Ankle Impingement: Difference between revisions

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Medical Protocol: NWB in boot ~3 days, WBAT day 3, elevation for swelling, NSAIDs, ankle pumps,&nbsp;suture removal 10-14 days post-op, and refer to physical therapy. <ref name="Coe 2011">Coetzee J, Ebeling P. Arthroscopic Ankle Debridement Rehabilitation Protocol Website. Available at: http://www.tcomn.com/images/wmimages/onlineforms/Arthroscopic_Ankle_Debridement.pdf. Accessed July 15, 2011.</ref>  
Medical Protocol: NWB in boot ~3 days, WBAT day 3, elevation for swelling, NSAIDs, ankle pumps,&nbsp;suture removal 10-14 days post-op, and refer to physical therapy. <ref name="Coe 2011">Coetzee J, Ebeling P. Arthroscopic Ankle Debridement Rehabilitation Protocol Website. Available at: http://www.tcomn.com/images/wmimages/onlineforms/Arthroscopic_Ankle_Debridement.pdf. Accessed July 15, 2011.</ref>  
== Nonsurgical ==
<u>'''Anterior ankle impingement:'''</u> (these are reasonable nonsurgical options for patients with AAI)
*Shock-absorbing shoes
*Steroid injections
*NSAIDs (http://www.physio-pedia.com/NSAID_Gastropathy)
*A heel-lift orthosis to prevent dorsiflexion
*Activity restrictions
*Image-guided corticosteroid injections
*Anti-inflammatory medication
<u>'''Posterior ankle impingement:<ref>Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)</ref>'''</u>
*Rest and ice (RICE)
*NSAIDs (http://www.physio-pedia.com/NSAID_Gastropathy)
*Avoidance of extreme plantar flexion
*Protective dorsiflexion taping
*Immobilization
*Activity restriction
*Anti-inflammatory medication


== Physical Therapy Management <br>  ==
== Physical Therapy Management <br>  ==

Revision as of 15:34, 2 June 2016

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Definition/Description[edit | edit source]

Ankle impingement is defined as pain in the ankle due to impingement in one of two areas: anterior (anterolateral and anteromedial) and posterior (posteromedial).[1] Location of pain is referenced from the tibiotalar (talocrural) joint.[2] 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.[3] Historically, it has been called "athlete's ankle" and "footballer's ankle".[4]

Epidemiology/Etiology
[edit | edit source]

Ankle Impingement is commonly seen in active individuals and athletes due to accumulation of subclinical trauma to the area.[5]

Anterior Impingement: aka: "athlete's ankle" or "footballer's ankle". Caused by repeated dorsiflexion, microtrauma, and repeated inversion injury causing damage to anteromedial structures such as the articular cartilage. Further classified into Anteromedial & Anterolateral Impingement.[5]Coincident chondral and osteochondral lesions may be found in patients with AI.[6] It can also be seen after nonsporting injuries, especially fractures about the ankle and foot. There appears to be an association with a subtle cavus foot (high arched foot) and ankle instability.[7]


Soft-tissue inflammation and cartilage lesions may cause pain. A triangular-shaped area of soft tissue consisting of synovium, collagen, blood vessels and adipose is located in the anterior joint space between the talus and tibia, these tissue are compressed between the talus and tibia on 15° of dorsiflexion. In patients with anterior impingement, pain may be secondary to impingement of this soft tissue.[8]

  • 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. [9]
  • 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.[5]

Posterior Impingement: aka: "dancer's heel". Posterior impingement is generally insidious in nature, occurring in athletes who routinely plantarflex, such as ballet dancers, jumping athletes, and those who kick. [5] Posterior ankle impingement is a common cause of chronic ankle pain.[10] May be caused by bony or soft tissue impingement, specifically flexor hallucis longus irritation, thickening of the posterior capsule, synovitis, inversion trauma/sprain, forced plantarflexion causing anterior sheering of the tibia, hypertrophy of the os trigonum impacting the posterior tibia. [9]Also known as os trigonum syndrome and posterior tibiotalar compression syndrome.[11] The os trigonum is the most common cause of symptomatic posterior ankle impingement.[12]

  • Posteromedial impingement: Chronic posteromedial pain is mostly caused by scar tissue that consists of the posterior fibers. When there’s an ankle inversion trauma, with the ankle in plantar flexion, the fibers of the posterior ligament become compressed.[13]
  • Posterolateral impingement: This injury is caused by the Posterior Talofibular Ligament (also called the Posterior intermalleolar ligament). However, this ligament is an anatomic variant, it is present in 56% of the population[14]. During a plantair flexion, the PTL will entrap and then finally torn.[15]

Screenshot from GoogleBody

Screenshot from GoogleBody: Lateral Foot

Characteristics/Clinical Presentation[edit | edit source]

People suffering from anterior/posterior ankle impingement were found to have moderate to severe limitation in activities of daily living due to pain.[16]

Onset: Symptoms development may be insidious or in response to sudden injury.[5]

Anterior: Anterior ankle pain accompanied by a 'blocking sensation' in dorsiflexion. May also present with palpable soft tissue swelling over anterior joint. [5]

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.[17] (http://www.physio-pedia.com/Chronic_Ankle_Instability)

  • 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.[5] Patients may have a history of ankles sprains or chronic ankle instability and now present with constant lateral ankle pain upon ambulation.
  • Anteromedial: A good portion 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.[9]

Posterior: Patients have posterior ankle pain intensified by forced plantarflexion or dorsiflexion. May also have joint line tenderness of the posterior tibiotalar joint (not involving the achilles tendon).[5]

  • 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.[18]  This helps to differentiate from pain that comes from a tibialis posterior abnormality. [5]
  • Posterolateral: A patient with a posterolateral impingement has the feeling of ankle locking and has pain at the posterior side of the ankle. The impingement is proceded 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.[19]


Ahtletes affected by posterior impingement may attempt to compensate for the loss of plantar flexion by assuming an inverted foot position this may predispose to:[20]

  1. • frequent ankle sprains (http://www.physio-pedia.com/Ankle_Sprain)
  2. • calf sprains (http://www.physio-pedia.com/Calf_Strain)
  3. • contractures
  4. • planter foot pain
  5. • toe curling

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


Differential Diagnosis[edit | edit source]

Posterior Ankle Pain[21][22]
  • Talar or calcaneal fractures
  • Achilles tendinopathy
  • Posterior ankle impingement
  • Isolated flexor hallucis longus injury
  • Retrocalcaneal bursitis
  • Haglund's deformity
  • Posterior tibial osteochondral injuries
  • Tarsal tunnel
Anterior Ankle Pain[22]
Lateral Ankle Pain[22]
  • Fracture

Talus, Fibula, 5th Metatarsal (Avulsion, Jones)

  • Fibularis tendon injury
  • Lateral ankle impingement
  • Fibular or sural nerve irritation
  • Cuboid subluxation
Medial Ankle Pain[22]


Outcome Measures[edit | edit source]


All contain evidence regarding score interpretation including content validity, construct validity, reliability, and responsiveness. [23]

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. Can be used to evaluate disorder of one or both lower extremities and consist 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 the disability.

The Foot Function Index (FFI) is viewed as an instrument tool 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 3 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. Used to detect changes in self-reported function over time, as well as to evaluate the effectiveness of a specific intervention being delivered by a clinician. Instrument is divided into 2 seperately scored subscales, that include activities of daily living and a sports sub-scale. 

The Foot Health Status Questionnaire (FHSQ) region specific instrument that was developed for individuals undergoing surgical treatment in a podiatry practice for common foot conditions.  This questionnaire takes 5 minutes to complete and consists of 4 sub-scales, including pain, function, footwear, general foot health. This questionnaire can be used by researcher 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 3 outcome measures that include a QOL measure, clinical rating score, and single numeric evaluation. The QOL measure, used to assess an athlete’s QOL after an ankle injury, contains 5 sub-scales that include symptoms, work and school activities, recreation and sports activities, activities of daily living, and lifestyle.


Examination[edit | edit source]

The physical examination should include inspection of the ankle for swelling, erythema, and alignment. Gait analysis may reveal asymmetry and mal alignment[24]: people can compensate for limited ankle DF for 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 DF in the midfoot.[25]

Anterior ankle impingement Examination: [26]
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) [27]
-pain during single leg squat
-lack of lateral ankle instability

Additional tests:[28]
An 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% [26]


Forced Dorsiflexion

Forced Dorsiflexion


Posterior Ankle Impingement Examination: [29]

-Loss of mobility, accompanied by pain in posterior aspect of ankle
-pain with forced plantarflexion
-Prominent posterior talar processes
-Hyperplantar flexion test [30]

Additional tests:[31]
• Deep pressure palpation of the posteromedial joint line: positive => tenderness
• Laxity tests:

  • Anterior drawer
  • Inversion

• Manual strength test:

  • Anterior tibialis
  • Peroneus complex
  • Gastrosoleus complex

• Flexibility tests:

  • Achillis tendon
  • Hamstring
Forced Plantarflexion

Forced Plantarflexion

Medical Management
[edit | edit source]

Diagnosis: [32]

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:

It is considered after conservative treatment has been tried first, at least 3 months.[33]

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 . [33]

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. [34]

Murawski et al showed 93% satisfaction, AOFAS and SF 36v2 significantly improved ~ 68% that had anteromedial impingement. [32]


Surgery Methods: 

Debridement, osteophyte removal, meniscoid lesion excision, partial capsulectomy, flexor hallux longus release, and chondroplasty of tibia may be performed.[35] [36]

Complications include: infection; neuropraxia; arthrofibrosis; complex regional pain syndrome and fibular nerve irritation. [32][34][36]


Post-op:

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. [37]

Nonsurgical[edit | edit source]

Anterior ankle impingement: (these are reasonable nonsurgical options for patients with AAI)

  • Shock-absorbing shoes
  • Steroid injections
  • NSAIDs (http://www.physio-pedia.com/NSAID_Gastropathy)
  • A heel-lift orthosis to prevent dorsiflexion
  • Activity restrictions
  • Image-guided corticosteroid injections
  • Anti-inflammatory medication

Posterior ankle impingement:[38]

Physical Therapy Management
[edit | edit source]

Treatment focuses on increasing available joint space for more mobility and less pain during activity. 

Anterior Impingement:

  • Distraction manipulation
  • A/P and lateral talocrural glides
  • A/P distal fibula glides
  • Cuboid whip (for those with decreased pronation)
  • HEP:  self A/P and lateral mobilization, single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises
  • Lateral ankle stability protocols[39][40][41]
Exercise 1
Basic exercise:
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:
Basic exercise:
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:
Basic exercise:
Jump from one leg to the other on an exercise mat and control landing for 4 seconds. Raise the contralateral leg
 Exercise 4:
Basic exercise:
Maintain balance in single-leg stance elevating the contralateral leg against resistance of an elastic strap. Hold 30 seconds each leg.
Exercise 5:
Basic exercise:
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 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 Thera-band can be used in this exercises.[42][43]

Posterior Impingement:

  • Plantarflexion mobilization
  • P/A talocrural mobilization
  • Rear-foot distraction manipulation
  • Proprioceptive work - wobble board
  • Peronei strengthening 
  • HEP: Achilles tendon stretching, Single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises[9][44]
  • • Protective dorsiflexion taping[45]

Key Research[edit | edit source]

  • 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.


Clinical Bottom Line
[edit | edit source]

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. 

Recent Related Research (from Pubmed)[edit | edit source]

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References
[edit | edit source]

  1. ↑ McClinton, S. Regis University. Ankle impingement sydromes: diagnosis and treatment. Available at: https//connect.regis.edu/p38686942/. Accessed on July 9, 2011.
  2. ↑ Robinson P. Impingement syndromes of the ankle. European Radiology [serial online]. December 2007;17(12):3056-3065
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Robinson P. Impingement syndromes of the ankle. European Radiology [serial online]. December 2007;17(12):3056-3065
  6. ↑ 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)
  7. ↑ Sports health: A Multidisciplinary Approach. Medial Impingement of the Ankle in Athletes. American Orthopaedic Society for Sports Medicine. (3B)
  8. ↑ Paul G. Talusan, MD, Jason Toy, MD, Joshua L. Perez, Matthew D. Milewski, MD, John S. Reach, Jr, MSc, MDAnterior Ankle Impingemeproprexnt: Diagnosis and Treatment: J Am Acad Orthop Surg 2014;22: 333-339 (3A)
  9. ↑ 9.0 9.1 9.2 9.3 Cite error: Invalid <ref> tag; no text was provided for refs named Presentation
  10. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  11. ↑ The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement
  12. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  13. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  14. ↑ Rosenberg Z.S., Cheung Y.Y., Beltran J., Posterior intermalleolar ligament of the ankle: normal anatomy and MR imaging features. AJR Am J Roentgenol (1995), 387-390.
  15. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  16. ↑ Paul G. Talusan, MD, Jason Toy, MD, Joshua L. Perez, Matthew D. Milewski, MD, John S. Reach, Jr, MSc, MDAnterior Ankle Impingemeproprexnt: Diagnosis and Treatment: J Am Acad Orthop Surg 2014;22: 333-339 (3A)
  17. ↑ Paul G. Talusan, MD, Jason Toy, MD, Joshua L. Perez, Matthew D. Milewski, MD, John S. Reach, Jr, MSc, MDAnterior Ankle Impingemeproprexnt: Diagnosis and Treatment: J Am Acad Orthop Surg 2014;22: 333-339 (3A)
  18. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  19. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  20. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  21. ↑ Maquirriain J. Posterior ankle impingement. J Am Acad Orthop Surg 2005;13:365-71
  22. ↑ 22.0 22.1 22.2 22.3 Goode L. Ankle Differential Diagnosis. Office of Inspector General. July 2006: 1-2.
  23. ↑ Martin R, Irrgang J. A survey of self-reported outcome instruments for the foot and ankle. Journal of Orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy [serial online]. February 2007;37(2):72-84. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 18, 2011.
  24. ↑ Paul G. Talusan, MD, Jason Toy, MD, Joshua L. Perez, Matthew D. Milewski, MD, John S. Reach, Jr, MSc, MDAnterior Ankle Impingemeproprexnt: Diagnosis and Treatment: J Am Acad Orthop Surg 2014;22: 333-339 (3A)
  25. ↑ Johanson M., Baer J., Hovermale H., Phouthavong P., Subtalar Joint Position During Gastrocnemius Stretching and Ankle Dorsiflexion Range of Motion (2008)
  26. ↑ 26.0 26.1 Liu S, Nuccion S, Finerman G. Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. American Journal of Sports Medicine [serial online]. May 1997;25(3):389-393. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 15, 2011.
  27. ↑ Molloy S, Solan M, Bendall S. Synovial impingement in the ankle: a new physical sign. Journal of Bone Joint Surgery, British Volume [serial online]. April 2003;85B(3):330-333. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 15, 2011
  28. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  29. ↑ Albisetti W, Ometti M, Pascale V, De Bartolomeo O. Clinical evaluation and treatment of posterior impingement in dancers. American Journal of Physical Medicine Rehabilitation [serial online]. May 2009;88(5):349-354. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 18, 2011
  30. ↑ Dijk van, C. Niek. Anterior and Posterior Ankle Impingement. Foot Ankle Clinica N Am 11 (2006) 663-683
  31. ↑ R. Coull, T. Raffiq, L. E. James, M. M. Stephens Open treatment of anterior impingement of the ankle
  32. ↑ 32.0 32.1 32.2 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.
  33. ↑ 33.0 33.1 Cite error: Invalid <ref> tag; no text was provided for refs named El-Sayed
  34. ↑ 34.0 34.1 Galla M, Lobenhoffer P. Technique and results of arthroscopic treatment of posterior ankle impingement. Foot Ankle Surgery (Elsevier Science) [serial online]. June 2011;17(2):79-84. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 2, 2011.
  35. ↑ Meislin R, Rose D, Parisien J, Springer S. Arthroscopic treatment of synovial impingement of the ankle. American Journal of Sports Medicine [serial online]. March 1993;21(2):186-189. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 9, 2011.
  36. ↑ 36.0 36.1 Hussan A. Treatment of anterolateral impingements of the ankle joint by arthroscopy. Knee Surg Sports Traumatol Arthrosec. 2007; 15:150-1154. Accessed July 15,2011.
  37. ↑ Coetzee J, Ebeling P. Arthroscopic Ankle Debridement Rehabilitation Protocol Website. Available at: http://www.tcomn.com/images/wmimages/onlineforms/Arthroscopic_Ankle_Debridement.pdf. Accessed July 15, 2011.
  38. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  39. ↑ Eils E.et all, Multistation Proprioceptive Exercise Program Prevents Ankle Injuries in Basketball, Medicine &amp; sience in sports &amp; exercise (2010)
  40. ↑ Mattacola C., Lloyd J., Effects of a 6-week strength and proprioception training program on measures of dynamic balance: a single case design, Journal of athletic training.
  41. ↑ Verhagen E. et all, The effect of a proprioceptive balance board training program for the prevention of ankle sprains, The American journal of sports(2004)
  42. ↑ Smith B. et all, Ankle strength and Force sense after a progressive 6-week strength training program in people with functional ankle instability, Journal of athletic training (2012)
  43. ↑ Baker A., Webright W., Perrin D., Affect of a “T-band” kick training protocol on postural sway, Journal of sport Rehabilitation (1998)
  44. ↑ Reischl SF, Noceti-Dewit LM. Current Concepts of Orthopaedic Physical Therapy. 2nd ed. The goot and ankle: Physical therapy patient management utilizing current evidence. APTA Independent Study Guide 16.2.11.
  45. ↑ Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
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