Ankle impingement syndrome

1. INSIGHT TO ANKLE IMPINGEMENT
SYNDROME IN SPORTS
Dr Navinderpal Singh ,Prof and Principal ,
Jammu College of Physiotherapy

2. OUTLINE
 Review of Basic Anatomy
 Basic Impingement Syndrome
 Treatment
 Summary

3. ANKLE IMPINGEMENT SYNDROME
 Anatomy
 The ankle joint (or talocrural
synovial joint located in the lower
formed by the bones of the leg
fibula) and the foot (talus).
 Tibia and fibula are held together
strong tibiofibular ligaments.
form a socket, covered in hyaline
This socket is known as

4. ANKLE IMPINGEMENT SYNDROME
 Anatomy
 The body of the talus fits into the
articulating part of the talus is wedge
broad anteriorly, and narrow posteriorly:
• Dorsiflexion – the anterior part of the
the mortise, and the joint is more
• Plantarflexion – the posterior part of the
the mortise, and the joint is less stable.

5. ANKLE IMPINGEMENT SYNDROME
 Anatomy
 Two ligaments -Medial and Lateral Ligament
 The medial ligament (or deltoid ligament) is attached
malleolus .
 The primary action of the medial ligament is to
the foot.
 Lateral Ligament
 The lateral ligament originates from the lateral
 It resists over-inversion of the foot, and is comprised
and separate ligaments: Anterior
talofibular Calcaneofibular

6. ANKLE IMPINGEMENT SYNDROME
 Anatomy

7. ANKLE IMPINGEMENT SYNDROME
 Ankle impingement syndrome are one of the
challenging diagnosis encountered among
sports persons.
 Fractures , ruptured ligaments and tendons
can easily be diagnosed with X rays,
Tomography and MRI but same is not
obvious in case of Ankle impingement which
is usually diagnosed as post traumatic
morbidity.

8. ANKLE IMPINGEMENT SYNDROME
 Ankle impingement occurs in different athletes
with different sporting abilities.
 Impingement occurs due to friction between
bone and soft tissue within ankle joint or in
periarticular spaces (Masciocchi et al.1998)
resulting in hypertrophy or inflammation of
synovium, ligaments, peritendinous soft tissue,
bone ,cartilage or combination of these.

9. ANKLE IMPINGEMENT SYNDROME
 Impingement syndrome is the diagnosis that
requires
 Detailed history
 Careful Physical examination
 Biomechanical examination
 Advanced imaging

10. ANKLE IMPINGEMENT SYNDROME
 What Is Ankle Impingement
Syndrome?(Footballer’s Ankle, Athlete’s
Ankle).
 Ankle impingement is defined as a painful
mechanical limitation of full ankle range of
motion secondary to an osseous or soft-tissue
abnormality.( Ferkel ,1996)
 Pain in impingement is due to
 Mechanical obstruction- osteophytes and/or
entrapment of various soft tissue structures due
to inflammation, scarring or hypermobility.
 Common in athletes-soccer players, distance
runners and ballet dancers.(Murawski,2011)
 Specially in those which require sudden
acceleration, jumping, and extremes of

11. ANKLE IMPINGEMENT SYNDROME
 Ankle impingement is a common condition
occurring secondary to sprain or repeated
microtrauma.
 After Ankle sprain 20 to 40 % of patient
have chronic ankle pain and about one
third of these patients have pain related to
impingement.(Marquirriain ,2005)

12. ANKLE IMPINGEMENT SYNDROME
 Types of Ankle Impingement
 Anterior
 Anterolateral
 Anteromedial
 Posterior
 Posteromedial
 Posterolateral

13. ANKLE IMPINGEMENT SYNDROME
 Anterior Impingement
 Relatively common, well recognized cause
of anterior ankle pain “Spurs” on anterior
tibial plafond and talus; intracapsular.
 Theories: Repetitive dorsiflexion
microtrauma (ballet, soccer)
 Supination causing anterior/medial
cartilage damage and proliferative fibrosis
 Repetitive direct trauma
 Capsular avulsion from forced plantar
flexion
Presence of spurs and associated proliferative

14. ANKLE IMPINGEMENT SYNDROME
 Anterior Impingement
Diniz P, et al.Diagnosis and treatment of anterior ankle impingement: state of the
art.Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 2020;5:295-303.

15. ANKLE IMPINGEMENT SYNDROME
 Clinical Picture
 Anterior impingement syndrome presents
with anterior ankle pain exacerbated by
dorsiflexion.
 Clinical examination reveal soft tissue
swelling over the anterior aspect of the ankle
joint with decreased range of dorsiflexion.
 In some instances the anterior bony spurs
may be palpable (Kane JW et.al,2008)

16. ANKLE IMPINGEMENT SYNDROME
 Anterolateral Impingement
 Relatively uncommon; 3% of sprains
 Three theories: Chronic injury to ATFL, scar tissue,
anomalous ligament
 Usually occurs after relatively minor
trauma; usually not unstable
 Often remains a clinical diagnosis

17. ANKLE IMPINGEMENT SYNDROME
 Clinical Picture
 Anterolateral ankle pain with tenderness and
swelling.
 Several clinical tests have been described but
symptoms exacerbated by single leg squatting
and ankle eversion or dorsiflexion have been
shown to correlate best with positive findings of
impingement.(Lui HI et al.,1994)
 Few individuals with impingement may describe
a popping sensation or an audible pop on ankle
dorsiflexion and eversion.(Molloy et al. ,2003)

18. ANKLE IMPINGEMENT SYNDROME
 Anteromedial Impingement
 Rare complication of inversion injury with
component; leads to AM capsular injury,
osteophytes
 Repeated microtrauma causes synovitis and
– “meniscoid lesion” anterior to tibiotalar

19. ANKLE IMPINGEMENT SYNDROME
 Clinical picture
 Patients describe focal anteromedial
tenderness and pain increased on
dorsiflexion and inversion.
 Clinical examination shows restriction
of these movements. There may be
associated soft tissue thickening.

20. ANKLE IMPINGEMENT SYNDROME
 Posterior Impingement
 Arises from compression of posterior
tissues between posterior calcaneal
posterior tibia on plantar flexion
 Repetitive / forced plantar flexion.
acute traumatic injury relatively rare
 Involved capsular soft tissues include
posterior intermalleolar ligament, FHL

21. ANKLE IMPINGEMENT SYNDROME
https://footeducation.com/posterior-ankle-impingement-os-trigonum-syndrome

22. ANKLE IMPINGEMENT SYNDROME
 Clinical Picture
 Progressive posterior ankle pain.
 Patients may also complain of mild
posterior swelling.
 Tenderness can be elicited on palpation of
the posterolateral ankle between the
Achilles and peroneal tendons.(Robinson
et al.,2006)
 On examination, pain on plantar flexion or
by dorsiflexion of the great toe. Associated
tethering of the flexor hallucis longus
tendon within the fibro-osseous tunnel
behind the talus causes restricted plantar
and dorsiflexion movement of the great toe

23. ANKLE IMPINGEMENT SYNDROME
 Posteromedial Impingement
 Uncommon; occurs after inversion injury where deep
ligament crushed between medial malleolus and
tubercle
 Development of “meniscoid” lesion as in AL and AM
 Clinically patients have persistent, isolated PM ankle
medial malleolus.

24. ANKLE IMPINGEMENT SYNDROME
 Clinical Picture
 Initially after injury lateral symptoms predominate; as
these settle, it is followed by insidious onset of
posteromedial and medial activity-related pain,
typically after 4 to 6 weeks.(Paterson et al.,2001)
 Focal posteromedial tenderness on examination and
pain can be elicited by posteromedial palpation
during plantar flexion and inversion.

25. ANKLE IMPINGEMENT SYNDROME
 Posterolateral Impingement
 Very rare ,thought to be due to forced plantar
flexion and increased pressure on posterior soft
tissues and/or inversion injury
 Clinical picture
 Patient with a posterolateral impingement has the
sense of ankle getting locked and has pain at the
posterior side of the ankle.

26. ANKLE IMPINGEMENT SYNDROME
 Diagnosis of Ankle Impingement
 Examination
 Anterior Ankle Impingement
• Pain with activities
• Anterolateral ankle joint tenderness
• Recurrent joint swelling
• Anterolateral pain with forced
dorsiflexion and eversion pain during
single leg squat
• Lack of lateral ankle instability

27. ANKLE IMPINGEMENT SYNDROME
 Diagnosis of Ankle Impingement
 Clinical Test
• An Anterior Drawer Test for lateral
ankle instability
• Forced dorsiflexion

28. ANKLE IMPINGEMENT SYNDROME
 Diagnosis of Ankle Impingement
 Examination
 Posterior Ankle Impingement
• Loss of mobility, accompanied by
pain in posterior aspect of ankle
• Pain with forced plantarflexion
• Prominent posterior talar processes
• Hyperplantar flexion test

29. ANKLE IMPINGEMENT SYNDROME
 Diagnosis of Ankle Impingement
 Clinical Test
• Deep pressure palpation of the
posteromedial joint line: positive =>
tenderness
• Laxity tests (anterior drawer and inversion)
• Manual strength test: Anterior tibialis,
Peroneus complex, Gastrosoleus complex
• Flexibility tests: Achillies tendon, Hamstring
• Forced Plantarflexion
• Forced Inversion

30. ANKLE IMPINGEMENT SYNDROME
 Diagnostic procedures
 Radiograph is first diagnostic imaging
performed to assess any bony problem
in anterior or posterior impingement.
 Others include CT scan and Isotope
scan ,there use is now limited due to
MRI .
 MRI helps to investigate bony and soft
tissue oedema and also soft tissue
impingement in anterior and posterior
ankle impingement.
 Ultrasonography good option in soft
tissue impingement in anterolateral

31. ANKLE IMPINGEMENT SYNDROME
Gary, MRI Web Clinic — October 2010,Posterior Ankle
Impingement
https://radiopaedia.org/cases/anterior-ankle-impingement-1

32. ANKLE IMPINGEMENT SYNDROME
 Treatment approach to Ankle
impingement
 Initial treatment includes conservative
management :
 Non steroidal anti inflammatory drugs.
 Limitation of symptom-provoking
activity combined with physiotherapy
is successful in most patients.
 Ultrasound guided injection of steroid.

33. ANKLE IMPINGEMENT SYNDROME
 Physical therapy should include
manual therapy and exercise that aim
to increase mobility of the ankle joint
and decrease pain with ambulation.
 Current literature favors surgical
intervention.
 There is limited evidence for efficacy
of non surgical treatment.

34. ANKLE IMPINGEMENT SYNDROME
 Surgical intervention is generally
reserved for those cases where
conservative therapies have failed to
provide adequate relief.
 Long-term follow-up studies have
shown open and arthroscopic excision
of the bony spurs, hypertrophic
synovium, and scar tissue to be
effective treatments for anterior
impingement(Coull et al.,2003)

35. SUMMARY
 Impingement syndromes are important cause of chronic
ankle pain.
 It is a often a clinical diagnosis, but MR / arthrography
can help in detecting the extent of soft tissue
abnormalities.
 Specially in posterior and posteromedial syndromes
 Limited evidence on efficacy of conservative treatment
 Understanding of the main syndromes and their
manifestations can help the clinician

36. Thank you