Ankle Impingement

Contents

Search Strategy

Databases searched; PubMed, Physiopedia,  Prometheus, SpringerLink, Journal of Orthopaedic Surgery and Research,
Keywords searched: “Ankle Impingement”, “Ankle Impingement Anterior”, “Ankle Impingement Posterior”, “Therapy”

Definition/Description

Ankle impingement is defined as pain in the ankle due to impingement in one of two areas: anterior (anterolateral and anteromedial) and posterior (posterolateral and posteromedial).[1] Location of pain is referenced from the tibiotalar (talocrural) joint.[2] Anterior ankle impingement generally refers to entrapment of structures along the anterior margin 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 is caused by mechanical obstruction due to osteophytes and/or entrapment of various soft tissue structures due to inflammation, scarring or hypermobility. The condition is common in athletes, especially soccer players, distance runners and ballet dancers.[4] It is noted in athletes whose sports require sudden acceleration, jumping and/or extremes of dorsiflexion or plantar flexion.[5] Historically, it has been called "athlete's ankle" and "footballer's ankle".[6]

Clinical Relevant Anatomy

The ankle is the region where the foot and leg meet and is made of the upper and lower ankle joint.

  1. Upper joint (Art. talocruralis) The upper ankle joint is formed by the distal ends of the tibia and fibula, and the talus trochlea. The art. talocruralis has thereby a good conduction of bones and tires and thus contribute to an ensuring and erect posture.
  2. Lower joint (Art. subtalaris)The lower joint articulates the talus with the calcaneus and ossis navicularis.
  3. Ligaments of the ankle The medial and lateral ligaments are together with the syndesmose bands of decisive importance for the stabilization and guiding of the upper ankle joint.[7]

Epidemiology/Etiology

Impingement syndromes in the ankle include a broad spectrum of pathology with varying etiologies. Although no official classification exists, these syndromes are generally defined by the particular anatomic area involved, specifically anterior, anterolateral, anteromedial, posterior, posteromedial, posterolateral.[8] Ankle impingement is a common condition occurring secondary to sprain or repeated microtrauma. [9]

Anterior Impingement (AI)

Also known as "athlete's ankle" or "footballer's ankle," condition is caused by repeated dorsiflexion, microtrauma and repeated inversion injury causing damage to anteromedial structures such as the articular cartilage. Further classified into Anteromedial and Anterolateral Impingement.[2] Concurrent chondral and osteochondral lesions may be found in patients with AI.[10] It can also be seen after nonsporting injuries, especially fractures of the ankle and foot. There appears to be an association with a subtle cavus foot (high arched foot) and ankle instability.[11]

Anterior intra-articular soft tissues may contribute to impingement in isolation or in conjunction with bony lesions. A triangular soft tissue mass composed primarily of adipose and synovial tissues exists in the anterior joint space. These tissues are compressed after 15° of dorsiflexion in asymptomatic individuals. Anterior osteophytes may limit the space available for this soft tissue and exacerbate its entrapment, resulting in chronic inflammation, synovitis and capsuloligamentous hypertrophy. In patients with anterior impingement, pain and restricted range of motion may be secondary to impingement of this soft tissue.[8][12]

Anteromedial Impingement

Hypothesized etiology includes: inversion ankle sprains; repetitive dorsiflexion resulting in spurs; repetitive capsular traction causing the formation of osteophytes, and chronic microtrauma to the anterior joint area. However, the cause remains unknown with the above theories mentioned in the literature.[1]

Anterolateral Impingement

May be caused by inversion ankle sprains causing inflammation and scar formation or reactive synovitis. May also be due to forced plantarflexion and supination which can tear anterolateral capsular tissues.[2]

Posterior Impingement (PI)

Also known as "dancer's heel," this condition is generally insidious in nature, occurring in athletes who routinely plantarflex (such as ballet dancers or jumping athletes) and those who kick. [2] Posterior ankle impingement is a common cause of chronic ankle pain.[13] It may be caused by bony or soft tissue impingement, specifically flexor hallucis longus irritation, thickening of the posterior capsule, synovitis, inversion trauma/sprain, forced plantar flexion causing anterior sheering of the tibia, hypertrophy of the os trigonum impacting the posterior tibia.[1] Also known as os trigonum syndrome and posterior tibiotalar compression syndrome.[14] The os trigonum is the most common cause of symptomatic posterior ankle impingement.[13]

Posteromedial impingement

Chronic posteromedial pain is mostly caused by scar tissue that consists of the posterior fibers. When there is an ankle inversion trauma, with the ankle in plantar flexion, the fibers of the posterior ligament become compressed.[15] The structures involved in posteromedial ankle impingement include the posteromedial tibiotalar capsule and posterior fibers of the tibiotalar ligament. Their location between the talus and medial malleolus predisposes to the entrapment during supination. The subsequent fibrosis and thickening of the injured posterior tibiotalar ligament and posteromedial capsule cause impingement between the medial wall of the talus and posterior margin of the medial malleolus, resulting in formation of collagenous and fibrous meniscoid lesions and synovitis at the posteromedial ankle. [16]

Posterolateral impingement

This injury is caused by the Posterior Talofibular Ligament (also called the Posterior intermalleolar ligament). However, this ligament is an anatomic variant, being present in 56% of the population[13]. During plantar flexion, the PTL will entrap and then finally torn.[13]

Characteristics/Clinical Presentation

People suffering from anterior/posterior ankle impingement were found to have moderate to severe limitation in activities of daily living due to pain.[17] Symptom development may be insidious or in response to sudden injury.[2]

Anterior

Anterior ankle pain accompanied by a blocked sensation during dorsiflexion. May also present with palpable soft tissue swelling over anterior joint. [2]

As anterior impingement becomes chronic, additional symptoms may include instability, limited ankle motion, and pain with squatting, sprinting, stair climbing, and hill climbing. Normal gait may be unaffected.[13]

Anterolateral

Patients experience anterolateral ankle pain that is intensified with supination or pronation of the foot, anterolateral point tenderness, pain with a single-leg squat and swelling.[2] Patients may have a history of ankles sprains or chronic ankle instability and now present with constant lateral ankle pain upon ambulation.

Anteromedial

Many of these patients will have chronic anteromedial pain that is intensified by dorsiflexion, tender to palpation over anteromedial joint line, soft tissue swelling, and decreased ROM into forced dorsiflexion as well as supination.[1]

Posterior

Patients have posterior ankle pain intensified by forced plantar flexion or dorsiflexion. They may also have joint line tenderness of the posterior tibiotalar joint (not involving the achilles tendon).[2]

Athletes affected by posterior impingement may attempt to compensate for the loss of plantar flexion by assuming an inverted foot position which may predispose them to:[13]

  1. frequent ankle sprains 
  2. calf strains
  3. contractures
  4. plantar foot pain
  5. toe curling

Physicians use radiographs as a means of medical diagnosis but any radiographic findings must be correlated to patient symptoms.

Posteromedial

A key clinical finding for a patient with a posteromedial impingement is tenderness to the posteromedial aspect upon inversion with the ankle in plantar flexion. Tenderness is most seen in passive ankle inversion and passive plantar flexion. There is also pain in the posteromedial region of the ankle.[13]  This helps to differentiate from pain that comes from a tibialis posterior abnormality.[2]

Posterolateral

A patient with a posterolateral impingement experiences a feeling of the ankle locking as well as pain over its posterior aspect. The impingement is preceded by an acute inversion injury with plantar flexion. The ligament (posterior talofibular) is compressed and torn, this leads to an hypertrophy of this ligament. This injury is the most common in sports with a repetitive plantar flexion (e.g. ballet, soccer, volleyball). The ankle has a limited plantar flexion and a ligamentous instability with thickening of the soft tissue.[13]

Causes

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. Ligament tears and ankle instability can cause pain, swelling, ankle locking, cracking and a feeling of instability during weight-bearing activities.

[18]

Moreover, a group of fibers fuse with the posterior intermalleolar ligament. The posterior intermalleolar ligament tenses during dorsiflexion and relaxes during plantar flexion. Thus, trauma that causes forced dorsiflexion can be assumed to produce either injury or rupture of this ligament, or osteochondral avulsion. Plantar flexion would cause it to relax and become susceptible to trapping between the tibia and the talus, leading to impingement. This structure has been implicated as a cause of chronic pain following ankle sprain in the condition known as anterolateral soft tissue impingement or more specifically, syndesmotic impingement.[19][20]

Posterior ankle impingement syndrome encompasses a range of pathological entities causing chronic pain at the posterior aspect of the ankle. Patients typically report recurrent pain localized to the posterior ankle, exacerbated by forced plantar flexion or push-off activities.
The common cause of posterior ankle impingement syndrome is impingement of an Os trigonum or a prominent posterior talar process and results from compression of bony or soft tissue structures during ankle plantar flexion. Posteromedial soft tissue impingement generally arises from an inversion injury, with compression of the posterior tibiotalar ligament between the medial malleolus and talus. Posterolateral soft tissue impingement is caused by an accessory ligament, the posterior intermalleolar ligament, which spans the posterior ankle between the posterior tibiofibular and posterior talofibular ligaments. Finally, anomalous muscles have also been described as a cause of posterior impingement.

The condition is commonly encountered in ballet dancers and individuals who participate in sports requiring repeated plantar flexion and, and can be secondary to overuse or trauma. Differentiation of the two causes is important, as impingement resulting from overuse has better prognosis.

Consequences

Symptoms of PAIS are thought to result from two main mechanisms:

  1. Impaction of osseous structures against each other, where the posterior talar prominence may be compressed between the posterior tibia and posterior calcaneal tuberosity
  2. Compression of soft tissue structures between two opposing bony structures.

Variations in the bony anatomy can predispose to PAIS. A prominent tuberosity arising from the superior calcaneum was found to be the most common associated anatomical variant in a study of ballet dancers with PAIS. Variations to the posterolateral talus include an unusually long lateral tubercle of the posterior talar process, and failure of fusion of a secondary ossification center found posterior to the lateral tubercle resulting in an Os trigonum. Previous trauma or degenerative arthritis, for example in repeated plantar hyperflexion, may result in hypertrophy of the posterior process of the talus, subtalar arthritis, posterior osteophytes and osteochondral loose bodies. Repeated trauma may result in thickening of the posterior tibiotalar and subtalar joint capsule. Other soft tissue findings on MR imaging include post traumatic scar tissue and FHL tenosynovitis. In the anteroposterior view of the ankles, the affected feet showed an obvious deformity compared with the normal feet. Such a deformity will not occur even with the feet internally or laterally rotated by 10° in healthy feet.[21]

Differential Diagnosis

Posterior Ankle Pain[22][23]
Anterior Ankle Pain[23][24]
  • Anterior ankle impingement
  • Talar dome injuries
  • Compartment syndrome
  • Deep fibular nerve lesion
  • Stress fracture of the talus
  • Tendinopathy/synovitis of anterior ankle tendons
  • Degenerative changes of the ankle or talonavicular joint
  • Nerve entrapment at ankle or knee
  • Radicular spinal pain
  • Other causes including tumour
Lateral Ankle Pain[23]
  • Fracture: Talus,Fibula, 5th Metatarsal (Avulsion, Jones)
  • Fibularis tendon injury
  • Lateral ankle impingement
  • Fibular or sural nerve irritation
  • Cuboid subluxation
Medial Ankle Pain[23]


Diagnostic Procedures

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

Conventional radiography is usually the first imaging technique performer and allows assessment of any potential bone abnormality, particularly in anterior and posterior impingement. Computed tomography (CT) and isotope bone scanning have been largely superseded by magnetic resonance (MR) imaging. MR imaging can demonstrate osseous and soft-tissue edema in anterior or posterior impingement. MR imaging is the most useful imaging modality in evaluating suspected soft-tissue impingement.[25]

Also ultrasound is accurate in diagnosing soft tissue impingement lesions within the anterolateral aspect of the ankle and can evaluate associated ligament injuries and differentiate the disease from bony impingement.[3]

Outcome Measures

All contain evidence regarding score interpretation including content validity, construct validity, reliability and responsiveness. [26]

The Lower Extremity Function Scale (LEFS) was created to be a broad region-specific measure appropriate for individuals with musculoskeletal disorders of the hip, knee, ankle or foot. It can be used to evaluate disorders of one or both lower extremities and consists of 20 items that specifically address the domains of activity and participation. Scores range from 0-80 with the lower the score representing a greater disability.

The Foot Function Index (FFI) is viewed as an instrument to measure function in patients with rheumatoid arthritis. However, the authors claim there is no specific disease relation to rheumatoid arthritis in this assessment. The FFI is a region-specific instrument for pathologies in the older population and consists of 23 items grouped into three sub-scales, including activity limitation, disability and pain subscales. A lower FFI score represents a higher level of function.

The Foot and Ankle Ability Measure (FAAM) was developed as a region-specific instrument to comprehensively assess physical performance among individuals with a range of leg, foot and ankle musculoskeletal disorders. It is used to detect changes in self-reported function over time and to evaluate the effectiveness of a specific intervention being delivered by a clinician. The instrument is divided into two subscales (activities of daily living and sports); these scales are scored separately.

The Foot Health Status Questionnaire (FHSQ) is a region-specific instrument that was developed for individuals undergoing surgical treatment in a podiatry practice for common foot conditions. This questionnaire takes five minutes to complete and consists of four sub-scales (pain, function, footwear and general foot health). This questionnaire can be used by researchers and clinicians to identify changes in foot health status in response to therapeutic and surgical interventions.

The Sports Ankle Rating System (QOL) is a self-reported and clinician-completed assessment tool with three outcome measures (quality of life, clinical rating score and single numeric evaluation). The QOL measure contains five sub-scales; symptoms, 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, alignment, joint effusion or soft tissue edema. Gait analysis may reveal asymmetry and malalignment.[27] People can compensate for limited ankle dorsiflexion in many ways. From a proximal compensation, runners can shorten their step length, have an early heel rise or reduce their knee flexion. It can also be compensated for more distally by increasing pronation in order to allow more dorsiflexion in the midfoot.[28]

The bone and soft tissue structures are systematically palpated to assess for localized tenderness. While anterior or anterolateral tenderness is characteristic in anterior impingement, posterior impingement signs can be more difficult to elicit and localize, as structures are deeper. Posteromedial 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 more likely to involve pathology associated with the trigonal process.[8]

Passive and active ranges of motion of the joints bilaterally are measured, including dorsiflexion, plantar flexion, subtalar and midfoot motions. Laterally, the peroneal tendon is assessed for tenderness, deformity, or subluxation. The sural nerve is evaluated for sensitivity. Posteriorly, the Achilles tendon is assessed for fusiform enlargement or retrocalcaneal bursitis. Medially, the tibial nerve is evaluated 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 straight leg raise test in the seated or supine position may be done to exclude an L5 or S1 radiculopathy.[8]

Anterior ankle impingement Examination [29]

Five 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) [30]
  • pain during single leg squat
  • lack of lateral ankle instability

Additional tests:[13]

Anterior drawer test for lateral ankle instability. (Sen= .86 Spec= .74 +LR .22 and -LR .0018)

The Silfverskiöld test for an isolated gastrocnemius contracture:

  • The test is considered positive when ankle dorsiflexion is greater with the knee in flexion than in extension.

MRI sensitivity = 39% Physical Examination sensitivity = 94% [29]

Posterior Ankle Impingement Examination[31]

  • Loss of mobility, accompanied by pain in posterior aspect of ankle
  • Pain with forced plantar flexion
  • Prominent posterior talar processes
  • Hyperplantar flexion test [32]

Additional tests[33]

  • Deep pressure palpation of the posteromedial joint line: positive => tenderness
  • Laxity tests:
  1. Anterior drawer
  2. Inversion
  • Manual strength test:
  1. Anterior tibialis
  2. Peroneus complex
  3. Gastrosoleus complex
  • Flexibility tests:
  1. Achilles tendon
  2. Hamstring
Forced Dorsiflexion
Forced Dorsiflexion
Forced Plantarflexion
Forced Plantarflexion
Forced Inversion
Forced Inversion

Medical Management

Diagnosis [34]

1. Standard radiographs

2. MRI for soft tissue swelling and extent of injury

3. Diagnostic injection is a local anesthetic administered into joint capsule and soft tissue, if injection relieved the symptoms it is a positive test.

Surgery

Surgery is considered after conservative treatment has been tried for at least three months.[6]

El-Sayed et al states that arthroscopy is a useful method to treat patients with anterolateral impingement, results at follow-up showed 85% improved completely according to JSSF.[6]

Chirugie et al showed VAS and AOFAS score improved significantly and 79% of patients returned to prior level of sport that had posterior ankle impingement. [35]

Murawski et al showed 93% satisfaction, AOFAS and SF36v2 significantly improved ~ 68% that had anteromedial impingement. [34]

However, if athletic patients want to return to their activity promptly, then surgical intervention can be recommended early in the treatment process. The surgical approach and technique vary by the anatomic region and pathology involved.[8] (Level of Evidence: 3a)

Anterior ankle impingement

Surgical goals for the treatment of anterior impingement involve removing the offending pathologic lesion contributing to the symptoms. This may involve resection or debridement of bony lesions, soft tissue lesions or both.[8] (Level of Evidence: 3a)

Posterior ankle impingement

Similarly, the surgical goal of treating posterior impingement involves resection of the causative anatomy. Most commonly, symptom relief is achieved by excision of a painful trigonal process or os trigonum, with debridement of surrounding inflammatory or hypertrophic soft tissues. Posterior pathology can be targeted through an open lateral, open medial, or endoscopic approach. A lateral approach allows for more direct access to the trigonal process with less risk to the medial neurovascular bundle. A medial approach allows for concomitant FHL pathology to be addressed more easily.[8] (Level of Evidence: 3a)

Surgery Methods

Debridement, osteophyte removal, meniscoid lesion excision, partial capsulectomy, flexor hallux longus release and chondroplasty of tibia may be performed.[36] [37]

Complications include: infection; neuropraxia; arthrofibrosis; complex regional pain syndrome and fibular nerve irritation. [34][35][37]

Post-operative Care

Following surgery for posterior ankle impingement, a compression bandage is applied and patients are allowed to bear weight as tolerated immediately after surgery. Patients may also begin ankle ROM exercises as tolerated. The goal of early ROM and weightbearing is to prevent post-operative stiffness and hopefully limit the delay in return to sport. Typically, ankle immobilization is not necessary, unless patients had more significant osseous injury, which may require modifications of the above protocol.[16] (Level of Evidence: 2a)

Medical Protocol: NWB in boot ~3 days, WBAT day 3, elevation for swelling, NSAIDs, ankle pumps, suture removal 10-14 days post-op, and refer to physical therapy. [38]

Conservative Management

Physical Therapy Management

Treatment focuses on increasing available joint space for more mobility and less pain during activity. Nonsurgical treatment remains the initial approach to the management of both anterior and posterior impingement syndromes, despite limited evidence of its efficacy.For acute symptoms, a period of rest and avoidance of provocative activities is recommended. In chronic cases, shoe modifications, including heel lift orthoses to prevent dorsiflexion, have been utilized.[8] (Level of Evidence: 3a)

Patients should be treated conservatively after an inversion sprain of the ankle for at least six months, [5] (Level of Evidence: 3a) with adequate joint rehabilitation, peroneal strengthening, and muscle rebalancing.[1] (Level of Evidence: 3a)

Patients who do not respond to conservative management may require surgical intervention.[16] (Level of Evidence: 2a)

Anterior ankle impingement

  • Shock-absorbing shoes
  • Steroid injections
  • NSAIDs
  • A heel-lift orthosis to prevent dorsiflexion
  • Activity restrictions
  • Image-guided corticosteroid injections
  • Anti-inflammatory medication
  • HEP: self A/P and lateral mobilization, single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises
  • Lateral ankle stability protocols[39][40][41]
  • Manual Therapy;
  1. Distraction manipulation
  2. A/P and lateral talocrural glides
  3. A/P distal fibula glides
  4. Cuboid whip (for those with decreased pronation)
[42] [43] [44] [45]

Posterior ankle impingement:[13]

  • Rest and ice (RICE)
  • NSAIDs
  • Avoidance of extreme plantar flexion
  • Protective dorsiflexion taping
  • Immobilization
  • Activity restriction
  • Anti-inflammatory medication
  • Proprioceptive exercises e.g. on a wobble board
  • Peronei strengthening
  • Isometric and eccentric exercises to strengthen and stretch the lower-leg muscles.[46] (Level of Evidence: 2b)
  • exercises to improve deep muscle action during plantarflexion. By using the deep muscles, the talus is shifted forward during plantarflexion, what will reduce the impact of the os trigonum on the posterior tibia.[46] (Level of Evidence: 2b)
  • HEP: Achilles tendon stretching, Single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises [1][47]
  • Protective dorsiflexion taping[13]
  • Manual Therapy;
  1. Plantarflexion mobilization
  2. P/A talocrural mobilization
  3. Rear-foot distraction manipulation
[48] [49] [50]


Exercise 1
Walking slowly back and forth on a balance board (1 step = 3 seconds). The contralateral leg swings through and nearly touches the ground.
Exercise 2
Single leg (knee and hip flexed) stance on exercise mat with the contralateral leg flexed. Lower and raise the body. Distribute load on the foot. Only small knee movements to the left and right are allowed.
Exercise 3
Jump from one leg to the other on an exercise mat and control landing for 4 seconds. Raise the contralateral leg.
Exercise 4
Maintain balance in single-leg stance elevating the contralateral leg against resistance of an elastic strap. Hold 30 seconds each leg.
Exercise 5
Maintain balance in single leg stance on inversion-eversion tilt board. The contralateral leg rested on an inclined surface nearly without being loaded.
Variation 1:
Walking faster than before on the balance board. Way back: slowly with same execution as above.
Variation 1:
Single limb stance as above opposite to a partner. A ball is passed to the partner. After catching the ball the position is controlled for 2 seconds. Pass the ball back and forth.
Variation 1:
Jump from one leg to the other on an exercise mat with a partner. Disturb each other during the flight phase (hand contact) and control the landing and stance for 4 seconds.
Variation 1:
Maintain balance in single leg stance (eyes closed) elevating the contralateral leg against resistance of an elastic strap.
Variation 1:
Maintain balance in single leg stance on inversion-eversion tilt board. The contralateral leg rested on an inclined surface nearly without being loaded. This with a partner. Pass a ball and control stance after catching the ball.
Variation 2:
Stance on a balance board. The contralateral leg moves a ball that lies on the ground in circles. Focus on the supporting leg.
Variation 2:
Single leg stance on a soft mat. Balance a ball on the dorsum of the elevated contralateral foot.
Variation 2:
Jump from one leg to the other on an soft exercise mat with a partner. Disturb each other during the flight phase (hand contact) and control the landing and stance for 4 seconds.
Variation 2:
Maintain balance in single leg stance moving the contralateral leg sideways against resistance of an elastic strap. Evert the lateral edge of the contralateral toot.
Variation 2:
Maintain balance in single leg stance on inversion-eversion tilt board. The contralateral leg is elevated.


All of these exercises can be performed on the different perturbations. For peroneal strengthening, a resistive exercise band can be used.[51][52]

Prevention:
Protective ankle dorsiflexion taping is recommended with the belief that it prevents posterior ankle impingement. However, the relationship between ankle taping and ball-kicking performance remains unclear.
At soccer players the subjects' ankle plantar flexion was limited by taping. Four angles of plantar flexion (0°, 15°, 30°, and without taping) were formed by gradation limitation. The subjects performed maximal instep kicks at each angle.
Passive ankle plantar-flexion angle, maximal plantar-flexion angle at ball impact, ball velocity, and foot velocity were measured. Ankle dorsiflexion taping could gradually limit both passive plantar flexion and plantar flexion at the impact. Furthermore, limitation of 0° and 15° reduced the ball velocity generated by instep kicks. Plantar-flexion-limiting taping at 30° has a potential to prevent posterior ankle impingement without decreasing the ball velocity generated by soccer instep kicks.
Protective ankle dorsiflexion taping is recommended with the belief that it prevents posterior ankle impingement.[53] (Level of Evidence: 2b)
There is no consensus as to whether ankle support can interfere with normal function instead of reducing the pain and dysfunction caused by sports injury. While posterior impingement may be reduced by protective ankle dorsiflexion taping, but it also reduced the ankle plantar-flexion movement.[24] (Level of Evidence: 2b)

Key Research

  • Liu S, Nuccion S, Finerman G. Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. American Journal of Sports Medicine. May 1997;25(3):389-393.
  • Ankle Impingement Syndromes: Diagnosis and Treatment, Shane McClinton, Regis University OMPT Fellowship, 2008.
  • Robinson P. Impingement syndromes of the ankle. European Radiology. December 2007;17(12):3056-3065.

Presentations

https://connect.regis.edu/p38686942/
Ankle Impingement Syndromes: Diagnosis and Treatment

This presentation was created by Shane McClinton as part of the Manual Therapy Fellowship at Regis University.

Ankle Impingement Syndromes: Diagnosis and Treatment / View the presentation

Clinical Bottom Line

Ankle impingement is common within certain populations of athletes who repeatedly dorsiflex or plantarflex and/or have a history of inversion ankle sprains and other microtrauma. Current literature favors surgical intervention as treatment. There is a limited amount of high quality evidence for conservative management. Physical therapy should include manual therapy and exercise that aim to increase mobility of the ankle joint and decrease pain with ambulation. 

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References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 McClinton, S. Regis University. Ankle impingement syndromes: diagnosis and treatment. Available at: https//connect.regis.edu/p38686942/. Accessed on July 9, 2011.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Robinson P. Impingement syndromes of the ankle. European Radiology [serial online]. December 2007;17(12):3056-3065
  3. 3.0 3.1 3.2 Vaseenon, Tanawat, and Annunziato Amendola. "Update on anterior ankle impingement.” Current reviews in musculoskeletal medicine 5.2 (2012): 145-150. http://link.springer.com/article/10.1007/s12178-012-9117-z (Level of Evidence: 3a)
  4. Murawski C, Kennedy J. Anteromedial impingement in the ankle joint: outcomes following arthroscopy. American Journal of Sports Medicine [serial online]. October 2010;38(10):2017-2024. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 9, 2011.
  5. 5.0 5.1 van den Bekerom, Michel PJ, and Eric EJ Raven. "The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review." Knee Surgery, Sports Traumatology, Arthroscopy 15.4 (2007): 465-471. http://link.springer.com/article/10.1007/s00167-006-0275-7 (Level of Evidence: 3a)
  6. 6.0 6.1 6.2 El-Sayed A. Arthroscopic treatment of anterolateral impingement of the ankle. Journal of Foot Ankle Surgery [serial online]. May 2010;49(3):219-223. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 2, 2011.
  7. Michael Schünke, Erik Schulte,Udo Schumacher. Prometheus : Algemene anatomie en bewegingsapparaat, 2de druk, 2010 p452,453,454
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Lavery, Kyle P., et al. "Ankle impingement." Journal of Orthopaedic Surgery and Research 11.1 (2016): 97. https://josr-online.biomedcentral.com/articles/10.1186/s13018-016-0430-x (Level of Evidence: 3a)
  9. Marquirriain J. Posterior “ankle impingement syndrome.” J AM Acad Orthop Surg. 2005 Oct; 13(6): 365-71 http://journals.lww.com/jaaos/Abstract/2005/10000/Posterior_Ankle_Impingement_Syndrome.1.aspx
  10. Rasmussen S, Hjorth Jensen C: Arthroscopic treatment of impingement of the ankle reduces pain and enhances function. Scand J Med Sci Sports 2002;12(2):69-72)
  11. Sports health: A Multidisciplinary Approach. Medial Impingement of the Ankle in Athletes. American Orthopaedic Society for Sports Medicine. (3B)
  12. Talusan PG, Toy J, Perez JL, Milewski Reach JS. Anterior Ankle Impingement: Diagnosis and Treatment: J Am Acad Orthop Surg 2014;22: 333-339 (3A)
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