Posterior Ankle Impingement and Posterior Process Fracture of the Talus

Description

Posterior ankle impingement is characterized by pinching and inflammation of the tissues in the back of the ankle. This may be associated with a fracture in the back of the ankle bone, the talus, or with an extra bone behind the ankle, called the os trigonum. This injury occurs in people who are often on their toes, such as ballet dancers, ice skaters, and gymnasts.

Common signs and symptoms

• Pain with forcing the toes downward (plantar flexion), when standing on tiptoes, and when wearing shoes with high heels

• Pain with flexing (bending) of the big toe

• Tenderness in the back of the ankle and occasionally on the outside of the ankle

• Pain when running, jumping, or walking down stairs or hills or when squatting while standing on the toes

• Mild swelling and occasionally bruising in the back of the ankle or heel (with fracture)

Causes

• Forced plantar flexion injury, in which the toes are forced to point down, such as from heels catching while going down stairs, from sliding and catching the heel of the shoe or cleats on something, when kicking a football, or when standing on the tips of the toes repeatedly

• Less commonly caused by excessive dorsiflexion, extension of the ankle with the toes pointing up, often associated with twisting of the ankle

Factors that increase risk

• Sports that require repeated standing on the tips of the toes (ballet dancing, gymnastics, ice skating)

• Sports that involve sliding in shoes with cleats, where the heel may catch the ground, causing a forced flexion of the ankle (soccer, baseball)

• Repeated kicking with the toes flexed downward, such as when kicking a football

• Previous foot or ankle sprains or dislocations

• Wearing shoes with inadequate support to prevent forced flexion of the ankle

• Wearing shoes with excessively long cleats

• Poor physical conditioning (strength, flexibility)

Preventive measures

• Appropriately warm up and stretch before practice and competition.

• Maintain appropriate conditioning that includes ankle and leg flexibility, muscle strength, and endurance training.

• Use proper technique, and have a coach correct improper technique.

• Taping, protective strapping, bracing, or high-top shoes may help prevent injury. Initially, tape is best, however, it loses most of its supportive function within 10 to 15 minutes.

• Wear proper protective shoes; high-top shoes with taping or bracing are more effective than either alone.

• Wear the correct length of cleats for the playing surface.

Expected outcome

Posterior ankle impingement and process fracture of the talus are usually curable within 4 to 6 weeks with appropriate treatment. Recovery is quicker if not associated with fracture.

Possible complications

• Healing time is prolonged if the injury is not appropriately treated, or if it is not given enough time to heal.

• Prolonged disability may result.

• Symptoms may often recur; appropriately addressing the problem with rehabilitation decreases the frequency of recurrence and optimizes healing time.

• Complications of surgery may include infection, bleeding, injury to nerves, pain, ankle stiffness, and weakness.

General treatment considerations

Initial treatment consists of medications and ice to relieve pain, stretching and strengthening exercises, and modification of the activity that initially caused the problem. These exercises can all be carried out at home for acute cases. Occasionally, immobilizing the ankle with bracing, casting, or a walking boot may be attempted to allow the inflammation to settle down. Chronic cases often require referral to a physical therapist or athletic trainer for further evaluation and treatment. If symptoms persist, an injection of cortisone and anesthetics or surgical intervention may be required. Uncommonly, surgery may be necessary to remove the small piece of bone that may be causing the pinching and pain with flexion of the foot and ankle.

Medication

• Nonsteroidal antiinflammatory medications, such as aspirin and ibuprofen (do not take for 7 days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician, and contact your doctor immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.

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