Key Insights On Ankle Impingement Syndrome In Athletes
Ankle impingement syndromes are among the more challenging diagnoses one can encounter in athletes. A broken bone is easily visible on radiographs or computed tomography (CT), and ruptured ligaments and tendons are visible on magnetic resonance images (MRIs). In contrast, impingement is not always so obvious because it is commonly a diagnosis of post-traumatic morbidity.
Impingement syndrome is a diagnosis that requires a detailed history (sometimes dating back over a year), a careful physical and biomechanical examination, and advanced imaging. Additionally, there is not always a clear outline as to what treatment is best for recurring symptoms and these treatment regimens can be further complicated in athletes during midseason when surgery is not the best option.
Impingement often occurs in athletes of various levels and abilities. Impingement in the ankle is the friction of bone and soft tissue within a joint or within the periarticular spaces.1 Impingement is caused by the abnormal hypertrophy and/or inflammation from the subintima and inflamed synovium, ligaments, peritendinous soft tissue, bone, cartilage or from a combination of these etiologies.
Furthermore, impingement can exist in various areas around the ankle and one can easily mistake impingement for tendonitis or arthritis. Seventeen percent of the time, a talar dome lesion will be present in those with ankle impingement, potentially exacerbating ankle pain.2 In eight years of experience working with Division I athletes and high school athletes, the three most common ankle impingement syndromes the senior author has encountered are anterolateral impingement, anterior impingement and posterior impingement.
What You Should Know About Anterolateral Ankle Impingement
The anterolateral ankle gutter is the most common site of ankle impingement.3 During an inversion ankle injury, the anterior talofibular ligament and calcaneofibular ligament are affected as is the distal syndesmosis.3 Over time, a meniscoid lesion is often the result of the lateral ankle injury. Patients will complain of pain around the anterolateral ankle gutter during weightbearing and may feel like the pain is deep in the joint. Pain will occur with internal or external rotation of the ankle joint and the patient may have limited dorsiflexion.4 In the athletic population, pain may occur when running around the turns on a track or when cutting.
The clinical test for anterolateral ankle impingement is the impingement test or Molloy-Bendall test. Athletes perform this by dorsiflexing the ankle while simultaneously palpating and pressing the anteromedial ankle joint area. If there is pain with this test, there is a 95 percent chance that the injury in question is impingement.5 With a sensitivity of 83 percent and a specificity of 79 percent, MRI is an invaluable adjunct in diagnosing anterolateral impingement syndrome.4 When one is evaluating a MRI, an uncommon finding would be an injured Bassett’s ligament (accessory anterior inferior tibiofibular ligament), which is often a cause of impingement in the anterolateral ankle gutter as well.6
Bracing and corticosteroid injections are good first-line treatments for anterolateral ankle impingement as these treatments allow for a prompt return to play, and are generally successful in 86 percent of patients, according to Grice and colleagues.7 If conservative therapy has failed, ankle arthroscopy with debridement has proven to be a successful surgical treatment option for anterolateral ankle impingement.8
Anterior Ankle Impingement: Essential Tips On Diagnosis And Treatment
While less common, anterior ankle impingement can be a sidelining injury that can easily go overlooked. Anterior ankle impingement is located at the anterocentral portion of the anterior tibia and anterior talar dome. With the condition first being described by Morris and McMurray, the typical patient is a soccer player or a ballet dancer.4,9,10 The injury’s etiology is from repetitive microtrauma to the anterior talar dome and anterior tibia. This microtrauma spurs exogenous bone formation. Once the spurs have formed, there is impingement of the soft tissue between the spurs.11-13
Patients will often say there is pain just above their shoe or cleat over the front of the ankle during play. Sprinters may complain of a sharp pain over the front of the ankle while in the blocks and after the first 10-plus meters of sprinting. During the clinical exam, one can palpate pain anteriorly and dorsiflexion will exacerbate pain. Radiographic imaging will show anterior osteophyte formation over the talus and tibia. Not as useful as radiographs or CT in identifying osteophytic growth, MRI is useful for surgical planning and can evaluate for any other possible soft tissue defects within and outside the ankle joint and periarticular structures.
Treatment involves removal of spur formation via arthroscopy or an open approach. The senior author has had success with both but advocates arthroscopy if additional debridement is necessary. During arthroscopy, the podiatric surgeon must maintain awareness of the anterior ankle anatomy as excessive debridement of the anterior joint capsule could result in insult to the neurovascular bundle and extensor tendons.
What You Should Know About Posterior Ankle Impingement
Posterior impingement is largely confined to the posterior talus, calcaneus and the posterolateral (“trigonal”) process of the talus as well as the surrounding soft tissue structures. Pain is the result of the compression or entrapment of soft tissue and osseous structures during plantarflexion.14
Osseous impingement can involve the posterior malleolus, posterior talus (os trigonum or trigonal process) and calcaneus. Although the os trigonum is asymptomatic most of the time, it may become painful in athletes or dancers who experience repetitive plantarflexion.15 Forced dorsiflexion can also play a role in exacerbating posterior impingement by fracturing the posterolateral tubercle of the talus from increased tension of the posterior talofibular ligament.16
The diagnosis of posterior ankle impingement is primarily clinical. Patients will complain of pain with plantarflexion or pain in the posterior aspect of the ankle while going down stairs. On occasion, athletes will complain that they experience the pain when accelerating or decelerating during sprinting. While running, athletes will attempt to invert the foot to accommodate for the loss of plantarflexion. Palpation elicits posteromedial and posterior pain. There may also be pain with plantarflexion against resistance. Flexion of the hallux against resistance will also generate pain.
Radiographs will identify the os trigonum or fractured posterolateral process of the talus. Magnetic resonance imaging will be able to identify inflammation around the os trigonum and possible marrow edema.17 The flexor hallucis longus tendon may exhibit areas of tenosynovitis at or around the os trigonum. Chronically inflamed tissue will also be evident on an MRI.
Immobilization, nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy are acceptable conservative treatment options and are successful 60 percent of the time.15 If these treatments fail, surgery is indicated. Surgery involves removal of the os trigonum and debridement of surrounding tissue, which can be open or arthroscopic. If an arthroscopic approach is indicated, the podiatric surgeon should take care not to disrupt the medial neurovascular bundle and sural nerve to the lateral aspect of the ankle.
Although challenging at times, ankle impingement syndrome remains among one of the most rewarding diagnoses the senior author sees among the athletic and non-athletic populations. Conservative and surgical treatments remain successful and are relatively uncomplicated. It is important to evaluate each patient and athlete as individuals. Regardless of the sport, one should not exclude ankle impingement syndrome as a possible diagnosis. Furthermore, the time of the season is also relevant in how the surgeon should frame the treatment algorithm. One should treat a high school senior playing his or her last game differently than an All-American junior with college scholarship offers.
While ankle impingement syndrome can be a challenging diagnosis in the athletic population, a thorough workup and appropriate imaging can go a long way toward facilitating timely and effective treatment.
Dr. Green is the Team Physician at McNeese State University. He is the Program Director of the Christus Saint Patrick Hospital Podiatric Medicine and Surgery Residency Program in Lake Charles, La.
Dr. McCabe is the Chief Resident with the Christus Saint Patrick Hospital Podiatric Medicine and Surgery Residency Program in Lake Charles, La.
- Masciocchi C. Catalucci A, Barile A. Joint impingement syndrome. Eur J Radiol. 1998;27(Suppl 1):S70-3.
- Odak S, Ahluwalia R, Shivarathre DG, Mahmood A, Blucher N, Hennessy M, Platt S. Arthroscopic evaluation of impingement and osteochondral lesions in chronic lateral ankle instability. Foot Ankle Int. 2015;36(9):1045-9.
- Shane AM, Reeves CL, Vazales R, Farley Z. Soft tissue impingement of the ankle: pathophysiology, evaluation, and arthroscopic treatment. Clin Podiatr Med Surg. 2016;33(4):503-20.
- Berman Z, Tafur M, Ahmed SS, Huang BK, Chang EY. Ankle impingement syndromes: an imaging review. Br J Radiol. 2017;90(1070):20160735.
- Molloy S, Solan MC, Bendall SP. Synovial impingement in the ankle. A new physical sign. J Bone Joint Surg Br. 2003;85(3):330-3.
- Cerezal L, Abascal F, Canga A, Pereda T, García-Valtuille R, Pérez-Carro L, Cruz A. MR imaging of ankle impingement syndromes. AJR Am J Roentgenol. 2003;181(2):551-9.
- Grice J, Marsland D, Smith G, Calder J. Efficacy of foot and ankle corticosteroid injections. Foot Ankle Int. 2017;38(1):8-13.
- Buda R, Baldassarri M, Parma A, Cavallo M, Pagliazzi G, Castagnini F, Giannini S. Arthroscopic treatment and prognostic classification of anterior soft tissue impingement of the ankle. Foot Ankle Int. 2016;37(1):33-9.
- Morris LH. Athlete’s ankle. J Bone Joint Surg Am. 1943; 25: 220.
- McMurray TP. Footballer’s ankle. J Bone Joint Surg Am. 1950; 32: 68–9.
- Cerezal L, Abascal F, Canga A, Pereda T, Garcia-Valtuille R, Perez-Carro L, et al. MR imaging of ankle impingement syndromes. AJR Am J Roentgenol. 2003; 181(2):551–9.
- Tol JL, van Dijk CN. Etiology of the anterior ankle impingement syndrome: a descriptive anatomical study. Foot Ankle Int. 2004; 25(6):382–6.
- Amendola N, Drew N, Vaseenon T, Femino J, Tochigi Y, Phisitkul P. CAM-type impingement in the ankle. Iowa Orthop J. 2012; 32: 1–8.
- Giannini S, Buda R, Mosca M, Parma A, Di Caprio F. Posterior ankle impingement. Foot Ankle Int. 2013;34(3):459-65.
- Hedrick MR, McBryde AM. Posterior ankle impingement. Foot Ankle Int. 1994;15(1):2-8.
- Mouhsine E, Crevoisier X, Leyvraz PF, et al. Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc. 2004;12(3):250-253.
- Bureau NJ, Cardinal E, Hobden R, Aubin B. Posterior ankle impingement syndrome: MR imaging findings in seven patients. Radiology. 2000;215(2):497-503.
For further reading, see “When Patients Present With Posterior Ankle Impingement” in the May 2016 issue of Podiatry Today.