Mastering Ankle Impingement Syndromes

By Shine John, DPM, Robert W. Mendicino, DPM, and Alan R. Catanzariti, DPM

Impingement syndromes can result in chronic ankle pain. Initially described as “athlete’s ankle” and “footballer’s ankle,” these syndromes have been associated with athletic activities such as soccer, running, volleyball, high jumping and ballet dancing.1-3 These syndromes can affect either the anterior or posterior aspect of the ankle joint and its causal pathway can be of soft tissue and/or osseous origin.

Only one reported study describes impingement syndromes occurring concurrently at the anterior and posterior ankle.4 Patients will usually complain of painful limitation with ankle range of motion. As with all patients presenting with ankle pain, one should obtain a detailed patient history. In addition, the clinician should possess a good working knowledge of ankle pathologies to ensure accurate recognition and diagnosis.

Anterior Ankle Impingement: What To Look For In The Physical Exam
Patients will often complain of vague, chronic anterior ankle pain, swelling after activity and limited dorsiflexion.5 Impingement symptoms at the anterior ankle may affect the medial or lateral aspect of the joint. Accordingly, one must clarify this with the physical exam. Tol, et al., described three distinctive regions or sections of the anterior ankle joint line: central, anteromedial and anterolateral.6

The central region is the area between the medial border of the tibialis anterior tendon and the lateral border of the peroneus tertius tendon at the ankle joint line. The anteromedial region is medial to the tibialis anterior tendon at the joint line and extends toward the medial malleolus. The anterolateral region is lateral to the peroneus tertius tendon at the ankle joint line and extends toward the lateral malleolus.

Eliciting pain upon palpation at a particular region of the anterior ankle joint line assists in differentiating between anteromedial and anterolateral impingement. However, due to coverage of the central region by neurovascular structures and tendons, this part of the ankle is difficult to assess by palpation.6 The clinician may palpate and appreciate the presence of osteophytic changes with the ankle in slight plantarflexion.

What About Recurrent Traction Of The Anterior Joint Capsule?
Researchers have postulated that osteophytic formation partially contributes to the development of anterior ankle impingement.7 Other authors initially attributed the development of osteophytes at the anterior ankle joint to repetitive traction of the anterior joint capsule.2,5,8,9 They believed that repetitive traction on the capsular and ligamentous structures at the anterior joint line with extensive plantarflexion movements lead to traction spur formation, which is particularly common among athletes. Typically, bony spur formation occurs at a ligament, tendon or capsule insertion, and its growth follows the direction of the natural traction pull of these soft tissue structures.10

However, arthroscopic studies have noted that the anterior ankle spurs are invested and situated within the joint capsule at the articular margin rather than at the capsular insertion.7,11 A recent anatomic study by Tol, et al., described the ankle’s exact anatomic anterior cartilage rim, capsular attachment, anterior soft tissue component and their relativity to the anterior ankle joint.12 Their findings illustrate the anterior joint capsule attaching onto the tibia an average of 6 mm proximal to the anterior cartilage rim and at the talus approximately 3 mm from the distal cartilage border.

Given the fairly large distance between the arthroscopically observed location of anterior ankle joint spurs and the studied anatomic origins of the ankle joint capsule, the researchers concluded that the formation of talotibial spurs due to recurrent traction of the joint capsule is implausible.12

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