Ankle Impingement Syndrome Clinical Presentation

Updated: Sep 30, 2015
  • Author: Marc A Molis, MD, FAAFP; Chief Editor: Craig C Young, MD  more...
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Presentation

History

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  • 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.

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Physical

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  • 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

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  • 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.

    Radiograph of an os trigonum in a ballet dancer. I Radiograph of an os trigonum in a ballet dancer. Image courtesy of Dr. Craig Young.
  • 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]

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