is char- affected side, which affected their self-evaluation, when
acterized by easy operation, relative objectivity of indica- standing for 10 s.
tors, a higher acceptance and a short learning curve. The According to the results of arthroscopic exploration,
standing state of patients with one foot is relatively objec- the research group found DTSI could be accompanied
tive, and the false positive rate is low. The best part of by a variety of complications such as synovitis, osteo-
the method is that when checking the patient’s condition chondral lesion of the talus and chronic lateral ankle
during exercise, an external elastic bandage functionally syndesmosis injury [2, 5, 22]. The results of arthroscopic
replaces the distal tibiofibular syndesmosis. And patients exploration shew that the prevalence of DTSI exceeded
with DTSI are more willing to cooperate with the exam- 37% (32/85) and 16% (5/32) of DTSI patients were accom-
iner since pain or instability are relieved, and, as a result, panied by only synovial hyperplasia. The SOSF-B test
the diagnostic accuracy is improved. In general, when the designed by the research group was only aimed at how
patient reports a recent injury, and complains of inabil- to accurately diagnose DTSI and ignored other complica-
ity to walk following injury and physical checkup reveals tions of ankle sprain, which highlighted the significance
tenderness, the SOSF-B test is highly recommended to of the SOSF-B test in the diagnosis of special disease.
confirm or eliminate the diagnosis. When the SOSF-B This study has some limitations. First, the participants
test is positive, DTSI is highly likely and confirmatory were selected from patients who have been found to
imaging should ensue. But we also need to note that long have dyskinesia of ankle joint in the outpatient depart-
term SOSF-B test can cause obstruction of blood flow in ment and were recommended or scheduled for surgery.
the lower limbs of patients and adverse symptoms such Therefore, caution should be exercised when the results
as numbness and pain. Therefore, the examination pro- are extrapolated to healthy people. Second, EMG (elec-
cess should not be too long and the patient’s condition tromyogram) may be a better objective index to judge
should be observed at any time. the muscle contraction of patients, but because it is an
The selection of pressure index and standing time in invasive examination, it is not suitable to be widely car-
this test all come from the pre-experiment. (1) We set ried out in sports medicine clinics [21]. Third, the test
Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 8 of 9

Declarations
may be substantially affected by the presence of general-
ized ligament laxity [15, 20]. In our cohort, 9 cases had Ethics approval and consent to participate
multiple generalized ligament laxity and 3 cases were Ethical approval for this study was obtained from the Ethics Committee of
Chinese PLA General Hospital (2021 − 637). All participants provided written
misdiagnosed. How generalized ligament laxity affects informed consent before evaluation, and all study activities adhered to the
the stability of distal tibiofibular syndesmosis warrants principles of the Declaration of Helsinki.
further studies. Fourth, according to statistical data
Consent for publication
(Table 1), age might be another important contributor N/A.
to DTSI and it might be related to the higher or different
sports activities engaged by young people. The correla- Competing interests
The authors disclose no conflict of interest and state that the results of the
tion between age and DTSI needs to be further studied present study do not constitute any endorsement and declare that the
in future research. Therefore, we recommend that future results of the study are presented clearly, honestly, and without fabrication,
studies use prediction models that include multiple com- falsification, or inappropriate data manipulation.
binations of clinical symptoms and signs and diagnostic Author details
tests. This would help to better investigate the diagnos- 1
Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital,
tic power of these tests in the determination the injury Beijing, China
2
Department of Orthopedics, the Fourth Medical Center, Chinese PLA
severity. General Hospital (BEIJING, Beijing, China
To sum up, the SOSF-B test has satisfactory sensitivity 3
Department of Orthopedics/Chinese National Clinical Research Center
and specificity and can serve as an excellent alternative of for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese
PLA General Hospital, Beijing, China
physical examinations, though the symptoms of patients
with ankle injury vary. We believe that the result of the Received: 27 November 2022 / Accepted: 26 December 2023
test is clinically helpful in the diagnosis of DTSI patients.

Conclusion
The prospective and double-blind diagnostic-accuracy References
study demonstrated that the Standing on single foot- 1. Biz C, Nicoletti P, Tomasin M, et al. Is Kinesio Taping Effective for Sport perfor-
mance and ankle function of athletes with chronic ankle instability (CAI)? A
Binding test (SOSF-B test) could be used as a new clinical systematic review and Meta-analysis. Med (Kaunas). 2022;58(5):620.
diagnostic experiment for diagnosing distal tibiofibular 2. Blázquez Martín T, Iglesias Durán E, San Miguel Campos M. Complica-
syndesmosis instability (DTSI), and may play a role in the tions after ankle and hindfoot arthroscopy. Rev Esp Cir Ortop Traumatol.
2016;60(6):387–93.
diagnosis and treatment of ankle sprain. 3. Bolboacă SD. Medical diagnostic tests: a review of test anatomy,
phases, and statistical treatment of data. Comput Math Methods
Abbreviations
Med,2019;28;2019:1891569.
AITFL anterior inferior tibiofibular ligament
4. Chan KB, Lui TH. Role of Ankle Arthroscopy in Management of Acute Ankle
PITFL posterior inferior tibiofibular ligament
fracture. Arthroscopy. 2016;32(11):2373–80.
TFIL tibiofibular interosseous ligament
5. Chun K-Y, Choi YS, Lee SH, et al. Deltoid ligament and Tibiofibular Syn-
TTFL transverse tibiofibular ligament
desmosis Injury in chronic lateral ankle instability: magnetic resonance
DTSI distal tibiofibular syndesmosis instability
imaging evaluation at 3T and comparison with arthroscopy. Korean J Radiol.
SOSF-B test Standing on single foot-Binding test
2015;16(5):1096–103.
PPV positive predictive value
6. Cleland J, Koppenhaver S, Su J. The reliability and diagnostic utility of the
NPV (negative predictive value
orthopaedic clinical examination. In: Cleland J, Koppenhaver S, Netter F,
LR+ positive likelihood ratio
edsNetter’s orthopaedic clinical examination: an evidence-based approach.
LR− negative likelihood ratio
Elsevier Health Sciences. 2015:1–21.
EMG electromyogram
7. Dalmau-Pastor M, El-Daou H, Stephen JM, et al. Clinical relevance and func-
tion of Anterior Talofibular Ligament Superior and Inferior fascicles: a robotic
Acknowledgements
study. Am J Sports Med. 2023;51(8):2169–75.
None.
8. Gohar AN 1, Cunningham P, Lynch B et al. Fixation of ankle syndesmotic
injuries: comparison of tightrope fixation and syndesmotic screw fixation for
Author contributions
accuracy of syndesmotic reduction. Am J Sports Me, 2012;40(12):2828-35.
SQS and MW designed the research; SQS and TST collected and analyzed the
9. Hermans JJ, Wentink N, Beumer A, Hop WCJ, Heijboer MP, Moonen AFCM,
data with critical input from all co-authors; PTS and CY were responsible for
Ginai AZ. Correlation between radiological assessment of acute ankle frac-
analyzing statistical data; SQS drafted the manuscript; WJW, LC and MW were
tures and syndesmotic injury on MRI. Skeletal Radiol. 2012;41:787–801.
responsible for the final review of the article; all authors contributed to editing
10. Jiao C, Gui J, Kurokawa H, et al. APKASS Consensus Statement on Chronic
and approved the final manuscript.
Syndesmosis Injury, Part 1: clinical manifestation, radiologic examination,
diagnosis criteria, classification, and Nonoperative Treatment. Orthop J Sports
Funding
Med. 2021;9(6):23259671211021057.
N/A.
11. Langner I, Frank M, Kuehn JP, Hinz P, Ekkernkamp A, Hosten N, Langner S.
Acute inversion injury of the ankle without radiological abnormalities: assess-
Data availability
ment with high-field MR Imagingand correlation of findings with clinical
All data are available upon reasonable request from the corresponding author.
outcome. Skeletal Radiol. 2011;40:423–30.
12. Magarey ME, Jones MA, Cook CE, Hayes MG. Does physiotherapy diagnosis
of shoulder pathology compare to arthroscopic findings? Br J Sports Med.
2016;50(18):1151–7.
Sun et al. BMC Musculoskeletal Disorders (2024) 25:53 Page 9 of 9

13. Mentiplay BF, Perraton LG, Bower KJ, et al. Assessment of Lower Limb muscle 23. Tourné Y, Molinier F, Andrieu M, et al. Diagnosis and treatment of tibiofibular
strength and power using hand-held and fixed Dynamometry: a reliability syndesmosis lesions. Orthop Traumatol Surg Res. 2019;105(8S):275–S286.
and validity study. PLoS ONE. 2015;10(10):e0140822. 24. Vega J, Peña F, Golanó P, et al. Minor or occult ankle instability as a cause of
14. Mulligan EP. Evaluation and management of ankle syndesmosis injuries. Phys anterolateral pain after ankle sprain. Knee Surg Sports Traumatol Arthrosc.
Ther Sport. 2011;12(2):57–69. 2016;24(4):1116–23.
15. Razak HRBA, Ali NB, Howe TS. Generalized ligamentous laxity may be a predis- 25. Wake J, Martin KD. Syndesmosis Injury from diagnosis to repair: physical
posing factor for musculoskeletal injuries. J Sci Med Sport. 2014;17(5):474–8. examination, diagnosis, and arthroscopic-assisted reduction. J Am Acad
16. Ryan LP, Hills MC, Chang J, Wilson CD. The lambda sign: a new radiographic Orthop Surg. 2020;28(13):517–27.
indicator of latent syndesmosis instability. Foot Ankle Int. 2014;35(9):903–8. 26. Yu GS, Lin YB, Xiong GS, et al. Diagnosis and treatment of ankle syndesmosis
17. Sharif B, Welck M, Saifuddin A. MRI of the distal tibiofibular joint. Skeletal injuries with associated interosseous membrane injury: a current concept
Radiol. 2020;49(1):1–17. review. Int Orthop. 2019;43(11):2539–47.
18. Sman AD, Hiller CE, Refshauge KM. Diagnostic accuracy of clinical tests for 27. Yuen CP, Lui TH. Distal tibiofibular syndesmosis: anatomy, Biomechanics,
diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med. Injury and Management. Open Orthop J. 2017;11:670–7.
2013;47(10):620–8. 28. Zhang P, Liang Y, He JS, et al. A systematic review of Tightrope versus syndes-
19. Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle motic screw in the treatment of distal tibiofibular syndesmosis injury. BMC
syndesmosis injury. Br J Sports Med. 2015;49(5):323–9. Musculoskelet Disord. 2017;18(1):286.
20. Sueyoshi T, Emoto G, Yuasa T. Generalized joint laxity and Ligament Injuries
in High School-aged female Volleyball players in Japan. Orthop J Sports Med.
2016;4(10):2325967116667690. Publisher’s Note
21. Tankisi H, Burke D, Cui L, et al. Standards of instrumentation of EMG. Clin Springer Nature remains neutral with regard to jurisdictional claims in
Neurophysiol. 2020;131(1):243–58. published maps and institutional affiliations.
22. Theodorakys Marín Fermín JM, Hovsepian P. Arthroscopic debridement
of osteochondral lesions of the talus: a systematic review. Foot (Edinb).
2021;49:101852.