eMedicine Specialties > Sports Medicine > Foot and Ankle
Ankle Impingement Syndrome: Treatment & Medication
Updated: Aug 12, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
The initial treatment of ankle impingement syndrome includes nonsteroidal antiinflammatory drugs (NSAIDs) as needed for pain, physical therapy, bracing, and orthotics.
Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Surgical Intervention
With the failure of conservative modalities, surgical intervention is indicated. Arthroscopic excision and debridement is the treatment of choice.15,16,17,18,19
Related Medscape topics:
Specialty Site Orthopaedics
Specialty Site Surgery
Other Treatment
Occasionally, steroid injection into the affected area may give relief. Intra-articular anesthetic (lidocaine) ankle injection can be used as a differential tool to distinguish between ankle pain and subtalar pain.
Electrotherapeutic modalities may also be helpful.
In ballet dancers, technique assessment is helpful and essential to prevent further pain and injury.
Related eMedicine topics:
Corticosteroid Injections of Joints and Soft Tissues
Local Anesthetic Agents, Infiltrative Administration
Therapeutic Injections for Pain Management
Recovery Phase
Rehabilitation Program
Physical Therapy
Postoperatively, advise posterior splinting for 1 week, as well as a supportive brace and elastic compression stocking. Physical therapy is initiated at 2-3 weeks for strengthening, range of motion, proprioception, and sport-specific rehabilitation.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Related eMedicine topics:
Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-800 mg PO tid with food
Pediatric
10 mg/kg PO tid with food
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Ketoprofen (Actron, Orudis, Oruvail)
For the relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease.
Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution and closely observe the patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Naprosyn, Anaprox, Naprelan)
For the relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Sulindac (Clinoril)
Decreases the activity of cyclooxygenase which, in turn, inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.
Adult
150-200 mg PO bid or 300-400 PO qd; not to exceed 400 mg/d
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may the increase concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; hypersensitivity to aspirin, iodides or other NSAIDs; GI bleeding; renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia; caution in the presence of anticoagulation defects or in patients who are receiving anticoagulant therapy
Flurbiprofen (Ansaid)
May inhibit the cyclooxygenase enzyme, which, in turn, inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Opioid analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Acetaminophen and codeine (Tylenol #3)
May inhibit the cyclooxygenase enzyme, which, in turn, inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
30-60 mg/dose PO q4-6h (based on codeine content) or 1-2 tab PO q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose PO q4-6h (based on codeine content); 10-15 mg/kg/dose PO (based on acetaminophen content); not to exceed 2.6 g/d of acetaminophen
The toxicity of codeine increases with CNS depressants, TCAs, MAOIs, neuromuscular blockers, phenothiazines, and opioid analgesics; rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen.
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen is possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses that exceed recommended the maximum dose.
Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h (based on acetaminophen content) prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg PO q4h (based on acetaminophen content); not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/d
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or TCAs
Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Hydrocodone and ibuprofen (Vicoprofen)
Drug combination indicated for the short-term (<10 d) relief of moderate to severe acute pain.
Adult
1-2 tab PO q4-6h prn; not to exceed 5 tab/d
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; third trimester of pregnancy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; the duration of action may increase in elderly persons
Propoxyphene and acetaminophen (Darvocet-N 100, Propacet, Wygesic)
Drug combination indicated for mild to moderate pain.
Adult
1-2 tab PO q4h prn; not to exceed 600 mg/d
Pediatric
Not established
May increase the serum concentrations of MAOIs, TCAs, carbamazepine, phenobarbital, and warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
More on Ankle Impingement Syndrome |
| Overview: Ankle Impingement Syndrome |
| Differential Diagnoses & Workup: Ankle Impingement Syndrome |
 Treatment & Medication: Ankle Impingement Syndrome |
| Follow-up: Ankle Impingement Syndrome |
| Multimedia: Ankle Impingement Syndrome |
| References |
| « Previous Page | Next Page » |
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
