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 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 TANTIFA 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 comfortably 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 repeated concussion or 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 result from 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

Patients have severe posterior ankle pain by forcing the heel into or out of the heel. It can also develop articular cartilage in the posterior tibiotalar joint (not around the achilles tendon)[5]. The ankle has limited plantar flexion and severe ligamentous instability nervous system.[2]

• Posteromedial: The main clinical finding for a patient with posteromedial impingement is weakness of the posteromedial aspect when the ankle is rotated in plantar flexion. Significant slowing is seen in passive ankle inversion and passive plantar flexion. There is also pain in the posteromedial region of the toes.[2] This helps to distinguish between pain caused by an abnormality of the tibialis posterior.[5]
• Back: The patient with back flexion feels the ankle bent and has pain at the back of the ankle. Impingement is preceded by an acute inversion injury with plantar flexion. The ligament ( posterior talofibular) has been compressed and this one has been torn though hypertrophy of these muscles. This type of injury is most common in sports with a high-impact lower leg (e.g. ballet football volleyball).

Athletes affected by back concussion may attempt to compensate for the loss of lower leg flexion by assuming an inverted foot position which can:

• 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 anterior ankle tendons;Degenerative changes in the ankle or talonavicular joint;Nerve entrapment in the ankle or knee;Radicular spinal pain;Other causes of causes with tumor Posterior toe pain[18][20]Talar or calcaneal akisikuruAchilles tendinopathyAkyi ankle impingementIsolated flexor hallucis longus opiraRetrocalcaneal bursitisHaglund’s deformityAkyi tibial osteochondral opiraTarsal tunnelMedial ankle ɛyaw[18]Tarsal tunnel syndromeAkyi tibial tendonitisMaleolar fracturesMedial ankle impingementSubtalar joint pathologyMedial tibial stress syndrome (shin splints)Posterior thigh pain[18]Fractured thigh (Talus Fibula 5th Metatarsal) Pernoeal tendon injuryPosterior hip impingementFibular or sural nerve irritationCuboid subluxation

Diagnostic Procedures

Chronic ankle pain with swelling and lack of ankle dorsiflexion are common complaints. Imaging is valuable for the diagnosis of bony thrombosis but not for soft tissue thrombosis based on clinical findings.[3]

Conventional imaging is usually the first imaging modality performed and allows for the evaluation of any potential bony compromise especially in terms of anterior and posterior osteolysis. Computed tomography (CT) and isotope bone scanning have largely been replaced by magnetic resonance (MR) imaging. MR imaging may reveal osteolytic and soft tissue deformities in anterior or posterior impacts. MR imaging is the most useful imaging modality in the evaluation of suspected soft tissue lesions.[19] Also ultrasound is accurate in diagnosing soft tissue impingement lesions on the anterolateral side is able to assess the associated nerve injury and distinguish the disease from osteoporosis.[3]

Outcome Measures

All contain evidence of score interpretation including content validity construct validity reliability and responsiveness.[21]

• The Lower Extremity Function Scale (LEFS) was developed to be a broad region-specific scale suitable for individuals with musculoskeletal disorders of the hip knee or foot. It can be used to assess problems in one or both lower extremities and consists of 20 specific items aspects of activity and participation. Scores range from 0-80 with lower scores representing the severity of the disability.
• The Foot Function Index (FFI) is considered a functional measurement tool in patients with rheumatoid arthritis but the authors state that there is no disease-specific association with arthritis in this study. The FFI is a region-specific tool for diseases in the elderly population and consists of 23 items divided into 3 subscales including functional limitation disability and pain subscales. A lower FFI score represents a higher level of functioning.
• The Foot and Ankle Ability Measure (FAAM) was developed as a region-specific tool to effectively assess physical performance in individuals with foot and lower leg musculoskeletal disorders. It is used to identify and assess changes in self-reported activity over time the effectiveness of a particular intervention being offered by a practitioner. Instrument is divided into 2 separately scored subscales including activities of daily living and sports subscales.
• The Foot Health Status Questionnaire (FHSQ) region-specific instrument developed for individuals undergoing surgical treatment at a podiatry practice regarding common foot conditions. This questionnaire takes 5 minutes to complete and consists of 4 subscales including pain activity shoes overall foot health. This questionnaire can be used by researchers and clinicians to determine changes in foot health status in response to medical and surgical interventions.
• The Sports Ankle Rating System (QOL) is a self-reported and clinician-completed assessment tool with 3 outcome measures including a QOL measure clinical score and one statistical analysis. The QOL measure used to assess an athlete’s QOL after an ankle injury contains 5 sub-scales including sign work and school activities recreation and sports activities activities of daily living and lifestyle.

Examination

The physical examination should include inspection of the ankle for swelling erythema and alignment joint effusion or soft tissue edema.[22] Gait analysis can reveal asymmetry and malalignment because people can compensate for limited ankle DF in many ways. From proximal compensation runners can their shorter stride length allows them to raise their heel earlier or reduces knee flexion. It can also be compensated at a greater distance by increasing pronation in order to create more DF in the midfoot.

They plan to palpate the bone and soft tissue structures to assess for localized tenderness. While anterior or anterolateral tenderness is characteristic in anterior impingement posterior impingement symptoms can be more difficult to achieve and localize as the structures are deeper. The middle of the back ankle tenderness with resisted plantar flexion of the first metatarsophalangeal joint is more consistent with FHL pathology while posterolateral tenderness with forced ankle plantar flexion is usually related to pathology associated with the trigonal process.[7]Passive and active ranges of joint motion is measured bilaterally including dorsiflexion plantar flexion subtalar and midfoot motion. Laterally, the peroneal tendon is examined for laxity or subluxation. The sural nerve is examined for sensation. Externally, the Achilles tendon is examined for fusiform enlargement or retrocalcaneal bursitis. Centrally, the tibial nerve is explored for tarsal tunnel syndrome and the posterior tibial tendon’s function is assessed. The anterior drawer and talar tilt tests of the tibiotalar joint are performed to exclude ankle instability. Finally a a straight leg raise test can be performed in a sitting or standing position to exclude L5 or S1 radiculopathy.[7]

Anterior ankle impingement Review[23] .

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

• pain with activities
• anterolateral ankle joint tenderness
• recurrent joint swelling
• pain in the face with forced spinal impingement (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 of hind toe instability (Sen= .86 Spec= .74 +LR .22 and -LR .0018) .
• Silfverskiöld test for isolated gastrocnemius contracture. The test is considered positive when ankle dorsiflexion is greater with knee flexion than with extension. MRI sensitivity = 39% Physical Examination sensitivity = 94% [23].
• Forced dorsiflexion

Posterior Ankle Impingement Evaluation[25]

• Loss of mobility accompanied by pain on the outer side of the ankle
• pain with forced plantarflexion
• Prominent posterior talar processes
• Hyperplantar flexion test

Additional tests:[26]

• Deep palpation pressure of the posteromedial joint: good => tenderness
• Laxity tests (front drawer and inversion) .
• Hand strength test: Anterior tibialis Peroneus complex Gastrosoleus complex
• Adaptive tests: Achilles tendon Hamstring
• Forced Plantarflexion  
• Forced Inversion

Medical Management

Diagnosis[27]

1. Standard radiographs
2. MRI showing soft tissue swelling and extent of injury
3. Diagnostic injection is a local anesthetic injected into the joint capsule and soft tissue as an injection for relief of symptoms which is a positive test.

Surgery

It is considered after a preliminary trial of conservative treatment for at least 3 months.[6] El-Sayed and colleagues state that arthroscopy is a useful method for treating patients with anterolateral impingement results at follow-up showed 85% complete improvement according to JSSF. Chirugie et al identified the VAS and AOFAS scores improved significantly and 79% of patients returned to previous sports with posterior ankle impingement.[28] Murawski et al showed 93% satisfaction AOFAS and SF 36v2 improved significantly ~ 68% had anteromedial impingement.[27] But if sports patients want to come back to sports activity immediately then surgical intervention may be recommended early in the course of treatment. Surgical approach and technique vary with anatomical site and associated pathology[7].

Surgical procedures include debridement osteophyte removal meniscoid lesion excision partial capsulectomy flexor hallux longus release and chondroplasty of the tibia may be performed.[29][30]

Complications include infection; neurological diseases; neuromuscular disease; acute regional pain and inflammation of the fibular nerve.[27][28][30]

Anterior ankle impingement:

Surgical goals for the treatment of facial concussions involve the removal of the offending pathological lesions that contribute to the symptoms. This may involve orthopedic incision or amputation soft tissue lesions or both.[7]

Posterior ankle impingement:

Similarly, the surgical goal of treating posterior curvature requires amputation of the causative body. Relief of symptoms is usually achieved by excision of a painful trigonal process or os trigonum with debridement of surrounding soft tissue or hypertrophic tissue. Back infection can be targeted by open lateral open medial or endoscopic approach. The posterior approach provides more direct access to the trigonal process with minimal risk to the medial neurovascular bundle. A medial approach allows for rapid management of concomitant FHL disease.[7]

Post-op:

For posterior ankle impingement, a compression bandage is applied postoperatively and patients are allowed as much weight bearing as tolerated immediately after surgery. Patients can also begin to move their toes as tolerated. The goal of early ROM management and weight bearing is postoperative prevention stiffness and hopefully limit the delay in returning to sport. In general, ankle immobilization is not required unless the patients had a significant orthopedic injury that 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 a one 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 an incline with almost 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 decreased 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.