Ankle Impingement Syndrome

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.[10] 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.[10] 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.[11] 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.[12] 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.[13]

United States statistics

After an ankle sprain, 20-40% of patients have chronic ankle pain; of these patients, approximately one third have pain that is related to impingement.

Ankle impingement syndrome is most common among football and soccer players, track and field athletes, and ballet dancers.[14]

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).

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 anterior talofibular ligament (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.[15]  In ballet dancers, forcing turnout of the foot can predispose to this condition.[16]

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.

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.

Plain radiography, bone scanning, and computed tomography (CT) scanning findings are usually normal. Plain radiographs may show an enlarged posterior tubercle of the talus or an os trigonum in patients with posterior ankle impingement.[15, 17]  Having the patient adopt a lunge position that reproduces their pain may show bone-on-bone impingement on a plain radiograph. Patients with anterior ankle impingement may show tibial and talar spurring.

Magnetic resonance imaging (MRI) is the imaging technique of choice because of its advantage in identifying osseous and soft-tissue abnormalities.

Stress radiography findings are usually negative, and this study is not indicated.

Ultrasound may be useful in identifying some synovitic lesions, especially within the anterolateral gutter.[18]

Physical Therapy

The initial treatment of ankle impingement syndrome includes nonsteroidal antiinflammatory drugs (NSAIDs) as needed for pain, physical therapy, bracing, and orthotics.

Surgical Intervention

With the failure of conservative modalities, surgical intervention is indicated. Arthroscopic excision and debridement is the treatment of choice.[19, 20, 7, 8, 9, 21, 22]  

A study by Georgiannos et al reported lower complication rates and shorter return to full activities with endoscopic excision of the os trigonum compared to the open procedure.[23]

A meta-analysis by Zwiers et al found no statistically significant difference between open surgery for posterior ankle impingement and endoscopic surgery in terms of postoperative functional outcome scores, patient satisfaction, and return to preinjury level of activity. Endoscopic surgery was associated with fewer complications.[24]

Other Treatment

Occasionally, steroid injection into the affected area may give relief. In a study of athletes, corticosteroid injections improved ankle impingement symptoms in 84% of patients.[14] 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.

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.

Return to Play

Patients with ankle impingement syndrome are allowed to return to sports or activities as tolerated in approximately 4-6 weeks, depending on the completion of physical therapy goals. Somewhat longer rehabilitation may be required with syndesmotic impingement.

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Class Summary

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.

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.

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.

Sulindac (Clinoril)

Decreases the activity of cyclooxygenase which, in turn, inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.

Flurbiprofen (Ansaid)

May inhibit the cyclooxygenase enzyme, which, in turn, inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Class Summary

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.

Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab)

Drug combination indicated for moderate to severe pain.

Hydrocodone and ibuprofen (Vicoprofen)

Drug combination indicated for the short-term (< 10 d) relief of moderate to severe acute pain.

Propoxyphene and acetaminophen (Darvocet-N 100, Propacet, Wygesic)

Drug combination indicated for mild to moderate pain.