Ankle Impingement Syndrome Clinical Presentation
- Author: Marc A Molis, MD, FAAFP; Chief Editor: Craig C Young, MD more...
See the list below:
- Anterior ankle impingement: Chronic ankle pain occurs, usually presenting as persistent pain or disability after an ankle sprain.
- Anterolateral ankle impingement: Chronic vague pain over the anterolateral ankle occurs, usually associated with cutting and pivoting movements.
- Syndesmosis impingement: Syndesmotic or a "high" ankle sprain occurs in up to 10% of all ankle injuries.
- Posterior impingement: This syndrome is usually located posteriorly or posterolaterally following an ankle sprain.
See the list below:
- Anterior ankle impingement: Anterior ankle pain is present with a subjective feeling of stiffness or "blocking" on dorsiflexion. The pain is usually most severe with dorsiflexion, and dorsiflexion may be limited on examination. It is possible to do the anterior impingement test, in which the patient lunges forward maximally with the heel on the floor. If this test reproduces the pain, the test is positive and suggestive of anterior impingement. Swelling over the anterior aspect of the ankle may be present.
- Anterolateral ankle impingement: Tenderness is noted along the lateral gutter and ATFL. Proprioception may be poor in these patients.
- Syndesmosis impingement: Extreme tenderness along the syndesmosis and interosseous membrane is noted, along with pain on bimalleolar compression of the syndesmosis and on passive external rotation stress of the ankle.
- Posterior impingement: The diagnosis of posterior ankle impingement is often difficult, requiring a high index of clinical suspicion. Posterior impingement often causes lingering pain, swelling, and catching of a synovial nodule, and it may be worse with forced plantar flexion. If further confirmation is necessary, local anesthetic can be injected around the posterior talus, and then the impingement test (reproduction of pain with passive plantarflexion of the ankle) can be performed without pain.
See the list below:
- Anterior ankle impingement: Seen in activites that cause forced dosiflexion. Seen in soccer players while kicking (sometimes termed "footballer's ankle") and ballet dancers (especially with pliés, which are lunging maneuvers). Chronic damage or microtrauma leads to subsequent bone spur formation (anterior tibiotalar spurs), which cause subsequent limitation of movement and pain. See the image below.
- Anterolateral ankle impingement: Common causes are inversion ankle injuries and sprains sustained while playing basketball (45%), volleyball (25%), or soccer (31%). Injury to the ligament or joint capsule may lead to synovitis, scar tissue, hypertrophied soft tissue, and, ultimately, impingement.
- Syndesmosis impingement: Tearing of the syndesmosis or the ATFL results in chronic instability and extrusion of the anterolateral talus, leading to syndesmotic impingement. Ice hockey, football, and soccer players often sustain this type of injury.
- Posterior impingement: Hypertrophy or tear of the posterior inferior TFL, transverse TFL, tibial slip, or pathologic labrum on the posterior ankle joint can lead to posterior ankle impingement, which may pinch on the os trigonum or posterior talus of calcaneus. This syndrome can also result from pathology of the os trigonum-talar process, ankle osteochondritis, flexor hallucis longus tenosynovitis, subtalar joint disease, and fracture. Pain is caused by forced plantar flexion and push-off maneuvers, as seen in dancing, kicking, gymnastics, or downhill-running types of activities. In ballet dancers, forcing turnout of the foot can predispose to this condition.
Ferkel RD. Soft tissue pathology of the ankle. McGinty JB, Caspari RB, Jackson RW, Poehling GG, eds. Operative Arthroscopy. 2nd ed. Philadelphia, Pa: Lippincott Raven; 1996. 1141-55.
Ferkel RD. Ankle and foot injuries. Fu FH, Stone DA, eds. Sports Injuries. Baltimore, Md: Lippincott Williams & Wilkins; 1994.
Umans HR, Cerezal L. Anterior ankle impingement syndromes. Semin Musculoskelet Radiol. 2008 Jun. 12(2):146-53. [Medline].
Sanders TG, Rathur SK. Impingement syndromes of the ankle. Magn Reson Imaging Clin N Am. 2008 Feb. 16(1):29-38, v. [Medline].
Robinson P. Impingement syndromes of the ankle. Eur Radiol. 2007 Dec. 17(12):3056-65. [Medline].
Pfeffer GB, ed. Chronic Ankle Pain in the Athlete (monograph). Dec 2000.
Wolin I, Glassman F, Sideman S, Levinthal DH. Internal derangement of the talofibular component of the ankle. Surg Gynecol Obstet. 1950 Aug. 91(2):193-200. [Medline].
Waller JF. Hindfoot and midfoot problems. Symposium on the foot and leg. Mack RP, ed. Running Sports. St. Louis, Mo: Mosby; 1982. pp 64-71.
Bassett FH 3rd, Gates HS 3rd, Billys JB, Morris HB, Nikolaou PK. Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am. 1990 Jan. 72(1):55-9. [Medline]. [Full Text].
Hamilton WG. Tendonitis about the ankle joint in classical ballet dancers. Am J Sports Med. 1977 Mar-Apr. 5(2):84-8. [Medline].
Maquirriain J. Posterior ankle impingement syndrome. J Am Acad Orthop Surg. 2005 Oct. 13(6):365-71. [Medline].
Alfredson H, Cook J, eds. Pain in the Achilles region. Brukner P, Khan K. Clinical Sports Medicine. 2nd ed. New York: McGraw-Hill; 2000.
Lee JC, Calder JD, Healy JC. Posterior impingement syndromes of the ankle. Semin Musculoskelet Radiol. 2008 Jun. 12(2):154-69. [Medline].
McCarthy CL, Wilson DJ, Coltman TP. Anterolateral ankle impingement: findings and diagnostic accuracy with ultrasound imaging. Skeletal Radiol. 2008 Mar. 37(3):209-16. [Medline].
Henderson I, La Valette D. Ankle impingement: combined anterior and posterior impingement syndrome of the ankle. Foot Ankle Int. 2004 Sep. 25(9):632-8. [Medline].
Ferkel RD. Arthroscopy of the foot and ankle. Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. 7th ed. St Louis, Mo: Mosby; 1999. 1257-97.
Ogilvie-Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy. 1997 Oct. 13(5):564-74. [Medline].
Liu SH, Raskin A, Osti L, et al. Arthroscopic treatment of anterolateral ankle impingement. Arthroscopy. 1994 Apr. 10(2):215-8. [Medline].
Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med. 1991 Sep-Oct. 19(5):440-6. [Medline].
Wiegerinck JI, Vroemen JC, van Dongen TH, Sierevelt IN, Maas M, van Dijk CN. The posterior impingement view: an alternative conventional projection to detect bony posterior ankle impingement. Arthroscopy. 2014 Oct. 30 (10):1311-6. [Medline].
Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, et al. Posterior hindfoot arthroscopy: a review. Am J Sports Med. 2014 Jan. 42 (1):225-34. [Medline].
Jackson DW, Ashley RL, Powell JW. Ankle sprains in young athletes. Relation of severity and disability. Clin Orthop Relat Res. 1974 Jun. 101:201-15. [Medline].
Vilá J, Vega J, Mellado M, Ramazzini R, Golanó P. Hindfoot endoscopy for the treatment of posterior ankle impingement syndrome: a safe and reproducible technique. Foot Ankle Surg. 2014 Sep. 20 (3):174-9. [Medline].