Anterior Ankle Impingement Syndrome

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Search Strategy

1. SEARCH STRATEGY ARTICLES

Search engine : pub med, Pedro
Keywords : anterior impingement syndrome ankle,
Timeline : search performed end of October 2011

Definition/Description

The anterior impingement syndrome of the ankle  is a strangulation that can be caused by soft tissue ,like the joint capsule or scar tissue, and hard tissue which refers to bone tissue. It’s location is the anterior side of the ankle in the talocrural joint. Due to repeated micro trauma’s little “tics” occur against the ankle, the body will respond to this by building extra bone tissue called “osteophytes”. There are 3 types of osteophytes, traction spur, inflammatory spur and the genuine osteophyte or chondro-osteophyte. The one occurring here is a chondro-osteophyte.  It is a defense mechanism of the body that prevents further injury, but reduces mobility and can lead to pain due to an impingement. There may potentially be swelling of capsule, mucous membrane and connective tissue. The relative contributions of the osseous and soft-tissue abnormalities are variable, but whatever component is dominant there is physical impingement and painful limitation of ankle movement.

 • The joint capsule is ventral and dorsal minimally present, it is reinforced with ligaments at the lateral side. At the front are the tendons of the lower leg muscles, at the back is the tendon of the m. flexor hallucis longus. These muscles prevent that parts of the joint capsule get trapped between bones.
• foot free : In dorsal flexion the distal end of the talus moves lateral , the plantar side of the talus rotates to lateral    /    in plantar flexion the distal end of the talus moves medial, the plantar side of the talus rotates to medial.
• foot stabilized on the floor : dorsal flexion provokes an endorotation of the tibia, the distal end of the tibia moves to medial    /   plantar flexion provokes an exorotation of the tibia, the distal end of the tibia moves to lateral
• stability in the talocrural joint is the weakest in neutral position, this is because in this position the ligaments that surround the ankle are less tensed than in dorsal flexion or plantar flexion and there is less contact between joint facets. Plantar flexion has more stability, there is more contact between the joint facets and the tibionavicular part as well as the tibiotalar anterior part of the ligament deltoideum. The greatest stability occurs in dorsal flexion,  the large front part of the trochlea tali now comes in touch with the small, narrow back part of joint socket, when this happens, the tibia and the fibula widen a bit and keep the talus closely bound helped with the strong tibiofibular ligaments.

Epidemiology /Etiology

Fracture of the coccyx often arise after a fall on the buttock, most prevalent a fall of the stairs on the tailbone, or by an impact directly applied. (level of evidence D) An especially difficult childbirth occasionally injures the mother’s coccyx. ( level of evidence D)

Characteristics/Clinical Presentation

1. GENERAL SYMPTOMS
General symptoms that appear are (level of evidence D)iv,vii,viii :
• Pain that increases in severity when sitting or getting up from a chair
• Provoked pain over the tailbone
• Bruising or swelling in the tailbone area
• Bowel movements and straining are often painful
• There are no neurological signs

An important number of people suffer from long lasting pains over the coccyx following trauma (with or without fracture of the coccyx), better known as cocydynia.(level of evidence D)

2. CLINICAL PRESENTATION IN PATIENTS WITH SPINAL CORD INJURY
Patients with SCI, suffering from painful symptoms in the low back, gluteal, hip and thigh region, have coccyx fracture with a frequency of 34,6%. Patients who had coccyx fracture have higher pain scores when compared with those who don’t have any fracture, however the difference is only statistical significant regarding Sensory Pain Index (SPI) and total McGill scores.( level of evidence C)

Diagnostic Procedures

1. MEDICAL DIAGNOSIS
A plain radiography or MRI is necessary to confirm the diagnose of a coccyx fracture. (level of evidence D)

2. CLINICAL DIAGNOSIS
The diagnose is made after rectal examination. (level of evidence D)iv By passing the finger up the rectum and then pressing the bone backwards and forward, the unnatural degree of motion will then be felt. Related to the age and sex of the patient must be remembered that in the female this bone naturally possesses more motion than in the male, and that in youth a degree of motion, that does not exist at a later period of life, is present, allowing the ossification being less complete. However the free motion of the bone is taken as a symptom. (level of evidence D)

Outcome Measures

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Examination

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Medical Management

1. COCCYGEOPLASTY
By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)

2. COCCYGECTOMY
Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix

Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D
YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D
HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D
TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C
RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D
LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D
MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B
EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D
DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C
COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams & Wilkins, 2008, pag. 144, level of evidence D