eMedicine Specialties > Sports Medicine > Foot and Ankle
Ankle Impingement Syndrome
Updated: Aug 12, 2008
Introduction
Ankle impingement is defined as a painful mechanical limitation of full ankle range of motion secondary to an osseous or soft-tissue abnormality.1,2,3,4,5,6
Background
Soft-tissue impingement lesions of the ankle usually occur as a result of synovial or capsular irritation secondary to traumatic injuries, infection, or rheumatologic or degenerative disease states. Ankle impingement syndromes may also be congenital in origin. The leading causes of impingement lesions are posttraumatic injuries, usually ankle sprains, leading to chronic pain. Involved areas may include the anterolateral gutter, syndesmosis, and posterior ankle regions.
In 1950, Glassman et al reported on 9 patients who presented with chronic persistent pain and swelling around the anterolateral aspect of the ankle following an inversion ankle sprain.7 At the time of surgery, a massive hyalinized connective-tissue band that extended from the anteroinferior region of the talofibular ligament (TFL) into the ankle joint was found. The authors referred to this pathologic entity as a meniscoid lesion because of its resemblance to a torn meniscus of the knee.7 It was believed that repetitive tension on this tissue led to increasing hypertrophy and fibrosis, resulting in impingement on the talar cartilage and causing pain and swelling. Resolution of symptoms occurred in all cases with excision of the pathologic tissue.
In 1982, Waller described a pain syndrome along the anteroinferior border of the fibula and anterolateral talus following repetitive inversion injuries.8 Examination of his patients revealed foot pronation and heel valgus. Waller believed this pathology to be synovial compression or chondromalacia of the lateral talar dome and called it the anterolateral corner compression syndrome.
Bassett et al found and described a separate pathologic fascicle of the anterior TFL (ATFL) in syndesmotic impingement.9 Following a tear of the ATFL, the anterolateral talar dome extrudes anteriorly with dorsiflexion, resulting in impingement.
Hamilton described a labrum or pseudomeniscus of the posterior lip of the tibia, which can become torn or hypertrophied with ankle sprains and lead to posterior impingement.10
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Sports Injury Center, and Sprains and Strains Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.
Related eMedicine topics:
Ankle Injury, Soft Tissue
Ankle Sprain
Ankle Taping and Bracing
Recurrent Ankle Sprains
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Specialty Site Orthopaedics
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Frequency
United States
After an ankle sprain, 20-40% of patients have chronic ankle pain; of these patients, approximately one third has pain that is related to impingement.
Sport-Specific Biomechanics
The most common mechanism of an acute ankle impingement injury is plantar flexion/inversion injury that results in acute ankle sprain (eg, basketball player landing on opponent's shoe, cross-country runner stepping in a hole).
Clinical
History
- 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.
Physical
- 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.
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Causes
- 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.
- 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.11 In ballet dancers, forcing turnout of the foot can predispose to this condition.12
Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Joint Disorders
Specialty Site Orthopaedics
More on Ankle Impingement Syndrome |
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| Follow-up: Ankle Impingement Syndrome |
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| References |
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References
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Further Reading
Keywords
ankle impingement syndrome, impingement lesions, Haglund's syndrome, Haglund syndrome, ankle injury, inversion ankle sprain, chronic ankle sprain, chronic ankle pain, sports injuries, anterior talofibular ligament, ATFL, anterolateral ankle impingement, syndesmosis impingement, posterior impingement, pseudomeniscus, posterior ankle impingement, PAI, posteromedial ankle impingement, PoMI, os trigonum, meniscoid lesion, synovial irritation, capsular irritation, arthroscopic excision, arthroscopic debridement, anterolateral corner compression syndrome
