Ankle Impingement

Definition/Description

Ankle impingement is defined as pain in the ankle due to impingement in one of two locations: anterior (anterolateral and anteromedial) and posterior (posteromedial).[1] The location of the pain is determined from the tibiotalar (talocrural) joint.[2] Anterior ankle impingement usually indicates a mechanical structures at the anterior end of the tibiotalar joint in terminal dorsiflexion. Posterior ankle impingement results from compression of structures posterior to the tibiotalar and talocalcaneal articulations during terminal plantar flexion.[3] Pain from mechanical obstruction due to entrapment of osteophytes and/or soft tissue structures due to inflammatory lesions or hypermobility. The condition is common in athletes especially distance running football players and ballet dancers.[4] It was noticed in athletes whose sports required sudden jumps and extremes involving dorsiflexion or plantar flexion.[5] Historically it has been called athlete’s toe and footballer’s toe.[6]

Clinical Relevant Anatomy

Talocrural Joint

The Talus

The ankle joint is a hyaline synovial hinge joint covering the articular surfaces of the talus the tibia as well as the fibula which allows up to 20 degrees of dorsiflexion and 50 degrees of plantarflexion. The distal end of the tibia and fibula is held firmly by the medial ligaments (Deltoid) and the posterior hamstrings of the toes. The lines hold the tibia and fibula in place as deep as the bracket in which the talus sits.

• The TATAM of the cell is the distal lower portion of the tibia
• The MEDIAL SIDE of the joint is the medial malleolus of the tibia
• The POST of the joint is the posterior malleolus of the fibula

The articular portion of the talus is cylinder shaped and fits well into the bracket provided by the syndesmosis of the tibia and fibula when viewing the base of the talus the articular surface is wider anteriorly than posteriorly. This subsequently increases the complex matching nature of this joints when in dorsiflexion. Since this is a synovial joint there is a membrane and a fibrous membrane that provides the same function as a synovial joint any other synovial membrane.

Diagram of the Foot (Excluding Talus) .

Subtalar Joint

The Subtalar joint is also known as the Talocalcaneal joint and is located between:

• Large posterior calcaneal facet below talus; and
• The corresponding posterior surface of the calcaneus

This joint due to its orientation allows movements of inversion (0-35 degrees) and eversion (0-25 degrees) to break which this should mean that the joint allows a certain amount of glide and rotation. It is known as a simple synovial condyloid joint. There are many strong muscles that help joint.

Epidemiology/Etiology

Impingement syndromes of the ankle include a broad spectrum of pathologies with different etiologies. Although there is no official classification, these syndromes are generally defined by the specific anatomy involved. Specific: anterior anterolateral anteromedial posterior midline posterolateral.[7]Ankle impingement is a common condition secondary to concussion or repeated microtrauma.[8]

Anterior Impingement (AI)

Generally athlete’s toe or football player’s toe is known to result from repetitive dorsiflexion microtrauma and repetitive inversion injury causing damage to anteromedial structures such as articular cartilage. They are further classified as Anteromedial & Anterolateral Impingement[2]. It’s just a coincidence chondral and osteochondral lesions can be seen in patients with AI.[9] It can also be seen after non-sports injuries primarily involving fractures of the ankles and feet. There appears to be an association between subtle cavus foot (high arched foot) and ankle instability.[10]

Anterior intra-articular soft tissues may contribute to impingement in isolation or in association with bony lesions. The anterior joints contain triangular smooth muscle composed mainly of fat and cartilage. These muscles are inserted after 15° of dorsiflexion at asymptomatic individuals. Anterior osteophytes can restrict the space available for this soft tissue and increase its arrest resulting in chronic inflammatory synovitis and capsuloligamentous hypertrophy. In patients with anterior impingement pain and range of motion limitation may occur secondary to compression of these soft tissues.[7][11]

• Anteromedial Impingement: Suspected causes include: inversion ankle sprains; repetitive dorsiflexion with spurs; capsular traction with frequent traction resulting in osteophytes and chronic microtrauma of the anterior joint region. But the cause is still unknown to the above concepts described in the literature.
• Anterolateral Impingement: May result from inversion ankle sprains resulting in inflammation and scarring or reactive synovitis. It may also be due to forced plantarflexion and supination which can tear the anterolateral capsular tissues.[2]

Posterior Impingement (PI)

Commonly referred to as dancer’s foot, it is usually a dexterity in nature that occurs in typical athletic footwork such as ballet dancers jumping athletes and kickers.[2] Posterior toe impingement is a common cause of chronic ankle pain.[12]It can result from impingement of bone or soft tissue especially flexor hallucis longus irritation of the posterior capsule tightness synovitis inversion trauma/sprain forced plantarflexion causing anterior sheering tibial hypertrophy of the os trigonum affecting the posterior tibia. Also known as os trigonum syndrome and posterior tibiotalar obsessive-compulsive disorder.[13] The os trigonum is the most common cause of a symptom in posterior ankle sprains.[12]

• Posteromedial impingement: Chronic pain in the back is largely due to scar tissue forming the posterior fibers. With ankle inversion trauma with the ankle in plantar flexion, the posterior nerve fibers are compressed.[14] List of items included in posteromedial ankle impingement includes the posteromedial tibiotalar capsule and posterior fibers of the tibiotalar ligament. Their location between the talus and medial malleolus makes them easier to grasp in supine position. Subsequent fibrosis and thickening of the injured back the tibiotalar ligament and posteromedial capsule cause impingement on the medial wall of the talus and the posterior surface of the medial malleolus resulting in collagenous and fibrous meniscoid lesions and synovitis on the posteromedial ankle.
• Posterolateral impingement: This injury is caused by the Posterior Talofibular Ligament (also known as the Posterior intermalleolar ligament). However this ligament is an anatomic variant it is present in 56% of people. During plantar flexion the PTL will contract and then eventually tear.[16]

Characteristics/Clinical Presentation

People suffering from anterior/posterior ankle impingement were found to have moderate to severe limitations in activities of daily living due to pain.[17]The symptoms that occur may be subtle or a response to injury a it happens suddenly.

Anterior

Anterior ankle pain with ‘blocking sensation’ involved in dorsiflexion. It can also present with palpable soft tissue swelling on the facial joints.[5] While anterior impingement becomes chronic, other symptoms may become unstable; limited toe mobility; and pain during downhill running climbing stairs and climbing hills. Normal walking may have no effect.[2]

• Anterolateral: Patients experience severe anterolateral ankle pain when stepping on the foot or reclining on the ground anterolateral point tenderness pain that swells with single foot pronation.[5] Patients may have a history of ankle fracture or prolonged ankle instability and are currently involved constant back pain when walking.
• Anteromedial: A good proportion of these patients will have chronic anteromedial pain complicated by dorsiflexion tender to palpation over anteromedial joint line soft tissue swelling and decreased ROM to forced dorsiflexion as well as supination.

Posterior

The patient’s posterior ankle pain was exacerbated by exertion of plantarflexion or dorsiflexion. There may also be joint line tenderness of the posterior tibiotalar joint (without involving the Achilles tendon) [5]. Limited ankle plantarflexion, ligament instability, soft ligament thickening tissue[2]

• Posteromedial: A key clinical finding in patients with posteromedial impingement is posteromedial tenderness with ankle inversion during plantarflexion. Tenderness is most common with passive ankle inversion and passive plantarflexion. There is also pain in the posteromedial ankle area. [2] This helps differentiate pain from an abnormality of the tibialis posterior muscle. [5]
• Posterolateral: Patients with posterolateral impingement have a locking sensation of the ankle and pain in the back of the ankle. An acute varus injury with plantar flexion preceded the impact. The ligament (posterior talofibular) is compressed and torn, causing This ligament is hypertrophied. This injury is most common during repetitive plantarflexion sports such as ballet soccer volleyball.

Athletes affected by rear impingement may attempt to compensate for loss of plantarflexion by adopting an inverted foot position, which may result in:

• frequent ankle sprains
• calf sprain
• contractures
• planter foot pain
• toe curling

Differential Diagnosis

Anterior ankle pain [17][18] Stress fracture of the talus; tendinopathy/synovitis of the anterior ankle tendon; degenerative changes in the ankle or tanarovoid joint; nerve entrapment in the ankle or knee; radicular spinal pain; Other causes include tumor [19] posterior ankle pain [18] [20] talus or calcaneus Fracture Achilles tendinopathy Posterior ankle impingement Isolated flexor hallucis longus injury Retrocalcaneal bursitis Haglund’s deformity Posterior tibial osteochondral injury Tarsal tunnel Medial ankle pain [18] Tarsal tunnel syndrome Posterior tibial tendonitis Lateral malleolus fracture Medial malleolus joint Subtalar joint pathology Medial tibial stress syndrome (shin splints) Lateral ankle pain [18] Fracture (talus fibula 5th metatarsal) Peroneal tendon injury Lateral ankle impingement of fibula or sural nerve Stimulation Cuboid subluxation

Diagnostic Procedures

Chronic ankle pain swelling and limited ankle dorsiflexion are common complaints. Imaging is valuable for diagnosing bony impingement but not for soft tissue impingement based on clinical findings. [3]

Routine radiography is usually the first imaging technique performed to assess any underlying skeletal abnormalities, particularly in anterior and posterior impingement. Computed tomography (CT) and isotopic bone scans have largely been replaced by magnetic resonance (MR) imaging. gentlemen Imaging can show bone and soft tissue edema in anterior or posterior impacts. MR imaging is the most useful imaging modality for evaluating suspected soft tissue impingement. [19] Ultrasound is also accurate in diagnosing anterolateral soft tissue impingement injuries At the ankle, associated ligamentous injuries can be assessed and disease can be distinguished from bony impingement. [3]

Outcome Measures

All contain evidence on score interpretation, including content validity, construct validity, reliability and responsiveness. [twenty one]

• The Lower Limb Function Scale (LEFS) was created as a broad area-specific measure for individuals with musculoskeletal disorders of the hip, knee, ankle or foot. Can be used to assess disorders of one or both lower extremities and consists of 20 items specifically for Fields of activity and participation. Scores range from 0-80, with lower scores indicating greater disability.
• The Foot Function Index (FFI) is considered a tool to measure function in patients with rheumatoid arthritis, but the authors claim that there is no specific disease relationship to rheumatoid arthritis in this assessment. FFI is a region-specific tool for pathology in older adults Population, consisting of 23 items grouped into 3 subscales, including activity limitation disability and pain subscales. A lower FFI score indicates a higher level of functioning.
• The Foot and Ankle Ability Measure (FAAM) was developed as a region-specific tool for the comprehensive assessment of physical performance in individuals with a range of musculoskeletal disorders of the legs, feet and ankles. Used to detect changes in self-reported function over time and to assess Effectiveness of specific interventions delivered by clinicians. The instrument is divided into 2 separately scored subscales, including Activities of Daily Living and Movement subscales.
• The Foot Health Status Questionnaire (FHSQ) region-specific tool was developed for individuals undergoing surgery for common foot conditions in a podiatric practice. This questionnaire takes 5 minutes to complete and consists of 4 subscales including Pain Function Footwear General foot health. Researchers and clinicians can use this questionnaire to determine changes in foot health in response to therapeutic and surgical interventions.
• The Kinesiology Ankle Scoring System (QOL) is a self-report and clinician-completed assessment tool with 3 outcome measures, including a QOL measure clinical score and a single-number assessment. The QOL measure used to assess QOL in athletes following ankle injuries consists of 5 subscales This includes symptoms work and school activities recreational and physical activity daily life and lifestyle.

Examination

Physical examination should include examination of the ankle for swollen erythema and aligned joint effusion or soft tissue edema. [22] Gait analysis may reveal asymmetry and misalignment, as one can compensate for limited ankle DF in a variety of ways. Compensating runners from the proximal end can Shorten their stride length, lift their heels earlier or reduce their knee bends. It also compensates further by increasing pronation to allow more DF in the midfoot.

Bone and soft tissue structures are systematically palpated to assess localized tenderness. While anterior or anterolateral tenderness is characteristic of anterior impingement, signs of posterior impingement may be more difficult to elicit and localize as the structure is deeper. Posteromedial Ankle tenderness with resistance to plantarflexion of the first metatarsophalangeal joint is more consistent with FHL pathology, whereas posterolateral tenderness with resistance to plantarflexion of the ankle is more likely to involve pathology related to the trigone. [7] Passive and active range Measure bilateral joint motion, including dorsiflexion, plantarflexion, subtalar, and midfoot motion. Assess laterally for tender deformity or subluxation of the peroneal tendon. Assess the sensitivity of the sural nerve. Assess the back of the Achilles tendon Fusiform enlargement or retrocalcaneal bursitis. The tibial nerve was evaluated medially for tarsal tunnel syndrome and the function of the posterior tibial tendon was assessed. Anterior drawer and talar tilt tests of the tibiotalar joint are performed to rule out ankle instability. the last one A straight leg raising test may be performed in the sitting or supine position to rule out L5 or S1 radiculopathy. [7]

Anterior ankle impingement check [23]

5 or more present: Sen=.94 Spec=.75 +LR=3.76 -LR=.08

• pain with activities
• anterolateral ankle joint tenderness
• recurrent joint swelling
• Anterolateral pain with forced dorsiflexion and eversion (impingement sign: Sens=.95 Spec=.88 +LR=7.91 -LR=.06) [24]
• pain during single leg squat
• lack of lateral ankle instability

Additional tests:[12]

• Anterior Drawer Test for Lateral Ankle Instability (Sen= .86 Spec= .74 +LR .22 and -LR .0018)
• Silfverskiöld test for isolated gastrocnemius contracture. The test is considered positive when the ankle dorsiflexes more than it extends when the knee is flexed. MRI sensitivity = 39% Physical examination sensitivity = 94% [23]
• Forced dorsiflexion

Posterior ankle impingement check [25]

• Loss of mobility with pain in the back of the ankle
• pain with forced plantarflexion
• Prominent posterior talar processes
• Hyperplantar flexion test

Additional tests:[26]

• Deep pressure palpation of posteromedial joint line: positive => tenderness
• Slack Test (Front Drawer and Inversion)
• Manual strength test: tibialis anterior peroneus complex gastrocnemius soleus complex
• Flexibility Test: Achilles Hamstrings
• Forced Plantarflexion  
• Forced Inversion

Medical Management

Diagnosis[27]

1. Standard radiographs
2. MRI to check for soft tissue swelling and damage
3. A diagnostic injection is a local anesthetic injected into the joint capsule and soft tissue, and if the injection relieves symptoms, it is a positive test.

Surgery

Consider it after first trying conservative treatment for at least 3 months. [6] El-Sayed et al stated that arthroscopy is a useful approach in the management of patients with anterolateral impingement and according to the JSSF, follow-up showed complete improvement in 85% of patients. [6] Chirugie et al. showed that VAS and AOFAS scores improved significantly, with 79% of patients returning to the level of motion at which posterior ankle impingement had occurred. [28] Murawski et al showed 93% satisfaction with AOFAS and significant improvement with SF 36v2 ~68% with anteromedial impingement. [27] However, if exercising patients wish to return Immediately engaging in physical activity, surgical intervention can then be recommended early in the course of treatment. Surgical approaches and techniques vary according to the anatomical region and pathology involved [7].

Surgical methods include debridement, osteophyte removal, meniscal lesion resection, partial capsulectomy, flexor hallucis longus release, and tibial chondroplasty. [29] [30]

Complications include infection; neuropraxia; joint fibrosis; complex regional pain syndrome and peroneal nerve irritation. [27][28][30]

Anterior ankle impingement:

The goals of surgery in the treatment of anterior impingement include removal of deleterious pathological lesions causing symptoms. This may involve resection or debridement of bone lesions, soft tissue lesions, or both. [7]

Posterior ankle impingement:

Likewise, the surgical goal of treating posterior impingement involves resection of the causative anatomy. Symptom relief is most commonly achieved by excision of the painful trigone or triquetrum and debridement of surrounding inflammatory or hypertrophic soft tissue. Posterior pathology Targeting can be done via an open lateral open medial or endoscopic approach. The lateral approach allows more direct access to the trigone with less risk to the medial neurovascular bundle. A medial approach can more easily resolve concomitant FHL pathology. [7]

Post-op:

For posterior ankle impingement, apply a compression bandage after surgery and allow the patient to bear a tolerable weight bearing immediately after surgery. Patients can also begin to adjust their ankles within tolerance. The goal of early ROM and weight bearing is to prevent postoperative stiffness and hopefully limit the delay in recovery of motion. Ankle immobilization is usually not required unless the patient has a more severe bony injury, which may require modification of the above protocol. [31]

Medical Protocol: NWB in boot ~3 days WBAT day 3 elevation for swelling NSAIDs ankle pumps suture removal 10-14 days post-op and go to physical therapy.[32]

Physical Therapy Management

Treatment focuses on increasing available joint space for greater range of motion and less pain during activity. Nonoperative treatment remains the first-line approach for both anterior and posterior impingement syndromes despite limited evidence of efficacy. For acute symptoms, once a rest and avoidance of erotic activities are recommended. In chronic cases, footwear modifications including heel lift orthoses to prevent dorsiflexion have been used.[7]

Patients should be treated conservatively after ankle rotation for at least 6 months.[5] They should be treated conservatively after reverse injuries of the ankle with joint reconstruction to improve peroneal strength and muscle balance.[33] Patients who do not respond conservative management may require surgical intervention.[31]

Anterior Impingement

• Distraction manipulation
• A/P and lateral talocrural glides
• A/P distal fibula glides
• Cuboid whips (for those with reduced knees) .
• HEP: self A/P and lateral mobilization single leg balanced lunge dorsiflexion stretch developmental ankle resistance exercises
• Lateral ankle positioning protocols[34][35][36].

Activity 1Basic exercise:Walk slowly back and forth on a balance board (1 step = 3 seconds). The opposite leg swings through and almost touches the floorExercise 2:Basic exercise:One leg (knee and hip bent) stands on an exercise mat with feet the opposite has been created. Put it down and raise it body. Share weight on the legs. Only minor knee movements to the left and right are allowed.Exercise 3:Basic Exercise:Jump from one foot to the other on the exercise mat and watch your landing hold for 4 seconds. Raise the opposite legExercise 4:Basic exercise:Keep balance in one leg stance raising the parallel leg against a stiff resistance bar. Hold for 30 seconds each leg.Exercise 5:Basic Exercises:Provide balance in a one-leg stance on an inversion-eversion tilt board. The opposite leg stood on an incline with almost no loading.Variation 1:Walking faster than before on the balance board. Way back: same slow and execution as above.Variation 1:Single limb stance as above opposite partner. A ball is passed to the partner. After catching the ball, the position is maintained for 2 seconds.Move the ball back and forthVariation 1:Jump from one leg over the other on an exercise mat with a partner. Disturb each other during the flight phase (hand contact) and maintain the landing and stance for 4 seconds.Variation 1:Maintain balance in single leg stance ( eyes closed) elevating the contralateral leg against the resistance of an elastic strap.Variation 1:Maintain balance in a single-leg stance on an inversion-eversion tilt board. The opposite leg rested on a downward slope with virtually no loading. This is a partner. Pick up a ball and control standing after catching the ball.Variation 2:Stand on balance board. The opposite feet curl a horizontal ball. Focus on the supporting leg.Variation 2:One leg position on soft mattress. Balance a ball on the outside of the back of the parallel horizontal leg.Variation 2:Jump from one leg to the other on a flexible exercise mat with a spouse. Disturb each other during the flight phase (hand contact) and maintain the landing and stance for 4 seconds.Variation 2:Maintain balance in a single leg stance moving the contralateral leg sideways against the resistance of an elastic strap. Evert on the opposite side toot.Variation 2:For balancing in a single leg position on an inversion-eversion tilt board. The opposite leg goes up.

All of these exercises can be done on the perturbations. With peroneal strengthening, a Thera-band can be used in this exercise.[37][38]

Posterior Impingement

• Plantarflexion mobilisation
• P/A talocrural mobilisation
• Rear-foot distraction manipulation
• Proprioceptive work – wobble board
• Peronei strengthening
• Isometric and eccentric exercises to strengthen and stretch the lower leg muscles.[39]
• exercises that improve deep muscle tone during heel strikes. By manipulating the deep muscles, the talus is rotated forward in plantarflexion what to reduce the impact of the os trigonum on the posterior tibia.[39]
• HEP: Achilles tendon extension Single leg balance lunge dorsiflexion extension sustained ankle resistance exercise[40].
• Protective dorsiflexion taping[16]

Prevention

Protective ankle dorsiflexion taping is recommended with the belief that it prevents posterior ankle impingement.[41] There is no opinion as to whether ankle support may interfere with normal function rather than reduce pain and dysfunction caused by sports injuries. After a while impingement could be reduced by protective ankle dorsiflexion taping but also reduced the plantar-flexion movement of the ankle.[20]

Clinical Bottom Line

Ankle impingement is common in a number of athletes who repeatedly dorsiflex or plantarflex and/or have a history of inversion ankle sprains and other microtrauma. Current literature suggests surgical intervention as treatment. There is little high-quality evidence conservative management. Exercises should include manual therapy and exercises aimed at maximizing ankle joint mobility and reducing pain during walking.