Definition/Description
Ankle impingement is defined as pain in the ankle due to impingement in one of two areas: anterior (anterolateral and anteromedial) and posterior (posteromedial).[1] Location of pain is referenced from the tibiotalar joint.[2] Pain is caused by mechanical obstruction due to osteophytes and/or entrapment of various soft tissue structures. The condition is common in athletes, especially soccer players, distance runners and ballet dancers.[3] Historically, it has been called "athlete's ankle" and "footballer's ankle". [4]
Epidemiology/Etiology
Ankle Impingement is commonly seen in active individuals and athletes due to accumulation of subclinical trauma to the area.[2]
Anterior Impingement: aka: "athlete's ankle" or "footballer's ankle". Caused by repeated dorsiflexion, microtrauma, and repeated inversion injury causing damage to anteromedial structures such as the articular cartilage. Further classified into Anteromedial & Anterolateral Impingement.[2]
- Anteromedial Impingement: Hypothesized etiology includes: inversion ankle sprains; repetitive dorsiflexion resulting in spurs; repetitive capsular traction causing the formation of osteophytes, and chronic microtrauma to the anterior joint area. However, the cause remains unknown with the above theories mentioned in the literature. [1]
- Anterolateral Impingement: May be caused by inversion ankle sprains causing inflammation and scar formation or reactive synovitis. May also be due to forced plantarflexion and supination which can tear anterolateral capsular tissues.[2]
Posterior Impingement: aka: "dancer's heel". Posterior impingement is generally insidious in nature, occurring in athletes who routinely plantarflex, such as ballet dancers, jumping athletes, and those who kick. [2] May be caused by bony or soft tissue impingement, specifically flexor hallucis longus irritation, thickening of the posterior capsule, synovitis, inversion trauma/sprain, forced plantarflexion causing anterior sheering of the tibia, hypertrophy of the os trigonum impacting the posterior tibia. [1]
Characteristics/Clinical Presentation
Onset: Symptoms development may be insidious or in response to sudden injury.[2]
Anterior: Anterior ankle pain accompanied by a feeling of blocking in dorsiflexion. May also present with palpable soft tissue swelling over anterior joint. [2]
- Anterolateral: Patients experience anterolateral ankle pain that is intensified with supination or pronation of the foot, anterolateral point tenderness, pain with a single-leg squat, and swelling.[2] Patients may have a history of ankles sprains or chronic ankle instability and now present with constant lateral ankle pain upon ambulation.
- Anteromedial: A good portion of these patients will have chronic anteromedial pain that is intensified by dorsiflexion, tender to palpation over anteromedial joint line, soft tissue swelling, and decreased ROM into forced dorsiflexion as well as supination.[1]
Posterior: Patients have posterior ankle pain intensified by forced plantarflexion or dorsiflexion. May also have joint line tenderness of the posterior tibiotalar joint (not involving the achilles tendon).[2]
- Posteromedial: A key clinical finding for a patient with a posteromedial impingement is tenderness to the posteromedial aspect upon inversion with the ankle in plantar flexion. This helps to differentiate from pain that comes from a tibialis posterior abnormality. [2]
Physicians use radiographs as a means of medical diagnosis, but any radiographic findings must be correlated to patient symptoms.
Differential Diagnosis
| Posterior Ankle Pain[5][6] |
|
| Anterior Ankle Pain[6] |
|
| Lateral Ankle Pain[6] |
|
| Medial Ankle Pain[6] |
|
Outcome Measures
All contain evidence regarding score interpretation including content validity, construct validity, reliability, and responsiveness. [7]
The Lower Extremity Function Scale (LEFS) was created to be a broad region-specific measure appropriate for individuals with musculoskeletal disorders of the hip, knee, ankle, or foot. Can be used to evaluate disorder of one or both lower extremities and consist of 20 items that specifically address the domains of activity and participation. Scores range from 0-80 with the lower the score representing a greater the disability.
The Foot Function Index (FFI) is viewed as an instrument tool to measure function in patients with rheumatoid arthritis, however, the authors claim there is no specific disease relation to rheumatoid arthritis in this assessment. The FFI is a region specific instrument for pathologies in the older population and consists of 23 items grouped into 3 sub-scales, including activity limitation, disability, and pain subscales. A lower FFI score represents a higher level of function.
The Foot and Ankle Ability Measure (FAAM) was developed as a region-specific instrument to comprehensively assess physical performance among individuals with a range of leg, foot, and ankle musculoskeletal disorders. Used to detect changes in self-reported function over time, as well as to evaluate the effectiveness of a specific intervention being delivered by a clinician. Instrument is divided into 2 seperately scored subscales, that include activities of daily living and a sports sub-scale.
The Foot Health Status Questionnaire (FHSQ) region specific instrument that was developed for individuals undergoing surgical treatment in a podiatry practice for common foot conditions. This questionnaire takes 5 minutes to complete and consists of 4 sub-scales, including pain, function, footwear, general foot health. This questionnaire can be used by researcher and clinicians to identify changes in foot health status in response to therapeutic and surgical interventions.
The Sports Ankle Rating System (QOL) is a self-reported and clinician completed assessment tool with 3 outcome measures that include a QOL measure, clinical rating score, and single numeric evaluation. The QOL measure, used to assess an athlete’s QOL after an ankle injury, contains 5 sub-scales that include symptoms, work and school activities, recreation and sports activities, activities of daily living, and lifestyle.
Examination
Anterior ankle impingement Examination: [8]
5 or more present: Sen= .94 Spec=.75 +LR=3.76 -LR=.08
-pain with activities
-anterolateral ankle joint tenderness
-recurrent joint swelling
-anterolateral pain with forced dorsiflexion and eversion (Impingement sign: Sens=.95 Spec=.88 +LR=7.91 -LR=.06) [9]
-pain during single leg squat
-lack of lateral ankle instability
5 or more present: Sen= .94 Spec=.75 +LR=3.76 -LR=.08
-pain with activities
-anterolateral ankle joint tenderness
-recurrent joint swelling
-anterolateral pain with forced dorsiflexion and eversion (Impingement sign: Sens=.95 Spec=.88 +LR=7.91 -LR=.06) [9]
-pain during single leg squat
-lack of lateral ankle instability
MRI sensitivity = 39% Physical Examination sensitivity = 94% [8]
Posterior Ankle Impingement Examination: [10]
-Loss of mobility, accompanied by pain in posterior aspect of ankle
-pain with forced plantarflexion
-Prominent posterior talar processes
-Hyperplantar flexion test [11]
-pain with forced plantarflexion
-Prominent posterior talar processes
-Hyperplantar flexion test [11]
Medical Management
Diagnosis: [3]
1. Standard radiographs
2. MRI for soft tissue swelling and extent of injury
3. Diagnostic injection is a local anesthetic administered into joint capsule and soft tissue, if injection relieved the symptoms it is a positive test.
Surgery:
It is considered after conservative treatment has been tried first, at least 3 months.[4]
El-Sayed et al states that arthroscopy is a useful method to treat patients with anterolateral impingement, results at follow-up showed 85% improved completely according to JSSF . [4]
Chirugie et al showed VAS and AOFAS score improved significantly and 79% of patients returned to prior level of sport that had posterior ankle impingement. [12]
Murawski et al showed 93% satisfaction, AOFAS and SF 36v2 significantly improved ~ 68% that had anteromedial impingement. [3]
Surgery Methods:
Debridement, osteophyte removal, meniscoid lesion excision, partial capsulectomy, flexor hallux longus release, and chondroplasty of tibia may be performed.[13] [14]
Post-op:
Medical Protocol: NWB in boot ~3 days, WBAT day 3, elevation for swelling, NSAIDs, ankle pumps, suture removal 10-14 days post-op, and refer to physical therapy. [15]
Physical Therapy Management
Treatment focuses on increasing available joint space for more mobility and less pain during activity.
Anterior Impingement:
Distraction manipulation
A/P and lateral talocrural glides
A/P distal fibula glides
Cuboid whip (for those with decreased pronation)
HEP: self A/P and lateral mobilization, single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises
Posterior Impingement:
Plantarflexion mobilization
P/A talocrural mobilization
Rear-foot distraction manipulation
Proprioceptive work - wobble board
Fibularis strengthening
HEP: Achilles tendon stretching, Single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises[1][16]
Key Research
- Liu S, Nuccion S, Finerman G. Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. American Journal of Sports Medicine. May 1997;25(3):389-393.
- Ankle Impingement Syndromes: Diagnosis and Treatment, Shane McClinton, Regis University OMPT Fellowship, 2008.
- Robinson P. Impingement syndromes of the ankle. European Radiology. December 2007;17(12):3056-3065.
Clinical Bottom Line
Ankle impingement is common within certain populations of athletes who repeatedly dorsiflex or plantarflex and/or have a history of inversion ankle sprains and other microtrauma. Current literature favors surgical intervention as treatment. There is a limited amount of high quality evidence for conservative management. Physical therapy should include manual therapy and exercise that aim to increase mobility of the ankle joint and decrease pain with ambulation.
Recent Related Research (from Pubmed)
References
- ↑ 1.0 1.1 1.2 1.3 1.4 McClinton, S. Regis University. Ankle impingement sydromes: diagnosis & treatment. Available at: https://connect.regis.edu/p38686942/. Accessed on July 9, 2011.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Robinson P. Impingement syndromes of the ankle. European Radiology [serial online]. December 2007;17(12):3056-3065
- ↑ 3.0 3.1 3.2 3.3 Murawski C, Kennedy J. Anteromedial impingement in the ankle joint: outcomes following arthroscopy. American Journal of Sports Medicine [serial online]. October 2010;38(10):2017-2024. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 9, 2011.
- ↑ 4.0 4.1 4.2 El-Sayed A. Arthroscopic treatment of anterolateral impingement of the ankle. Journal of Foot Ankle Surgery [serial online]. May 2010;49(3):219-223. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 2, 2011.
- ↑ Maquirriain J. Posterior ankle impingement. J Am Acad Orthop Surg 2005;13:365-71
- ↑ 6.0 6.1 6.2 6.3 Goode L. Ankle Differential Diagnosis. Office of Inspector General. July 2006: 1-2.
- ↑ Martin R, Irrgang J. A survey of self-reported outcome instruments for the foot and ankle. Journal of Orthopaedic & Sports Physical Therapy [serial online]. February 2007;37(2):72-84. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 18, 2011.
- ↑ 8.0 8.1 Liu S, Nuccion S, Finerman G. Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. American Journal of Sports Medicine [serial online]. May 1997;25(3):389-393. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 15, 2011.
- ↑ Molloy S, Solan M, Bendall S. Synovial impingement in the ankle: a new physical sign. Journal of Bone Joint Surgery, British Volume [serial online]. April 2003;85B(3):330-333. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 15, 2011
- ↑ Albisetti W, Ometti M, Pascale V, De Bartolomeo O. Clinical evaluation and treatment of posterior impingement in dancers. American Journal of Physical Medicine Rehabilitation [serial online]. May 2009;88(5):349-354. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 18, 2011
- ↑ Dijk van, C. Niek. Anterior and Posterior Ankle Impingement. Foot Ankle Clinica N Am 11 (2006) 663-683
- ↑ 12.0 12.1 Galla M, Lobenhoffer P. Technique and results of arthroscopic treatment of posterior ankle impingement. Foot Ankle Surgery (Elsevier Science) [serial online]. June 2011;17(2):79-84. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 2, 2011.
- ↑ Meislin R, Rose D, Parisien J, Springer S. Arthroscopic treatment of synovial impingement of the ankle. American Journal of Sports Medicine [serial online]. March 1993;21(2):186-189. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 9, 2011.
- ↑ 14.0 14.1 Hussan A. Treatment of anterolateral impingements of the ankle joint by arthroscopy. Knee Surg Sports Traumatol Arthrosec. 2007; 15:150-1154. Accessed July 15,2011.
- ↑ Coetzee J, Ebeling P. Arthroscopic Ankle Debridement Rehabilitation Protocol Website. Available at:http://www.tcomn.com/images/wmimages/onlineforms/Arthroscopic_Ankle_Debridement.pdf. Accessed July 15, 2011.
- ↑ Reischl SF, Noceti-Dewit LM. Current Concepts of Orthopaedic Physical Therapy. 2nd ed. The goot and ankle: Physical therapy patient management utilizing current evidence. APTA Independent Study Guide 16.2.11.
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