Ankle Impingement: Difference between revisions

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== Search strategy  ==
Databases searched: PubMed, Physiopedia, Prometheus, SpringerLink, Journal of Orthopaedic Surgery and Research, <br>Keywords searched: “Ankle Impingement”, “Ankle Impingement Anterior”, “Ankle Impingement Posterior”, “Therapy”
== Defenition/Description  ==
== Defenition/Description  ==


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== Clinical Relevant Anatomy  ==
== Clinical Relevant Anatomy  ==


The ankle is the region where the foot and leg meet and is made of the upper and lower ankle joint.  
[[Image:493x335 ankle.jpg|center|500px]]
 
=== Talocrural Joint  ===
 
[[Image:Talus.png|thumb|right|200px|The Talus]] The ankle joint is a synovial hinge joint comprised of hyaline covered articular surfaces of the talus, the tibia as well as the fibula, allowing up to 20 degrees dorsiflexion and 50 degress plantarflexion. The distal ends of the tibia and fibula are held together firmly by ligaments of the medial (Deltoid) and lateral ligament complexes of the ankle which can be damaged and contribute to ankle arthritis ([http://www.physio-pedia.com/Ankle_Sprain Ankle Sprain]). The ligaments hold the tibia and fibula into a deep bracket-like shape in which the talus sits<ref name="Gray's" />.
 
*The&nbsp;'''ROOF''' of the joint is the distal inferior surface of the tibia
*The '''MEDIAL SIDE''' of the joint is formed of the medial malleolus of the tibia
*The '''LATERAL SIDE''' of the joint is formed of the lateral malleolus of the fibula<br>
 
The articular part of the talus looks like a cylinder and fits snugly into the bracket provided by the syndemosis of the tibia and fibula, when looking down upon the talus the articular surface is wider anteriorly than posteriorly. Subsequently this increases the congruent, stable nature of this joint when it is in dorsiflexion. As this is a synovial joint, a membrane is present as well as a fibrous membrane providing the same functions as any other synovial joint&nbsp;[http://en.wikipedia.org/wiki/Synovial_membrane synovial membrane<ref name="Gray's" />].&nbsp;<br>
 
[[Image:Subtalar Joint.png|thumb|right|200px|Articulations of the Foot (Talus Removed)]]&lt;span style="font-size: 13.28px;" /&gt;
 
=== Subtalar Joint  ===
 
The Subtalar joint is also known as the Talocalcaneal joint and is between:


<u>'''Upper joint (Art.talocruralis).'''</u><br>the upper ankle joint is formed by the distal ends of the tibia and fibula, and the talus trochlea<br>The art. talocruralis has thereby a good conduction of bones and tires and thus contribute to an ensuring and erect posture. <br><u>'''Lower joint &nbsp;(Art.subtalaris)'''</u><br>The lower joint articulates the talus with the calcaneus and ossis navicularis.<br>'''<u>Ligaments of the ankle</u>'''<br>The medial and lateral ligaments are together with the syndesmose bands of decisive importance for the stabilization and guiding of the upper ankle joint.<ref name="prom">Michael Schünke, Erik Schulte,Udo Schumacher. Prometheus : Algemene anatomie en bewegingsapparaat, 2de druk, 2010 p452,453,454</ref>
*The large posterior calcaneal facet on the inferior surface of the talus; and  
*The corresponding posterior facet on the superior surface of the calcaneus<ref name="Gray's" />


[[Image:493x335_ankle.jpg]]<br>© 2014 WebMD, LLC. All rights reserved.<br>
This joint, due to its orientation, allows the movements of inversion (0-35 degrees) and eversion (0-25 degrees), broken down this must mean the joint allows some amount of glide and rotation. It is known as a simple synovial condyloid joint. There are a large number of strong ligaments supporting the joint.<br>  


== Epidemiology/Etiology  ==
== 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. Specific anterior, anterolateral, anteromedial, posterior, posteromedial, posterolateral.<ref name="Lavery">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)</ref><br>Ankle impingement is a common condition occurring secondary to sprain or repeated microtrauma.<ref name="Marq">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</ref>  
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.<ref name="Lavery">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)</ref><br>Ankle impingement is a common condition occurring secondary to sprain or repeated microtrauma.<ref name="Marq">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</ref>  


'''Anterior Impingement (AI):''' 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 &amp; Anterolateral Impingement.<ref name="Robinson">Robinson P. Impingement syndromes of the ankle. European Radiology [serial online]. December 2007;17(12):3056-3065</ref>Coincident chondral and osteochondral lesions may be found in patients with AI.<ref name="Rasmussen">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)</ref> 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.<ref name="Sports">Sports health: A Multidisciplinary Approach. Medial Impingement of the Ankle in Athletes. American Orthopaedic Society for Sports Medicine. (3B)</ref>
===


<br>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 a range of motion limitation may be secondary to impingement of this soft tissue.<ref name="Lavery" /><ref name="Paul">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)</ref>  
Often know as "athlete's ankle" or "footballer's ankle" is caused by repeated dorsiflexion, microtrauma, and repeated inversion injury causing damage to anteromedial structures such as the articular cartilage. It is further classified into Anteromedial &amp; Anterolateral Impingement<ref name="Robinson">Robinson P. Impingement syndromes of the ankle. European Radiology [serial online]. December 2007;17(12):3056-3065</ref>. &nbsp;Coincident chondral and osteochondral lesions may be found in patients with AI.<ref name="Rasmussen">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)</ref> 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.<ref name="Sports">Sports health: A Multidisciplinary Approach. Medial Impingement of the Ankle in Athletes. American Orthopaedic Society for Sports Medicine. (3B)</ref>  


<br>  
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 a range of motion limitation may be secondary to impingement of this soft tissue.<ref name="Lavery" /><ref name="Paul">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)</ref><br>  


*<u>'''Anteromedial Impingement'''</u>: 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.  
*<u>'''Anteromedial Impingement'''</u>: 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.  
*<u>'''Anterolateral Impingement:'''</u> 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.<ref name="Robinson" />
*<u>'''Anterolateral Impingement:'''</u> 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.<ref name="Robinson" />


<u>'''Posterior Impingement (PI)'''</u>: 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.<ref name="Robinson" /> Posterior ankle impingement is a common cause of chronic ankle pain.<ref name="Sandro">Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)</ref>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.]Also known as os trigonum syndrome and posterior tibiotalar compression syndrome.<ref name="16">The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement</ref> The os trigonum is the most common cause of symptomatic posterior ankle impingement.<ref name="Sandro" />  
=== Posterior Impingement (PI) ===
 
&lt;u&lt;/u&gt;&nbsp;Often known as "dancer's heel", is generally insidious in nature, occurring in athletes who routinely plantarflex, such as ballet dancers, jumping athletes, and those who kick.<ref name="Robinson" /> Posterior ankle impingement is a common cause of chronic ankle pain.<ref name="Sandro">Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)</ref>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.]Also known as os trigonum syndrome and posterior tibiotalar compression syndrome.<ref name="16">The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement</ref> The os trigonum is the most common cause of symptomatic posterior ankle impingement.<ref name="Sandro" />  


*<u>'''Posteromedial impingement'''</u>: 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.<ref name="Sandro17">Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)</ref> 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.<ref name="Paul19">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)</ref>  
*<u>'''Posteromedial impingement'''</u>: 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.<ref name="Sandro17">Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)</ref> 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.<ref name="Paul19">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)</ref>  
*<u>'''Posterolateral impingement'''</u>: 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. During a plantair flexion, the PTL will entrap and then finally torn.<ref name="Gi" />
*<u>'''Posterolateral impingement'''</u>: 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. During a plantair flexion, the PTL will entrap and then finally torn.<ref name="Gi" /><br>


== Characteristics/Clinical Presentaion  ==


People suffering from anterior/posterior ankle impingement were found to have moderate to severe limitation in activities of daily living due to pain.<ref name="13">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)</ref>&nbsp; Symptoms development may be insidious or in response to sudden injury.<ref name="Bekerom" />


[[Image:Ankle.jpg]]
=== Anterior  ===


<br>
&lt;u&lt;/u&gt;Anterior ankle pain accompanied by a 'blocking sensation' in dorsiflexion. May also present with palpable soft tissue swelling over anterior joint.<ref name="Bekerom" /><br>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.<ref name="Robinson" /> (http://www.physio-pedia.com/Chronic_Ankle_Instability)<br>  


== Characteristics/Clinical Presentaion ==
*<u>'''Anterolateral:''' </u>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.<ref name="Bekerom" /> Patients may have a history of ankles sprains or chronic ankle instability and now present with constant lateral ankle pain upon ambulation.
*<u>'''Anteromedial'''</u>''':''' 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.<ref name="Marq" />
 
=== Posterior ===
 
&lt;u&lt;/u&gt;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).<ref name="Bekerom" />
 
*<u>'''Posteromedial:''' </u>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.<ref name="Robinson" /> This helps to differentiate from pain that comes from a tibialis posterior abnormality.<ref name="Bekerom" />
*<u>'''Posterolateral:'''</u> 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).


People suffering from anterior/posterior ankle impingement were found to have moderate to severe limitation in activities of daily living due to pain.<ref name="13">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)</ref>  
The ankle has a limited plantar flexion and a ligamentous instability with thickening of the soft tissue.<ref name="Robinson" />  


<br>
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:


<u>'''Onset:'''</u> Symptoms development may be insidious or in response to sudden injury.<ref name="Bekerom" />  
*frequent [[Ankle Sprain|ankle sprains]]
*[[Calf Strain|calf sprain]]
*contractures
*planter foot pain
*toe curling<br>


<br><u>'''Anterior:'''</u> Anterior ankle pain accompanied by a 'blocking sensation' in dorsiflexion. May also present with palpable soft tissue swelling over anterior joint.<ref name="Bekerom" /><br>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.<ref name="Robinson" /> (http://www.physio-pedia.com/Chronic_Ankle_Instability)
<u>'''Causes'''</u>  


<br>  
&lt;u&lt;/u&gt;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 plantarflexion or push-off activities.<br>The common cause of posterior ankle impingement syndrome is impingement of the [[The Os Trigonum Syndrome|Os trigonum]] or the posterior talar process and of chronic ankle pain and results from compression of bony or soft tissue structures during ankle plantar flexion. Bony impingement is most commonly related to an os trigonum or prominent trigonal process. 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.<br>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.


*<u>'''Anterolateral:''' </u>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.<ref name="Bekerom" /> Patients may have a history of ankles sprains or chronic ankle instability and now present with constant lateral ankle pain upon ambulation.  
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.<br>Moreover, a group of fibers fuse with the posterior intermalleolar ligament. The posterior intermalleolar ligament tenses during dorsiflexion and relaxes during plantar flexion, and therefore, trauma that causes forced dorsiflexion of the ankle 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.  
*<u>'''Anteromedial'''</u>''':''' 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.<ref name="Marq" />


<u>'''Posterior:'''</u> 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).<ref name="Bekerom" />  
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.<ref name="Robinson" /><ref name="Rasmussen" />  


*<u>'''Posteromedial:''' </u>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.<ref name="Robinson" /> This helps to differentiate from pain that comes from a tibialis posterior abnormality.<ref name="Bekerom" />
<u>'''Consequences:'''</u>  
*<u>'''Posterolateral:'''</u> 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.<ref name="Robinson" /><br> <br>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:<br>1. • frequent ankle sprains (http://www.physio-pedia.com/Ankle_Sprain)<br>2. • calf sprains (http://www.physio-pedia.com/Calf_Strain)<br>3. • contractures<br>4. • planter foot pain<br>5. • toe curling<br>Physicians use radiographs as a means of medical diagnosis, but any radiographic findings must be correlated to patient symptoms.<ref name="Robinson" />
&lt;u&lt;/u&gt;Symptoms of PAIS are thought to result from two main mechanisms: Impaction of osseous structures against each other, where the posterior talar prominence may be compressed between the posterior tibia and posterior calcaneal tuberosity, as well as compression of soft tissue structures between two opposing bony structures.  


<u>'''Causes:'''</u><br>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 plantarflexion or push-off activities.<br>The common cause of posterior ankle impingement syndrome is impingement of the Os trigonum or the posterior talar process and of chronic ankle pain and results from compression of bony or soft tissue structures during ankle plantar flexion. Bony impingement is most commonly related to an os trigonum or prominent trigonal process. 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.<br>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.<br>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.<br>Moreover, a group of fibers fuse with the posterior intermalleolar ligament. The posterior intermalleolar ligament tenses during dorsiflexion and relaxes during plantar flexion, and therefore, trauma that causes forced dorsiflexion of the ankle 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.<br>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.<ref name="Robinson" /><ref name="Rasmussen" />
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.<br> 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.  


<br><u>'''Consequences:'''</u><br>Symptoms of PAIS are thought to result from two main mechanisms: Impaction of osseous structures against each other, where the posterior talar prominence may be compressed between the posterior tibia and posterior calcaneal tuberosity, as well as compression of soft tissue structures between two opposing bony structures.<br>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.<br> 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.<br>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.<ref name="Sports" />
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.<ref name="Sports" />  


== Differentiel Diagnosis  ==
== Differentiel Diagnosis  ==
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*Nerve entrapment at ankle or knee;  
*Nerve entrapment at ankle or knee;  
*Radicular spinal pain;  
*Radicular spinal pain;  
*Other causes including tumour&nbsp;<ref name="Russo">Russo A1, Zappia M, Reginelli A, Carfora M, D'Agosto GF, La Porta M, Genovese EA, Fonio P. “Ankle impingement: a review of multimodality imaging approach.” Musculoskelet Surg. 2013 Aug;97 Suppl 2:S161-8. https://www.ncbi.nlm.nih.gov/pubmed/23949938</ref>
*Other causes including tumour&nbsp;<ref name="Russo">Russo A1, Zappia M, Reginelli A, Carfora M, D'Agosto GF, La Porta M, Genovese EA, Fonio P. “Ankle impingement: a review of multimodality imaging approach.” Musculoskelet Surg. 2013 Aug;97 Suppl 2:S161-8. https://www.ncbi.nlm.nih.gov/pubmed/23949938</ref><br>
 
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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.<ref name="Vaseenon" />  
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.<ref name="Vaseenon" />  


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.<ref name="Russo" /><br>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.<ref name="Vaseenon" /><br>
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.<ref name="Russo" />&nbsp; 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.<ref name="Vaseenon" /><br>  


== Outcome Measures  ==
== Outcome Measures  ==
Line 128: Line 153:
All contain evidence regarding score interpretation including content validity, construct validity, reliability, and responsiveness.<ref name="Theposterior">The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement</ref>  
All contain evidence regarding score interpretation including content validity, construct validity, reliability, and responsiveness.<ref name="Theposterior">The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement</ref>  


<u>'''The Lower Extremity Function Scale (LEFS)'''</u> 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 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.  
<br><u>'''The Foot Function Index (FFI)'''</u> 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 isdivided 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.  
<br><u>'''The Foot and Ankle Ability Measure (FAAM)'''</u> 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 isdivided into 2 seperately scored subscales, that include activities of daily living and a sports sub-scale.
*'''The Sports Ankle Rating '''<u>'''System (QOL)'''</u> 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.<br>
 
<br><u>'''The Foot Health Status Questionnaire (FHSQ)''' </u>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.
 
<br><u>'''The Sports Ankle Rating System (QOL)'''</u> 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.
 
To assess the functional and radiological outcomes after arthroscopic treatment of anterior ankle impingement with a minimum 5-year follow-up in patients without osteoarthritis.<br>Patients with anterior ankle impingement underwent standardized arthroscopic debridement and followed uniform postoperative management.<br>Patients without osteoarthritis managed arthroscopically for anterior ankle impingement, the functional outcome scores had significantly improved at 5 years postoperatively despite a recurrence of radiographic osteophytes.<br>Crutches and non-steroidal anti-inflammatory drugs were used to reduce pain and inflammation after surgery. Patients were allowed for sportive activities after second week Preoperative posterior ankle pain of athletes disappeared completely after surgery, and returned to sports in 50 days postoperatively. AOFAS showed an improving score of the pre-treatment score and the postoperative score. Pain also reduce after the surgery.<br>Patients with chronic posterior ankle pain were evaluated. Tibiotalar synovitis , FHL synovitis and subtalar synovitis were observed. Os trigonum was prominent.<br>The mean time for return to sports was 36.3 days for patients who felt better after conservative treatment. Acute cases USG-guided corticosteroid injection was applied to patients who had failed the initial medical treatment. After 2 weeks of infection some patients were free of symptoms and the surgical treatment was planned for other patients having ongoing complaints. The mean AOFAS score was improved to 95.2 (90–100) from 60.6 (45–73) and VAS was decreased to 1.2 (0–2) from 8.4 (7–10). No severe complications were registered in the present series after surgery with a mean follow-up.<ref name="Sasadai">Sasadai, Junpei, et al. "The Effect of Ankle Taping to Restrict Plantar Flexion on Ball and Foot Velocity During an Instep Kick in Soccer." Journal of sport rehabilitation 24.3 (2015): http://journals.humankinetics.com/doi/abs/10.1123/jsr.2014-0156?url_ver=Z39.88-2003&amp;amp;amp;rfr_id=ori:rid:crossref.org&amp;amp;amp;rfr_dat=cr_pub%3dpubmed (accessed August 2015). (Level of Evidence: 2b)</ref>


== Examination  ==
== Examination  ==


The physical examination should include inspection of the ankle for swelling, erythema, and alignment,joint effusion,or soft tissue edema.<ref name="popo">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)</ref>&nbsp;Gait analysis may reveal asymmetry and mal alignment29: 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.30
The physical examination should include inspection of the ankle for swelling, erythema, and alignment,joint effusion,or soft tissue edema.<ref name="popo">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)</ref>&nbsp;Gait analysis may reveal asymmetry and malalignment as 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.  


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.<ref name="Lavery" /><br>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.<ref name="Lavery" />  
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.<ref name="Lavery" /><br>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.<ref name="Lavery" />  


<br><u>'''Anterior ankle impingement Examination'''</u>:<ref name="Liu">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.</ref><br>5 or more present: Sen= .94 Spec=.75 +LR=3.76 -LR=.08<br>-pain with activities<br>-anterolateral ankle joint tenderness<br>-recurrent joint swelling<br>-anterolateral pain with forced dorsiflexion and eversion (Impingement sign: Sens=.95 Spec=.88 +LR=7.91 -LR=.06)&nbsp;<ref name="Molloy">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</ref><br>-pain during single leg squat<br>-lack of lateral ankle instability<br><u>'''Additional tests:<ref name="Sandro" />'''</u><br><u>An anterior drawer test for lateral ankle instability</u> ( Sen= .86 Spec= .74 +LR .22 and -LR .0018)<br> (http://www.physio-pedia.com/Anterior_Drawer_of_the_Ankle)<br><u>The Silfverskiöld test for an isolated gastrocnemius contracture:</u><br>The test is considered positive when ankle dorsiflexion is greater with the knee in flexion than in extension.<br><u>MRI sensitivity = 39% Physical Examination sensitivity = 94%</u>&nbsp;<ref name="Liu" /><br><br>
=== Anterior ankle impingement Examination<ref name="Liu">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.</ref> ===
 
[[Image:Dorsiflexion.JPG]]
 
Forced Dorsiflexion
 
<u</u>
 
<u>'''Posterior Ankle Impingement Examination:'''</u>&nbsp;<ref name="Albisetti">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</ref><br>-Loss of mobility, accompanied by pain in posterior aspect of ankle<br>-pain with forced plantarflexion<br>-Prominent posterior talar processes<br>-Hyperplantar flexion test<ref name="Dijk">Dijk van, C. Niek. Anterior and Posterior Ankle Impingement. Foot Ankle Clinica N Am 11 (2006) 663-683</ref><br><u>'''Additional tests'''</u>:<ref name="Coull">R. Coull, T. Raffiq, L. E. James, M. M. Stephens Open treatment of anterior impingement of the ankle</ref><br>&nbsp;- Deep pressure palpation of the posteromedial joint line: positive =&gt; tenderness<br><u>• Laxity tests:</u>
 
*Anterior drawer
*Inversion
 
<u>'''• Manual strength test:'''</u>
 
*Anterior tibialis
*Peroneus complex
*Gastrosoleus complex
 
<u>'''• Flexibility tests:'''</u>


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


*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)&nbsp;<ref name="Molloy">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</ref>
*pain during single leg squat
*lack of lateral ankle instability


<u>'''Additional tests:<ref name="Sandro" />'''</u>


[[Image:Plantarflexion.JPG]]
*&lt;u&lt;/u&gt;An [[Anterior Draw of the Ankle|anterior drawer test]] for lateral ankle instability (Sen= .86 Spec= .74 +LR .22 and -LR .0018)
*The Silfverskiöld test for an isolated gastrocnemius contracture. &nbsp;The test is considered positive when ankle dorsiflexion is greater with the knee in flexion than in extension.&nbsp;MRI sensitivity = 39% Physical Examination sensitivity = 94%&nbsp;<ref name="Liu" /><br>
*Forced dorsiflextion


Forced Plantarflexion
=== Posterior Ankle Impingement Examination<ref name="Albisetti">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</ref>  ===


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


<u>'''Additional tests'''</u>:<ref name="Coull">R. Coull, T. Raffiq, L. E. James, M. M. Stephens Open treatment of anterior impingement of the ankle</ref>


[[Image:Inversion.png]]&nbsp;
*Deep pressure palpation of the posteromedial joint line: positive =&gt; tenderness
*Laxity tests (anterior drawer and inversion)
*Manual strength test:&nbsp;Anterior tibialis, Peroneus complex, Gastrosoleus complex
*Flexibility tests:&nbsp;Achillies tendon, Hamstring


Forced Inversion
*Forced Plantarflexion&nbsp;&nbsp;
*Forced Inversion


== Medical Management<br>  ==
== Medical Management<br>  ==


<u>'''Diagnosis:<ref name="Mura" />'''</u>  
=== Diagnosis<u>'''<ref name="Mura" />'''</u> ===
 
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.  
#Standard radiographs
#MRI for soft tissue swelling and extent of injury
#Diagnostic injection is a local anesthetic administered into joint capsule and soft tissue, if injection relieved the symptoms it is a positive test.


<br><u>'''Surgery:'''</u>
=== Surgery ===


It is considered after conservative treatment has been tried first, at least 3 months.<ref name="Sayed" />  
It is considered after conservative treatment has been tried first, at least 3 months.<ref name="Sayed" />&nbsp;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.<ref name="Sayed" />&nbsp;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.<ref name="Galla">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.</ref>&nbsp;Murawski et al showed 93% satisfaction, AOFAS and SF 36v2 significantly improved ~ 68% that had anteromedial impingement.<ref name="Mura">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.</ref>&nbsp;However, if athletic patients want to return to athletic 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<ref name="Lavery" />.


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.<ref name="Sayed" />  
Surgical methods include debridement, osteophyte removal, meniscoid lesion excision, partial capsulectomy, flexor hallux longus release, and chondroplasty of tibia may be performed.<ref name="Meis">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.</ref><ref name="Hus">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.</ref>  


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.<ref name="Galla">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.</ref>  
Complications include infection; neuropraxia; arthrofibrosis; complex regional pain syndrome and fibular nerve irritation.<ref name="Mura" /><ref name="Galla" /><ref name="Hus" />  


Murawski et al showed 93% satisfaction, AOFAS and SF 36v2 significantly improved ~ 68% that had anteromedial impingement.<ref name="Mura">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.</ref>  
'''<u>Anterior ankle impingement:</u>'''


However, if athletic patients want to return to athletic activity promptly, then surgical intervention can be recommended early in the treatment process.<br>The surgical approach and technique vary by the anatomic region and pathology involved.<ref name="Lavery" /> (Level of Evidence: 3a)
<u></u>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.<ref name="Lavery" /> (Level of Evidence: 3a)  


<br><u>Anterior ankle impingement:</u><br>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.<ref name="Lavery" /> (Level of Evidence: 3a)
'''<u>Posterior ankle impingement:</u>'''


<u>Posterior ankle impingement:</u><br>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.<ref name="Lavery" /> (Level of Evidence: 3a)
<u></u>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.<ref name="Lavery" />


Surgery Methods:  
<u>'''Post-op:'''</u>


Debridement, osteophyte removal, meniscoid lesion excision, partial capsulectomy, flexor hallux longus release, and chondroplasty of tibia may be performed.<ref name="Meis">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.</ref><ref name="Hus">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.</ref>  
For the posterior ankle impingement a compression bandage is applied after surgery and patients are allowed to be weightbearing as tolerated immediately after surgery. Patients may also begin ranging their ankle 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.<ref name="Yasui" />


Complications include: infection; neuropraxia; arthrofibrosis; complex regional pain syndrome and fibular nerve irritation.<ref name="Mura" /><ref name="Galla" /><ref name="Hus" />
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.<ref name="Coet">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>  
 
<br><u>'''Post-op:'''</u>
 
For the posterior ankle impingement a compression bandage is applied after surgery and patients are allowed to be weightbearing as tolerated immediately after surgery. Patients may also begin ranging their ankle 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.<ref name="Yasui" />(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.<ref name="Coet">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>


== Physical Therapy 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 an avoidance of provocative activities are recommended. In chronic cases, shoe modifications, including heel lift orthoses to prevent dorsiflexion, have been utilized.<ref name="Lavery" /> (Level of Evidence: 3a)<br>Patients should be treated conservatively after an inversion sprain of the ankle for at least 6 months.<ref name="Bekerom" />(Level of Evidence: 3a)<br>They should be treated conservatively after an inversion injury of the ankle, with adequate joint rehabilitation, peroneal strengthening, and muscle balancing.<ref name="Clinton">McClinton, S. Regis University. Ankle impingement sydromes: diagnosis and treatment. Available at: https//connect.regis.edu/p38686942/. Accessed on July 9, 2011.</ref> (Level of Evidence: 3a)<br>Patients who do not respond to conservative management may require operative intervention.<ref name="Yasui">Yasui, Youichi, et al. "Posterior ankle impingement syndrome: A systematic four-stage approach." World Journal of Orthopedics 7.10 (2016): 657. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5065672/ (Level of Evidence: 2a)</ref>(Level of Evidence: 2a)
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 an avoidance of provocative activities are recommended. In chronic cases, shoe modifications, including heel lift orthoses to prevent dorsiflexion, have been utilized.<ref name="Lavery" />


<br>  
Patients should be treated conservatively after an inversion sprain of the ankle for at least 6 months.<ref name="Bekerom" />&nbsp;They should be treated conservatively after an inversion injury of the ankle, with adequate joint rehabilitation, peroneal strengthening, and muscle balancing.<ref name="Clinton">McClinton, S. Regis University. Ankle impingement sydromes: diagnosis and treatment. Available at: https//connect.regis.edu/p38686942/. Accessed on July 9, 2011.</ref>&nbsp;Patients who do not respond to conservative management may require operative intervention.<ref name="Yasui">Yasui, Youichi, et al. "Posterior ankle impingement syndrome: A systematic four-stage approach." World Journal of Orthopedics 7.10 (2016): 657. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5065672/ (Level of Evidence: 2a)</ref><br>  


<u>'''Anterior Impingement:'''</u>  
=== <u</u>Anterior Impingement ===


*Distraction manipulation  
*Distraction manipulation  
Line 233: Line 242:
*Cuboid whip (for those with decreased pronation)  
*Cuboid whip (for those with decreased pronation)  
*HEP: self A/P and lateral mobilization, single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises  
*HEP: self A/P and lateral mobilization, single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises  
*Lateral ankle stability protocols<ref name="Eils">Eils E.et all, Multistation Proprioceptive Exercise Program Prevents Ankle Injuries in Basketball, Medicine &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; sience in sports &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; exercise (2010)</ref><ref name="Mat">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.</ref><ref name="Verhagen">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)</ref>
*Lateral ankle stability protocols<ref name="Eils">Eils E.et all, Multistation Proprioceptive Exercise Program Prevents Ankle Injuries in Basketball, Medicine &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; sience in sports &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; exercise (2010)</ref><ref name="Mat">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.</ref><ref name="Verhagen">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)</ref><br>
 
<br>  


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All of these exercises can be performed on the different perturbations. For peroneal strengthening, a Thera-band can be used in this exercises.<ref name="Smit">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)</ref><ref name="Baker">Baker A., Webright W., Perrin D., Affect of a “T-band” kick training protocol on postural sway, Journal of sport Rehabilitation (1998)</ref>  
All of these exercises can be performed on the different perturbations. For peroneal strengthening, a Thera-band can be used in this exercises.<ref name="Smit">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)</ref><ref name="Baker">Baker A., Webright W., Perrin D., Affect of a “T-band” kick training protocol on postural sway, Journal of sport Rehabilitation (1998)</ref>  


<u>'''Posterior Impingement:'''</u>  
=== <u>Posterior Impingement</u> ===


*Plantarflexion mobilization  
*Plantarflexion mobilization  
Line 278: Line 285:
*Protective dorsiflexion taping<ref name="Gi">Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)</ref>
*Protective dorsiflexion taping<ref name="Gi">Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)</ref>


<br><u>'''Prevention:'''</u><br>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.<br>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.<br>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.<br>Protective ankle dorsiflexion taping is recommended with the belief that it prevents posterior ankle impingement.<ref name="Sas">Sasadai, Junpei, et al. "The Effect of Ankle Taping to Restrict Plantar Flexion on Ball and Foot Velocity During an Instep Kick in Soccer." Journal of sport rehabilitation 24.3 (2015): http://journals.humankinetics.com/doi/abs/10.1123/jsr.2014-0156?url_ver=Z39.88-2003&amp;amp;amp;amp;amp;amp;amp;rfr_id=ori:rid:crossref.org&amp;amp;amp;amp;amp;amp;amp;rfr_dat=cr_pub%3dpubmed (accessed August 2015). (Level of Evidence: 2b)</ref>(Level of Evidence: 2b)<br>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.<ref name="Kon">Konstantinos Tsitskaris, Rowland Illing, Charles House, and Michael J Oddy “Osteoid osteoma as a cause of anterior ankle pain in a runner” BMJ Case Rep. 2014. http://casereports.bmj.com/content/2014/bcr-2014-204365.abstract (Level of Evidence: 3b)</ref> (Level of Evidence: 2b)
=== Prevention ===
 
== 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.


== Resources  ==
<u</u>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.<br>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.<br>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.<br>Protective ankle dorsiflexion taping is recommended with the belief that it prevents posterior ankle impingement.<ref name="Sas">Sasadai, Junpei, et al. "The Effect of Ankle Taping to Restrict Plantar Flexion on Ball and Foot Velocity During an Instep Kick in Soccer." Journal of sport rehabilitation 24.3 (2015): http://journals.humankinetics.com/doi/abs/10.1123/jsr.2014-0156?url_ver=Z39.88-2003&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;rfr_id=ori:rid:crossref.org&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;rfr_dat=cr_pub%3dpubmed (accessed August 2015). (Level of Evidence: 2b)</ref>(Level of Evidence: 2b)<br>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.<ref name="Kon">Konstantinos Tsitskaris, Rowland Illing, Charles House, and Michael J Oddy “Osteoid osteoma as a cause of anterior ankle pain in a runner” BMJ Case Rep. 2014. http://casereports.bmj.com/content/2014/bcr-2014-204365.abstract (Level of Evidence: 3b)</ref> (Level of Evidence: 2b)


== Clinical Bottom Line  ==
== 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.
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.<br>
 
== Recent Related Research (from pubmed)  ==
 
*Posterior ankle impingement syndrome: A systematic four-stage approach.


== References ==
== References ==


<references /><br>
<references /><br>

Revision as of 15:29, 22 March 2017

Defenition/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] 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] Noted in athletes whose sports necessitated sudden acceleration, jumping, and extremes of dorsiflexion or plantar flexion.[5] Historically, it has been called "athlete's ankle" and "footballer's ankle".[6]

Clinical Relevant Anatomy[edit | edit source]

493x335 ankle.jpg

Talocrural Joint[edit | edit source]

The Talus

The ankle joint is a synovial hinge joint comprised of hyaline covered articular surfaces of the talus, the tibia as well as the fibula, allowing up to 20 degrees dorsiflexion and 50 degress plantarflexion. The distal ends of the tibia and fibula are held together firmly by ligaments of the medial (Deltoid) and lateral ligament complexes of the ankle which can be damaged and contribute to ankle arthritis (Ankle Sprain). The ligaments hold the tibia and fibula into a deep bracket-like shape in which the talus sits[7].

  • The ROOF of the joint is the distal inferior surface of the tibia
  • The MEDIAL SIDE of the joint is formed of the medial malleolus of the tibia
  • The LATERAL SIDE of the joint is formed of the lateral malleolus of the fibula

The articular part of the talus looks like a cylinder and fits snugly into the bracket provided by the syndemosis of the tibia and fibula, when looking down upon the talus the articular surface is wider anteriorly than posteriorly. Subsequently this increases the congruent, stable nature of this joint when it is in dorsiflexion. As this is a synovial joint, a membrane is present as well as a fibrous membrane providing the same functions as any other synovial joint synovial membrane[7]

Articulations of the Foot (Talus Removed)

<span style="font-size: 13.28px;" />

Subtalar Joint[edit | edit source]

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

  • The large posterior calcaneal facet on the inferior surface of the talus; and
  • The corresponding posterior facet on the superior surface of the calcaneus[7]

This joint, due to its orientation, allows the movements of inversion (0-35 degrees) and eversion (0-25 degrees), broken down this must mean the joint allows some amount of glide and rotation. It is known as a simple synovial condyloid joint. There are a large number of strong ligaments supporting the joint.

Epidemiology/Etiology[edit | edit source]

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]

===

Often know as "athlete's ankle" or "footballer's ankle" is caused by repeated dorsiflexion, microtrauma, and repeated inversion injury causing damage to anteromedial structures such as the articular cartilage. It is further classified into Anteromedial & Anterolateral Impingement[2].  Coincident chondral and osteochondral lesions may be found in patients with AI.[10] 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.[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 a range of motion limitation 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.
  • 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)[edit | edit source]

<u</u> Often known as "dancer's heel", is generally insidious in nature, occurring in athletes who routinely plantarflex, such as ballet dancers, jumping athletes, and those who kick.[2] Posterior ankle impingement is a common cause of chronic ankle pain.[13]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.]Also known as os trigonum syndrome and posterior tibiotalar compression syndrome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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’s an ankle inversion trauma, with the ankle in plantar flexion, the fibers of the posterior ligament become compressed.[14] 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.[15]
  • 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. During a plantair flexion, the PTL will entrap and then finally torn.[16]

Characteristics/Clinical Presentaion[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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title  Symptoms development may be insidious or in response to sudden injury.[5]

Anterior[edit | edit source]

<u</u>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.[2] (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[edit | edit source]

<u</u>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.[2] 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.[2]

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:

Causes

<u</u>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 plantarflexion or push-off activities.
The common cause of posterior ankle impingement syndrome is impingement of the Os trigonum or the posterior talar process and of chronic ankle pain and results from compression of bony or soft tissue structures during ankle plantar flexion. Bony impingement is most commonly related to an os trigonum or prominent trigonal process. 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.

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.
Moreover, a group of fibers fuse with the posterior intermalleolar ligament. The posterior intermalleolar ligament tenses during dorsiflexion and relaxes during plantar flexion, and therefore, trauma that causes forced dorsiflexion of the ankle 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.[2][10]

Consequences:

<u</u>Symptoms of PAIS are thought to result from two main mechanisms: Impaction of osseous structures against each other, where the posterior talar prominence may be compressed between the posterior tibia and posterior calcaneal tuberosity, as well as 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.[11]

Differentiel Diagnosis[edit | edit source]

Anterior ankle painCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • 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 [17]
Posterior ankle painCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[18]
  • 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
Medial ankle painCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Tarsal tunnel syndrome
  • Posterior tibial tendonitis
  • Maleolar fractures
  • Medial ankle impingement
  • Subtalar joint pathology
  • Medial tibial stress syndrome (shin splints)
Lateral ankle painCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Fracture (Talus, Fibula, 5th Metatarsal) 
  • Fibularis tendon injury
  • Lateral ankle impingement
  • Fibular or sural nerve irritation
  • Cuboid subluxation

Diagnostic Procedures[edit | edit source]

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.[17]  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[edit | edit source]

All contain evidence regarding score interpretation including content validity, construct validity, reliability, and responsiveness.[19]

  • 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 isdivided 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,joint effusion,or soft tissue edema.[20] Gait analysis may reveal asymmetry and malalignment as 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.

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[21][edit | edit source]

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) [22]
  • pain during single leg squat
  • lack of lateral ankle instability

Additional tests:[13]

  • <u</u>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% [21]
  • Forced dorsiflextion

Posterior Ankle Impingement Examination[23][edit | edit source]

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

Additional tests:[24]

  • Deep pressure palpation of the posteromedial joint line: positive => tenderness
  • Laxity tests (anterior drawer and inversion)
  • Manual strength test: Anterior tibialis, Peroneus complex, Gastrosoleus complex
  • Flexibility tests: Achillies tendon, Hamstring
  • Forced Plantarflexion  
  • Forced Inversion

Medical Management
[edit | edit source]

Diagnosis[25][edit | edit source]

  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[edit | edit source]

It is considered after conservative treatment has been tried first, at least 3 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.[26] Murawski et al showed 93% satisfaction, AOFAS and SF 36v2 significantly improved ~ 68% that had anteromedial impingement.[25] However, if athletic patients want to return to athletic 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].

Surgical methods include debridement, osteophyte removal, meniscoid lesion excision, partial capsulectomy, flexor hallux longus release, and chondroplasty of tibia may be performed.[27][28]

Complications include infection; neuropraxia; arthrofibrosis; complex regional pain syndrome and fibular nerve irritation.[25][26][28]

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]

Post-op:

For the posterior ankle impingement a compression bandage is applied after surgery and patients are allowed to be weightbearing as tolerated immediately after surgery. Patients may also begin ranging their ankle 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.[29]

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.[30]

Physical Therapy Management[edit | edit source]

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 an avoidance of provocative activities are recommended. In chronic cases, shoe modifications, including heel lift orthoses to prevent dorsiflexion, have been utilized.[8]

Patients should be treated conservatively after an inversion sprain of the ankle for at least 6 months.[5] They should be treated conservatively after an inversion injury of the ankle, with adequate joint rehabilitation, peroneal strengthening, and muscle balancing.[31] Patients who do not respond to conservative management may require operative intervention.[29]

<uAnterior Impingement[edit | edit source]

  • 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[32][33][34]
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.[35][36]

Posterior Impingement[edit | edit source]

  • Plantarflexion mobilization
  • P/A talocrural mobilization
  • Rear-foot distraction manipulation
  • Proprioceptive work - wobble board
  • Peronei strengthening
  • Isometric and eccentric exercises to strengthen and stretch the lower-leg muscles.[37] (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.[37] (Level of Evidence: 2b)
  • HEP: Achilles tendon stretching, Single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises[38]
  • Protective dorsiflexion taping[16]

Prevention[edit | edit source]

<uProtective 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.[39](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.[18] (Level of Evidence: 2b)

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.

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. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 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 5.2 5.3 5.4 5.5 5.6 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.
  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. 7.0 7.1 7.2 Cite error: Invalid <ref> tag; no text was provided for refs named Gray's
  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. 9.0 9.1 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. 10.0 10.1 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. 11.0 11.1 Sports health: A Multidisciplinary Approach. Medial Impingement of the Ankle in Athletes. American Orthopaedic Society for Sports Medicine. (3B)
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  13. 13.0 13.1 13.2 Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  14. Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  15. 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)
  16. 16.0 16.1 Sandro Giannini, Roberto Buda, Massimiliano Mosca, Alessandro Parma and Francesco Di Caprio,Posterior ankle impingement, Foot Ankle Int 2013 34: 459 (3A)
  17. 17.0 17.1 Russo A1, Zappia M, Reginelli A, Carfora M, D'Agosto GF, La Porta M, Genovese EA, Fonio P. “Ankle impingement: a review of multimodality imaging approach.” Musculoskelet Surg. 2013 Aug;97 Suppl 2:S161-8. https://www.ncbi.nlm.nih.gov/pubmed/23949938
  18. 18.0 18.1 Konstantinos Tsitskaris, Rowland Illing, Charles House, and Michael J Oddy “Osteoid osteoma as a cause of anterior ankle pain in a runner” BMJ Case Rep. 2014. http://casereports.bmj.com/content/2014/bcr-2014-204365.abstract (Level of Evidence: 3b)
  19. The Posterior Impingement View: An Alternative Conventional Projection to Detect Bony Posterior Ankle Impingement
  20. 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)
  21. 21.0 21.1 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.
  22. 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
  23. 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
  24. R. Coull, T. Raffiq, L. E. James, M. M. Stephens Open treatment of anterior impingement of the ankle
  25. 25.0 25.1 25.2 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.
  26. 26.0 26.1 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.
  27. 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.
  28. 28.0 28.1 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.
  29. 29.0 29.1 Yasui, Youichi, et al. "Posterior ankle impingement syndrome: A systematic four-stage approach." World Journal of Orthopedics 7.10 (2016): 657. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5065672/ (Level of Evidence: 2a)
  30. 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.
  31. McClinton, S. Regis University. Ankle impingement sydromes: diagnosis and treatment. Available at: https//connect.regis.edu/p38686942/. Accessed on July 9, 2011.
  32. Eils E.et all, Multistation Proprioceptive Exercise Program Prevents Ankle Injuries in Basketball, Medicine &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; sience in sports &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; exercise (2010)
  33. 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.
  34. 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)
  35. 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)
  36. Baker A., Webright W., Perrin D., Affect of a “T-band” kick training protocol on postural sway, Journal of sport Rehabilitation (1998)
  37. 37.0 37.1 W. Albisetti, M. Ometti, V. Pascale, O. De Bartolomeo “Clinical Evaluation and Treatment of Posterior Impingement in Dancers.” American Journal of Physical Medicine and Rehabilitation 2008; 88:349–354. http://journals.lww.com/ajpmr/Abstract/2009/05000/Clinical_Evaluation_and_Treatment_of_Posterior.1.aspx (Level of Evidence: 2b)
  38. 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.
  39. Sasadai, Junpei, et al. "The Effect of Ankle Taping to Restrict Plantar Flexion on Ball and Foot Velocity During an Instep Kick in Soccer." Journal of sport rehabilitation 24.3 (2015): http://journals.humankinetics.com/doi/abs/10.1123/jsr.2014-0156?url_ver=Z39.88-2003&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;rfr_id=ori:rid:crossref.org&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;rfr_dat=cr_pub%3dpubmed (accessed August 2015). (Level of Evidence: 2b)