Anterior Ankle Impingement Syndrome

 

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Search Strategy

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.

Clinically Relevant Anatomy

• 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

This syndrome is called soccer’s ankle or athlete’s ankle, because these sports are responsible for a lot of pressure on the ankle cartilage, especially soccer where the kicking motion is responsible for reoccurring micro trauma’s, leading to an increased chance on anterior impingement syndrome. These 2 sports together with dance are the majority of AI patient’s. Epidemiological figures were not found but because anterior impingement is frequently preceded by an ankle sprain, ankle sprain figures will prove usefull : Ankle sprain is a common sports injury and is often regarded as trivial by athletes and coaches. This epidemiological study was conducted among three categories of Hong Kong Chinese athletes: national teams, competitive athletes and recreational athletes. This study shows that as much as 73% of all athletes had recurrent ankle sprain and 59% of these athletes had significant disability and residual symptoms which led to impairment of their athletic performance. This study indicates that a proper approach towards injury prevention and a comprehensive rehabilitation programme are required. An epidemiological survey on ankle sprain.

Characteristics/Clinical Presentation

Anterior impingement syndrome of the ankle is a chronic disorder. Pain occurs in full dorsal flexion or full plantar flexion. The anterior impingement syndrome is not a disorder that just happens out of the blue, there already has to be made damage. The cause of this damage can be an inflammation. Due to inflammation the soft tissue will swell and have reduced elasticity, leading to an impingement. The second cause can be arthritis, the body responds to arthritis by building extra bone tissue, these are called osteophytes, the body acts this way because it prevents reoccurring micro trauma’s due  to decreased ROM,

 Risk enhancing factors

Chances are high that one or more sprains have occurred in the past, when the ankle has been sprained, the ligaments stretch out and lose the ability to efficiently communicate with the brain. The result of this is decreased coordination of the ankle. Which in turn results in more micro trauma’s and ultimately to a higher possibility of anterior ankle impingement. Sports which require a high rate of full dorsiflexions result in a greater risk to obtain anterior impingement syndrome. These sports are primarily soccer and running. 

Diagnostic Procedures

Diagnose can be made based on 3 sources of information : clinical research, history and physiotherapy research.
1) clinical research
X-ray can bring clarity if osteophytes are present, this picture should be made from the lateral side, where the bone structures of the ankle are clearly visible. What should be kept in the back of the mind is that some osteophytes still may not be visible, to solve this problem research has shown that an Anteromedial impingement recording, this is an X-ray where the angle is changed for optimal osteophyte recognition,  is a relevant addition to a normal X-ray.
2) history
3) physiotherapy research
• Pain while palpating the anterior side of the  joint crack
• Pain with a forced dorsiflexion.
• It is possible to reproduce anterior impingement pain by palpating the anterolateral ankle in plantar flexion, then dorsiflexing the ankle while maintaining pressure with the examiner’s digit over the anterolateral ankle. An increase in pain is 95% sensitive and 88% specific for anterior soft tissue impingement.
• Anterior impingement test should be positive : standing on both feet and leaning forwards, positive is defined as pain and possibly a difference of approximately 5 degrees between the two ankles.
• Ankle may be swollen and can be red.

Medical Management

1. limitation
• The first advise that has to be given to the patient is that he or she should stop from any activity that increases pain, this allows the body to start the healing process without further tissue damage while at the same time preventing a worsening of the situation and the problem becoming chronic . Later on activity can gradually start building up.
• Alternative exercises can be used with less force on the ankle, this includes : swimming, cycling, water sports,.. etc
• Another option is to use a slightly raised heel, this means that the foot does not need to go as far up as normal. The use of crutches is another method to prevent further damage.
2. reducing pain
• cryotherapy , freezing tissue and let the body restore it.  Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned.  Additionally, the low methodological quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury. (Does Cryotherapy Improve Outcomes With Soft Tissue Injury? computer-based literature search Hubbard TJ, Denegar CR. Pennsylvania State University, University Park, PA. evidence level : 1 )
• Anti-inflammatory medication, reduces pain and supports the healing process.
• Corticoid injection : An occasional injection of corticosteroids into the ankle joint may be helpful particularly if there is some underlying ankle arthritis present.
3. surgery
In some instances of anterior ankle impingement operative treatment may be helpful. If the main cause of a patient’s symptoms is from impingement (rather than ankle arthritis) removing the prominent impinging bone spurs can help symptoms. Surgical treatment of ankle impingement involves removing the prominent bone spurs either arthroscopic or by opening up the ankle joint with an incision. If the bone spurs are large it is often easier and faster to simply open up the ankle joint and remove the bone spurs rather than attempt to do this arthroscopic. Surgery to remove impinging bone spurs from the front of the ankle will not typically help symptoms if the pain is generalized about the ankle due to significant ankle arthritis rather than specifically located in the front of the ankle. In some instances surgery to remove the bone spurs can make a patient’s symptoms worse if it allows the ankle joint to move more and the ankle joint itself has significant arthritis. The bone spurs themselves WILL tend to grow back over time. So recurrence of symptoms is not uncommon. At long-term follow-up, arthroscopic excision of both soft-tissue overgrowths and osteophytes was shown to be an effective way of treating anterior impingement, providedthat there was no preoperative narrowing of the joint space. ( proven by Arthroscopic treatment of anterior impingement in the ankle A PROSPECTIVE STUDY WITH A FIVE- TO EIGHT-YEAR FOLLOW-UP J. L Tol, C. P. P. M. Verheyen, C. N. van Dijk
From the University of Amsterdam, The Netherlands / evidence level : 1b)

4.potential other techniques
      soft tissue massage can help reduce pain.
      It is assumed that heat improves the blood circulation and stimulate the healing process
      electrotherapy is assumed to have a positive effect
      taping to monitor the control of movement
      bracing to monitor the control of movement
 These methods are questionable, because there hasn’t been a highly rated research that proves that any of these  therapies are effective. Although there might be a positive effect, it is not ethical to give not-scientifically-proven therapies  as a physiotherapist

Physical Therapy Management

Physiotherapy can be given following the KNGF guidelines, which are complementary with the different phases of inflammation    

 Phase 1of recovery    :   inflammation               : 0-3 days

• Rest and immobilization, but frequent movement within pain limits
• Use pain as a guideline to base you’re exercises on
• Eating behaviours ( vit C, proteins, anti-oxidants,…)
• Exercise basic functions, move feet and toes to improve blood circulation
• Limit painkillers to the bare minimum

  Phase 2 of recovery  :    limited functionality    : 4-10 days

• Mobilization to improve scar tissue quality
• Muscle endurance training within free ROM
• Proprioceptive training
• Train musclestrenght of “foot raiser muscles” ,using more weight and less repetitions
• Normal ROM should be reached 

  Phase 3 of recovery  :    early revalidation       : 11-21 days

• Mobilizations with a progressively enhancing ROM
• Proprioceptive training
• Musclestrenght training
• Research and estimate the level of daily activity, modify therapy with this info
 

Phase 4 of recovery  :   late revalidation          :  3-6 weeks

• Improve load capacity, running and climbing stairs
• Coordination training with ADL
• Goal is to end exercises with a load like before the incident
• Progressive build up of schedule : static  dynamic / selective  functional
 
Phase 5 of recovery  :   early sporting              : 6-8 weeks
                                         +
Phase 6 of recovery   :   late sporting               : starting week 8

• Improve sporting
• Practice and improve functions and activities based on sports
• Sufficient rest and repair moments

Resources

Books :
• KNGF praktijkrichtlijn enkelletsel
• Letsels van de Enkel en de Voet – J.B. van Mourik, dr P. Patka
• Reynaert, P., Nelen, G., Geens, G., Arthroscopic treatment of anterior impingement of the ankle. Acta Orthopaedica Belgica (1994) P384-388.
• Tol JL, Dijk van CN
Anterieur enkelimpingement, Geneeskunde en Sport 2006;
39(1): 24-27

Internet sites :
• www.pubmed.nl
• www.wikipedia.nl
• www.scopie.info/enkel_arthroscopie
• http://injuryupdate.com.au/injuries/foot_&_ankle/anterior_ankle_impingement.php
• http://www.eorthopod.com/public/patient_education/6583/ankle_impingement_problems.html
• http://www.scielo.br/pdf/rbr/v51n3/en_v51n3a09.pdf

Articles / pages of books :

1. Akseki, D., Pinar, H., Yaldiz, K., Arac, S., The distal fascicle of the anterior inferior tibiofibular ligament as a cause of anterolateral ankle impingement. Department of Orthopedics and Traumatology, Manisa, Turkey. Scandinavian University, Sweden (1999) P 478-482.
2. Brouwer, P.J., Geesink, R.G.T., Prompers, L.A.J.L., Verstappen, F.T.J., Klachten en afwijkingen aan knieën en enkels bij ex-profvoetballers uit 1956. Medische Faculteit van de Rijksuniversiteit van Limburg (1981) P 694-697.
3. Kim, S.H., Ha, K.I., Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle. Samsung Medical Centre, Seoul, Korea (2000) P 1019-1021. Evidence level : 2
4. Anterior Ankle Impingement
a. by Judith F. Baumhauer, MD, MPH

5. Soft-Tissue and Osseous Impingement Syndromes of the Ankle: Role of Imaging in Diagnosis and Management Philip Robinson, FRCR and Lawrence M. White, MD
6. Arthroscopic Management of Femoroacetabular Impingement:  evidence level : 2
a. Early Outcomes Measures
i. Christopher M. Larson, M.D., and M. Russell Giveans, Ph.D.

7. Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Computer based         research Hubbard TJ, Denegar CR.Source Pennsylvania State University, University Park, PA..        
8. Osteophytes: relevance and biology
Peter M. van der Kraan Ph.D., Associate Professor* and Wim B. van den Berg Ph.D.,
Professor of Experimental Rheumatology
Experimental Rheumatology & Advanced Therapeutics, NCMLS, Radboud University,
Medical Center Nijmegen, The Netherlands  evidence level : 1
                  

Thesis :

Thesis about the anterior impingement syndrome , made in the Netherlands :
Milan Lok Karolien Levink Liseth Oosterveld                                                                     Academie Fysiotherapie  Saxion Hogeschool Enschede   Juni 2009