Ankle Impingement



Ankle Impingement


Marcia Faustin, MD, CAQSM



BASICS


DESCRIPTION



  • Impingement is a clinical syndrome of end-range joint pain or restricted motion caused by direct abutment and/or compression of bone or soft tissues.


  • Classifications: based on types of impingement:



    • Posttraumatic synovitis


    • Bony spur


    • Intra-articular fibrous band/scar


    • Capsular scarring


  • Ankle impingement syndromes are classified based on location:



    • Anterior


    • Anterolateral


    • Anteromedial (less common)


    • Posterior


    • Posteromedial (less common)


EPIDEMIOLOGY



  • 1-2% of ankle inversion injuries lead to chronic disability requiring surgical intervention.


  • Common in athletes who play on grass or turf (1)


  • 10-25% of population have os trigonum.


ETIOLOGY AND PATHOPHYSIOLOGY



  • Arises from either traumatic or repetitive hyperdorsiflexion (anterior impingement) or hyperplantar flexion (posterior impingement)


  • Microtrauma from repetitive movements such as kicking soccer ball can lead to spur formation.


  • Initial ankle injuries in the subacute or chronic phase can lead to the development of abnormal osseous or soft tissue thickening.


  • Pain generators are typically the soft tissue caught between traction spurs and osteophytes, not the actual osteophytes/bone spurs.


  • Anterior impingement is typically easier to diagnose than posterior impingement, due to superficial location:



    • Anterior impingement:



      • Anterior lateral gutter—damage to lateral collateral ligament complex and joint capsule, resulting in synovitis, irregular thickening, and/or scarring of ligaments after inversion ankle sprain


      • Anterior:



        • Repeated capsuloligamentous traction or microtrauma in plantar flexion may induce spur formation (kicking a ball).


        • Tibial or talar osteophytes impinge soft tissue.


    • Anteromedial—unclear mechanism; possibly secondary to eversion ankle injury or inversion injury with rotational component that leads to soft tissue impingement


    • Posterior impingement: Spectrum of disorders characterized by posterior ankle pain after acute fracture or recurrent plantar flexion or hyperplantar flexion. Symptoms can arise due to impingement and mechanical irritation of the soft tissues between these posterior structures:



      • Os trigonum (accessory ossicle connected by a fibrous band to the posterolateral tubercle of the talus) (2)[C]


      • Talar compression syndrome


      • Prominent posterolateral process of talus (Stieda process)


      • Prominent medial malleoli process


      • Prominent posterior process of calcaneus


RISK FACTORS



  • Anterior impingement:



    • Risk factors include sports requiring recurrent forceful dorsiflexion of the ankle, recurrent ankle sprains (supination and plantar flexion) and/or chronic ankle instability, and acute ankle sprains/fractures.


    • Athletes: soccer players, gymnasts, basketball players, football players, high jumpers, running uphill


  • Posterior impingement:



    • Risk factors include acute or recurrent hyperplantar flexion (ballet on pointe), recurrent ankle sprains, or ankle instability.


    • Athletes: ballet dancers (“en pointe” and “demi pointe”), cheerleaders, running downhill (forced plantar flexion)


    • Poor shoe wear without appropriate support


    • Overuse injury is more common than traumatic injury (3)[C].



GENERAL PREVENTION



  • Preventing recurrent ankle sprains


  • Early exercise protocol for acute ankle sprain


  • Proper rehabilitation, including ankle strengthening, range of motion, and proprioception


  • Proper footwear/orthotics


  • Recognizing the condition early in order to allow early rest and rehabilitation




DIAGNOSIS


HISTORY



  • Typically, a clinical diagnosis of exclusion


  • Prior history of single or multiple episodes of traumatic ankle injuries (typically inversion injuries)


  • Mild swelling or effusion after activity (2,3,4,5)[C]


  • Anterior impingement:



    • Pain with activities requiring ankle in dorsiflexion (uphill running/walking)


    • Pain with kicking a soccer ball, especially a dead ball


    • Popping or snapping sensation of isolated soft tissue lesions


    • Subjective feeling of limited range of motion or blocking on dorsiflexion


  • Exacerbating factors: climbing stairs, ascending ladders, and deep squat (1,2,3,4,6)[C]


  • Posterior impingement:



    • Pain is difficult to localize, typically anterior to the Achilles tendon.


    • Pain described as consistent, sharp, dull and/or radiating


    • Prior history of inversion (supination) and plantar flexion injury


    • Posterior ankle pain exacerbated by either plantar flexion (compression of soft tissues or bony prominence) or dorsiflexion (stretching of the posterior capsule and ligaments)


  • History of repetitive push off or plantar flexion maneuvers (i.e., downhill running/walking, descending stairs, and high-heeled shoe wear) (1,2,3,5,6)[C]


PHYSICAL EXAM

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Mar 14, 2020 | Posted by in SPORT MEDICINE | Comments Off on Ankle Impingement

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