Marcia Faustin, MD, CAQSM
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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:
Intra-articular fibrous band/scar
Ankle impingement syndromes are classified based on location:
Anteromedial (less common)
Posteromedial (less common)
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 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
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 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
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].
Preventing recurrent ankle sprains
Early exercise protocol for acute ankle sprain
Proper rehabilitation, including ankle strengthening, range of motion, and proprioception
Recognizing the condition early in order to allow early rest and rehabilitation
Typically, a clinical diagnosis of exclusion
Prior history of single or multiple episodes of traumatic ankle injuries (typically inversion injuries)
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
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)
Complete neurovascular exam, strength, and range of motion
Possible soft tissue swelling or effusion
Tenderness to palpation over the anterior, anterolateral, or anteromedial ankle (most important clinical finding)
Pain in the anterior aspect of the ankle with either forced plantar flexion or dorsiflexion
Tenderness to palpation in the posterior aspect of ankle, typically anterior to and not involving the Achilles tendon
Possible palpable soft tissue thickening with tenderness to palpation
Positive plantar flexion test: pain in posterior ankle with plantar flexion (pathognomonic)
Reproducible pain with pressure over posteromedial aspect of the ankle during passive inversion and plantar flexion
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