{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T15:47:57Z","timestamp":1782488877112,"version":"3.54.5"},"reference-count":23,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2020,9,3]],"date-time":"2020-09-03T00:00:00Z","timestamp":1599091200000},"content-version":"unspecified","delay-in-days":2,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2020,7,21]]},"published-print":{"date-parts":[[2020,9]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Although several imaging options are available for diagnosing syndesmotic injury, a fundamental question that guides treatment remains unanswered. Syndesmotic instability is still challenging to diagnose correctly, and syndesmotic disruption and true syndesmotic instability should be differentiated. Currently, imaging tests quickly diagnose severe syndesmotic instability but have difficulty in diagnosing mild and moderate cases. This study aims to investigate which strategy among an existing CT index test and two new add-on CT index tests with stress manoeuvres more accurately diagnoses syndesmotic instability. The secondary objective is to investigate the participants\u2019 disability outcomes by applying the Foot and Ankle Ability Measure questionnaire.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analyses<\/jats:title>\n                    <jats:p>This study of a diagnostic accuracy test will consecutively select individuals older than 18 years with a clinical diagnosis of a suspected acute syndesmotic injury. Three strategies of the CT index test (one in the neutral position and two with stress) will examine the accuracy using MRI as the reference standard. The external rotation and dorsiflexion of the ankle will guide the stress manoeuvres. A comparison of measurements between the injured syndesmosis and the uninjured contralateral side of the same individual will investigate the syndesmotic instability, by evaluating the rotational and translational relationships between the fibula and tibia. Sensitivity, specificity, area under the receiver operating characteristic curve and likelihood analyses will compare the diagnostic accuracies of the strategies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>The Internal Review Board and the Einstein Ethics Committee approved this study (registered number 62100016.5.0000.0071). All participants will receive an oral description of the study\u2019s aim, and the choice to participate will be free and voluntary. Participants will be enrolled after they sign the written informed consent form, including the terms of confidentiality. The results will be presented at national and international conferences and published in peer-reviewed journals and social media.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      ClinicalTrials.gov Registry (\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" specific-use=\"clinicaltrial pre-results\" xlink:href=\"NCT04095598\">NCT04095598<\/jats:ext-link>\n                      ; preresults).\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2020-037239","type":"journal-article","created":{"date-parts":[[2020,9,4]],"date-time":"2020-09-04T03:01:45Z","timestamp":1599188505000},"page":"e037239","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":13,"title":["Comparative CT with stress manoeuvres for diagnosing distal isolated tibiofibular syndesmotic injury in acute ankle sprain: a protocol for an accuracy- test prospective study"],"prefix":"10.1136","volume":"10","clinical-trial-number":[{"clinical-trial-number":"nct04095598","registry":"10.18810\/clinical-trials-gov","type":"preResults"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7107-2621","authenticated-orcid":false,"given":"Jo\u00e3o Carlos","family":"Rodrigues","sequence":"first","affiliation":[{"name":"Radiologia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"},{"name":"Radiologia, Universidade de S\u00e3o Paulo Hospital das Cl\u00ednicas, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6672-1869","authenticated-orcid":false,"given":"Alexandre Leme Godoy","family":"Santos","sequence":"additional","affiliation":[{"name":"Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"},{"name":"Ortopedia, Universidade de S\u00e3o Paulo Hospital das Cl\u00ednicas, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0325-8050","authenticated-orcid":false,"given":"Marcelo Pires","family":"Prado","sequence":"additional","affiliation":[{"name":"Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7664-2064","authenticated-orcid":false,"given":"Jos\u00e9 Felipe Marion","family":"Alloza","sequence":"additional","affiliation":[{"name":"Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Renato Amaral","family":"Masag\u00e3o","sequence":"additional","affiliation":[{"name":"Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4395-1159","authenticated-orcid":false,"given":"Laercio Alberto","family":"Rosemberg","sequence":"additional","affiliation":[{"name":"Radiologia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"},{"name":"Radiologia, Universidade de S\u00e3o Paulo Hospital das Cl\u00ednicas, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5210-3605","authenticated-orcid":false,"given":"Durval do Carmo Santos","family":"Barros","sequence":"additional","affiliation":[{"name":"Radiologia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0649-3662","authenticated-orcid":false,"given":"Adham do Amaral e","family":"Castro","sequence":"additional","affiliation":[{"name":"Radiologia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1999-9478","authenticated-orcid":false,"given":"Marco Kawamura","family":"Demange","sequence":"additional","affiliation":[{"name":"Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"},{"name":"Ortopedia, Universidade de S\u00e3o Paulo Hospital das Cl\u00ednicas, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3497-2206","authenticated-orcid":false,"given":"Mario","family":"Lenza","sequence":"additional","affiliation":[{"name":"Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5298-2486","authenticated-orcid":false,"given":"Mario","family":"Ferretti","sequence":"additional","affiliation":[{"name":"Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,9,3]]},"reference":[{"key":"2026062608003612000_10.9.e037239.1","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1177\/107110079801901002","article-title":"Persistent disability associated with ankle sprains: a prospective examination of an athletic population","volume":"19","author":"Gerber","year":"1998","journal-title":"Foot Ankle Int"},{"key":"2026062608003612000_10.9.e037239.2","doi-asserted-by":"publisher","DOI":"10.1177\/036354659101900315"},{"key":"2026062608003612000_10.9.e037239.3","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-016-4017-1"},{"key":"2026062608003612000_10.9.e037239.4","doi-asserted-by":"crossref","first-page":"1200","DOI":"10.1007\/s00167-015-3942-8","article-title":"Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines","volume":"24","author":"van Dijk","year":"2016","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"2026062608003612000_10.9.e037239.5","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1007\/s00256-017-2823-2","article-title":"Imaging in syndesmotic injury: a systematic literature review","volume":"47","author":"Kr\u00e4henb\u00fchl","year":"2018","journal-title":"Skeletal Radiol"},{"key":"2026062608003612000_10.9.e037239.6","doi-asserted-by":"publisher","DOI":"10.1080\/00016470310013969"},{"key":"2026062608003612000_10.9.e037239.7","doi-asserted-by":"crossref","first-page":"265-272","DOI":"10.1016\/j.fas.2019.03.006","article-title":"Accuracy of cone-beam computed tomography for syndesmosis injury diagnosis compared to conventional computed tomography","volume":"26","author":"Hamard","year":"2020","journal-title":"Foot Ankle Surg"},{"key":"2026062608003612000_10.9.e037239.8","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.fas.2019.02.002","article-title":"Is load application necessary when using computed tomography scans to diagnose syndesmotic injuries? A cadaver study","volume":"26","author":"Kr\u00e4henb\u00fchl","year":"2020","journal-title":"Foot Ankle Surg"},{"key":"2026062608003612000_10.9.e037239.9","doi-asserted-by":"publisher","DOI":"10.1148\/radiol.2271011865"},{"key":"2026062608003612000_10.9.e037239.10","doi-asserted-by":"crossref","first-page":"693","DOI":"10.1177\/107110079701801103","article-title":"Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study","volume":"18","author":"Ebraheim","year":"1997","journal-title":"Foot Ankle Int"},{"key":"2026062608003612000_10.9.e037239.11","doi-asserted-by":"crossref","first-page":"828","DOI":"10.1016\/j.arthro.2017.01.009","article-title":"Isolated syndesmosis diastasis: computed tomography scan assessment with arthroscopic correlation","volume":"33","author":"Ahn","year":"2017","journal-title":"Arthroscopy"},{"key":"2026062608003612000_10.9.e037239.12","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2016-012799"},{"key":"2026062608003612000_10.9.e037239.13","doi-asserted-by":"publisher","DOI":"10.1097\/BOT.0b013e318284785a"},{"key":"2026062608003612000_10.9.e037239.14","doi-asserted-by":"crossref","first-page":"479","DOI":"10.1177\/1071100717745660","article-title":"Syndesmotic injury assessment with lateral imaging during stress testing in a cadaveric model","volume":"39","author":"LaMothe","year":"2018","journal-title":"Foot Ankle Int"},{"key":"2026062608003612000_10.9.e037239.15","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1177\/1938640016668235","article-title":"Modification of distal tibiofibular relationship after a mild Syndesmotic injury","volume":"10","author":"Nault","year":"2017","journal-title":"Foot Ankle Spec"},{"key":"2026062608003612000_10.9.e037239.16","doi-asserted-by":"publisher","DOI":"10.1302\/0301-620X.85B3.13174"},{"key":"2026062608003612000_10.9.e037239.17","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1007\/s00167-018-5229-3","article-title":"The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses","volume":"28","author":"Lubberts","year":"2020","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"key":"2026062608003612000_10.9.e037239.18","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1097\/00003086-200110000-00010","article-title":"Complications in foot and ankle arthroscopy","author":"Ferkel","year":"2001","journal-title":"Clin Orthop Relat Res"},{"key":"2026062608003612000_10.9.e037239.19","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1097\/JSA.0b013e31828e5c6c","article-title":"Complications in ankle and foot arthroscopy","volume":"21","author":"Carlson","year":"2013","journal-title":"Sports Med Arthrosc Rev"},{"key":"2026062608003612000_10.9.e037239.20","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s00256-019-03260-7","article-title":"MRI of the distal tibiofibular joint","volume":"49","author":"Sharif","year":"2020","journal-title":"Skeletal Radiol"},{"key":"2026062608003612000_10.9.e037239.21","doi-asserted-by":"crossref","first-page":"2479","DOI":"10.3109\/09638288.2015.1137979","article-title":"Translation, cross-cultural adaptation and validity of the Brazilian version of the foot and ankle ability measure questionnaire","volume":"38","author":"Moreira","year":"2016","journal-title":"Disabil Rehabil"},{"key":"2026062608003612000_10.9.e037239.22","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2474-8-6"},{"key":"2026062608003612000_10.9.e037239.23","doi-asserted-by":"crossref","first-page":"968","DOI":"10.1177\/107110070502601113","article-title":"Evidence of validity for the foot and ankle ability measure (FAAM)","volume":"26","author":"Martin","year":"2005","journal-title":"Foot Ankle Int"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2020-037239","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T15:02:10Z","timestamp":1782486130000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2020-037239"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,9]]},"references-count":23,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2020,9,3]]},"published-print":{"date-parts":[[2020,9]]}},"alternative-id":["10.1136\/bmjopen-2020-037239"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2020-037239","relation":{"has-preprint":[{"id-type":"doi","id":"10.1101\/2020.01.24.20018515","asserted-by":"object"}]},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,9]]}}}