Posterior Ankle Impingement
A Case Study
- Posterior Ankle Impingement
- Accident details
- Initial Physiotherapy Assessment and Treatment
- Ongoing incidents, and treatment
- Further Investigations
- Surgical Intervention
- Post Surgical Management
- Case Study
- Operative Treatment of Posterior Ankle Impingement
- points to note for the clinician
- Ankle sprains account for 15% of all sports injuries
( Runin and Sallis ‘96 )
- McBryde found ankle problems comprised of 13.2% of injuries sustained in 1000 consecutively treated runners.
- Of that number, 18% of these runners had posterior ankle impingement.
Posterior ankle impingement definition:
“impingement occurring at the anatomical interval between the posterior tibial articular surface and the calcaneus”
( Hendrick and McBryde ‘94 )
- posterior process of the talus has 2 projections, the medial and lateral tubercules.
- between these tubercles the groove contains the FHL tendon.
- the medial tubercle is shorter and wider, the lateral tubercle presents as a process, either short or long.
- if it is long, it is called either a Stieda’s Process (Brodsky and Khalil ‘86 ) or a Trigonal Process ( Marumoto and Ferkel ‘97 )
- instead of a process there may be an ossicle of bone, attached by a fibrous tissue, and this ossicle is known as an Os Trigonum
- this develops as a secondary center of ossification and appears btwn the ages of 8-13. It usually fuses within a year of its appearance.
- its incidence is reported to be btwn 7-13%, unilaterally and 3-7% bilaterally
- the majority of the population that have one ( or two ) remain asymptomatic
- it is anatomical semantics whether the impingement is due to an os trigonum or a trigonum, the symptoms and mechanisms of pain are the same.
Brown et al, 1995, proposed 4 mechanisms of injury;
1/ forced plantar flexion, resultant posterior lateral impingement
2/ direct trauma to area
3/ excessive dorsiflexion, thus inc. the tension of the post. ligament, and avulsing the os trigonum
4/ detachment of the os trigonum by repeated minor injury
- At risk athletes include ballet dancers, soccer players and downhill runners.
- The forceful and repetitive p/flex predisposes the posteriorlateral aspect of the talus to impinge btwn the calcaneus and the post. aspect of the tibial plafond. ( Brown et al ‘95 )
- Symptoms may be either gradual with inc. activity, or following acute injury.
Based on history, physical examination, clinical reasoning and x-rays or CT scan.
- pain is described as being posteriorlat aspect of ankle, with local TOP btwn the lat. malleolus and T.A.
- pain is reproduced with EOR p/flexion
- moderate swelling
- b/c of close approximation with FHL, may be inc. pain with resisted flexion of great toe
- x-rays are best taken in lat. view with flex. and ext.
- CT scan with coronal view is utilised to identify size and shape of impinged element.
- can be confirmed by injecting a local anaesthetic which will relieve the pain
Differential diagnoses include;
- FHL tendonitis
- peroneal and T.A. tendonitis
- retrocalcaneal bursitis
- ankle joint arthritis
- acute fracture of the talar tuberosities
- 18yr old, female, beach sprint athlete
- training for Auckland Rep team
- ran over dug blocks in sand, EOR p/flex
- athlete and others heard “crack”
- immediate ice, A+E – rest, ice, NSAID’s and Physio
- limping gait
- moderate swelling over the lat. malleolus
- reduced inversion and p/flexion by half
- TOP over ant. and lat aspects of lat lig of the right ankle and the distal half of the peroneals
GOAL: Compete in Inter-District competition in 4 days!
- ice, compression bandage
- u/s pulsed, 0.8 w/cm2 for 5 mins
- gentle STM and fricts to distal peroneals and lateral lig
- encouragement to walk heel-toe
- resisted gait
- Competed, heavily taped and frequent icing. Not in top form.
- Following competition, ankle back to acute initial stage.
GOAL: Compete in National Championships in 10 days!
- wobble board
- graduated return to training; running easy on track, running hard on track, easy on soft sand, finally doing starts on soft sand.
Patient progressed well, and prior Nationals was running pain free on soft sand.
- Retained National Beach Flags Title
- Went out in Semi’s of the Sprint
6 weeks post Nationals returned to Physiotherapy
- normal gait with walking
- mild swelling in the T.A. region
- full range inversion / eversion
- discomfort EOR d/flexion
- severe reproduction of pt’s pain with EOR p/flex and heel thrust
- tight and tender in soleus and medial gastroc
- TOP in posteriorlat. aspect of ankle, just lat to T.A.
? posterior capsulitis?
- fricts to posteriolat. aspect of ankle
- u/s pulsed at 1.0 w/cm2 for 4 mins
- STM to soleus and med. gastroc
- acupuncture on x1 occasion
No change?!! Off to the orthopod!
- Suggested injury to posterior talus process, and ? peroneal tendonitis.
- Had bone scan to reveal no tendonitis.
Surgical Procedures included;
1/ Arthroscopy of the anterior of the left ankle. This revealed the ankle surfaces looked good, there was just a small amount of contusion to the anterior aspect of the anterior tibial plafond. This was debrided back with a shaver.
There was also an area of synovitis and inflammation at the ankle synndesmosis between the fibula and the tibia. This was also debrided with the shaver.
2/ A lateral incision was made just beside the Achilles tendon and dissection continued through the capsule to the posterior process of the talus. An osteome was used to remove the posterior talar process and ‘spur’. The FHL tendon was seen to be intact.
4 weeks Post – op, Physiotherapy findings;
- walking painfree
- continued tight and tender gastroc and soleus
- TOP around and deep to scar
- numbness lateral to scar, behind lateral malleolus
- good 1 leg balance
- STM to soleus and gastroc
- gentle fricts around scar
- soleus and gastroc stretches
4 wks post-op - walking in the home, unassisted
5 wks post-op - inc. walking around streets, up to 1 hr
6 wks post-op returned to the track, walking drills and jogging
weight training within pain free range
7 wks post-op running drills, but no bounding
interval running, within pain
- 7th / 8th week post-op, subject is having Physiotherapy once a week, working predominantly on the soft tissues.
- Has occasional discomfort with running, bounding.
- Excellent lines of communication btwn athlete / coach / physio
- lengthened talar process
- initial injury, with subsequent trauma
- x-ray and surgical reports made reference to a ‘spur’
- subsequent soft tissue damage
- positive result with surgery thus far
Operative Treatment of Posterior Ankle Impingement
- 1st described by Howse in 1982, treating dancers in London.
- conservative treatment appears unsuccessful in literature
- operative excision reports good results
- Marotta and Micheli, 1992, reported 16 patients with surgical excision, all returned to full dance participation.
- average time post-op was 3 mnths
- authors stressed importance of early return to weight bearing and activity
- recent literature discusses open surgery vs arthroscopic surgery
- be wary of the ankle sprain that doesn’t respond
- check EOR p/flexion
- have an increased index of suspicion in the dancer, downhill runner, soccer player or athletes in similar sports
- give the guys at Unisports Med a call, good experience with this complaint and very helpful and approachable
- surgical intervention is very successful, and athletes should return to high performance with short rehabilitation
Based in Mooloolaba Sunshine Coast Queensland Australia
Katrina is a NZ trained physio holding a Masters degree. She is one of the few qualified Manipulative Physiotherapists on the beautiful Sunshine Coast in Australia.
Still a strong All Blacks New Zealand Rugby supporter, (we will forgive her for that!!) Katrina enjoys what the coast offers, paddling and swimming regularly with the Maroochydore SLSC. As a former international athlete (1992 World Surf Ski Champion), a national kayak coach and a recent finisher of the Coolangatta Gold, Katrina has a very good understanding of the athletic body and the need to keep training. Kat’s passion is her two dogs, Mana and Kia. Her canine and physio interests combined in completing a Level 1 Canine Physio course last year, and she is very happy to exchange ideas about your four legged family members.
As the practice principal Kat leads with enthusiasm and an excellent hands-on approach. After 20 years in the profession she has the experience and knowledge to assist everyone. Katrina also has a great network of other professionals that she is also happy to refer you to if necessary