AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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. They 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 presenting with chronic persistent pain and swelling around the anterolateral aspect of the ankle following an inversion ankle sprain. At the time of surgery, a massive hyalinized connective-tissue band extending from the anteroinferior region of the talofibular ligament into the ankle joint was found. They referred to this pathologic entity as a meniscoid lesion because of its resemblance to a torn meniscus of the knee. 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. Examination of his patients revealed foot pronation and heel valgus. He 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 talofibular ligament (ATFL) in syndesmotic impingement. 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.

Frequency

United States

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

Sport Specific Biomechanics

The most common mechanism of acute injury is plantar flexion/inversion injury resulting in acute ankle sprain (eg, basketball player landing on opponent's shoe, cross-country runner stepping in a hole).

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• 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 is usually located posteriorly or posterolaterally following an ankle sprain.

Physical

• 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 syndesmosis and on passive external rotation stress of the ankle.



• Posterior impingement: Diagnosis is often difficult, requiring a high index of clinical suspicion. Posterior impingement often causes lingering pain, swelling, and catching of a synovial nodule and 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.

Causes

• Anterolateral ankle impingement: Inversion ankle injuries and sprains sustained while playing basketball (45%), volleyball (25%), or soccer (31%) are common causes. 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 tibiofibular ligament, transverse tibiofibular ligament, tibial slip, or pathologic labrum on the posterior ankle joint can lead to posterior impingement, which may pinch on the os trigonum or posterior talus of calcaneus.  This 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, seen in dancing, kicking, gymnastics, or downhill-running types of activities (Maquirriain, 2005). In ballet dancers, forcing turnout of the foot can predispose to this condition (Brukner, 2000).

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Osteochondral lesions of the talus
Calcific ossicles
Peroneal subluxation
Degenerative joint disease
Tarsal coalition
Nerve entrapment (tarsal tunnel syndrome)
Occult fractures of the talus and calcaneus
Subtalar joint dysfunction
Reflex sympathetic dystrophy (complex regional pain syndrome)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Plain radiography, bone scanning, and 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 impingement. Having the paitent adopt a lunge position that reproduces their pain may show bone-on-bone impingement on a plain radiograph.



• Approximately 30% of MRI findings are positive in persons with anterolateral ankle impingement.  The most common finding is a low-signal "meniscoid" mass in the lateral gutter of the ankle.



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

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Initial treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain, physical therapy, bracing, and orthotics.

Surgical Intervention

With failure of conservative modalities, surgical intervention is indicated. Arthroscopic excision and debridement is the treatment of choice.

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 also may be helpful.

In ballet dancers, technique assessment is helpful and essential to prevent further pain and injury.

Recovery Phase

Rehabilitation Program

Physical Therapy

Postoperatively, advise posterior splinting for 1 week and a supportive brace and elastic compression stocking. Physical therapy is initiated at 2-3 weeks for strengthening, range of motion, proprioception, and sports-specific rehabilitation.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Drug Category: Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions, may exist as well

Drug Category: Opioid analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Return to Play

Patients 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.

Prevention

In sports such as ballet, correct technique can help prevent injury.

Education

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.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Special Concerns

• According to multiple follow-up studies, excellent and good postoperative results can be expected for approximately 84% of patients (Ferkle, 1991; Liu, 1994; Ogilvie-Harris, 1997).

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Brukner P, Khan K. Pain in the Achilles Region. In: Clinical Sports Medicine. 2nd. New York: McGraw-Hill; 2000:chapter 28.
• Ferkel RD. Ankle and foot injuries. In: Fu FH, Stone DA, eds. Sports Injuries. Baltimore, Md: Lippincott Williams & Wilkins; 1994.
• Ferkel RD. Arthroscopy of the Foot and Ankle. 7^th ed. St Louis, Mo: Mosby; 1999:1257-1297.
• Ferkel RD. Soft tissue pathology of the ankle. In: McGinty JB, Caspari RB, Jackson RW, Poehling GG, eds. Operative Arthroscopy. 2^nd ed. Philadelphia, Pa: Lippincott Raven; 1996:1141-1155.
• Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med. Sep-Oct 1991;19(5):440-6. [Medline].
• Glassman F, Wolin I, Sideman S, Levinthal DH. Internal Derangement of the Talofibular Component of the Ankle. Surg Gynecl Obstet. 1950;91:193-200.
• Henderson I, La Valette D. Ankle impingement: combined anterior and posterior impingement syndrome of the ankle. Foot Ankle Int. Sep 2004;25(9):632-8. [Medline].
• Jackson DW, Ashley RL, Powell JW. Ankle sprains in young athletes. Relation of severity and disability. Clin Orthop Relat Res. Jun 1974;101(01):201-15. [Medline].
• Liu SH, Raskin A, Osti L, Baker C, Jacobson K, Finerman G, et al. Arthroscopic treatment of anterolateral ankle impingement. Arthroscopy. Apr 1994;10(2):215-8. [Medline].
• Maquirriain J. Posterior ankle impingement syndrome. J Am Acad Orthop Surg. Oct 2005;13(6):365-71. [Medline].
• Ogilvie-Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy. Oct 1997;13(5):564-74. [Medline].
• Pfeffer G, ed. Chronic Ankle Pain in the Athlete. AAOS Monograph Series. ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2000:57-67.

Article Last Updated: Jul 5, 2006