What Is Ankle Impingement

Published: 17th December 2009
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Ankle impingement is a condition whereby the patient suffers from a restriction in their ankle movement due either to a bony or soft tissue problem. The typical causes of this condition are usually irritation of the capsule or synovial membrane of the ankle secondary to a single or a repeated series of accidents or incidents. Ankle sprains, especially if repetitive, can lead to chronic pain and impingement syndromes. This gives the patient continual pain on weightbearing and limits their mobility and sporting activities. Estimates vary but 10% of people suffering ankle sprains may develop some degree of impingement.

An acute ankle sprain which precedes impingement is commonly precipitated by a person stepping into a hole or on to something uneven, forcing the foot inwards and downwards with the body weight on it. Impingent can present as anterior (front of ankle), posterior (back) or as a problem with the tibial and fibular interconnection just above the ankle. Patients with anterior impingement report that the front of the ankle joint feels blocked as they try and pull the foot up. If the ankle is dorsiflexed, especially with some force as in lunging forward whilst standing on the foot, this may point to this diagnosis if painful.

If the intervening joint between the tibia and fibula is involved then there will be tenderness and pain on palpating that area firmly and on pressing the two sides of the ankle together. Posterior impingement may be harder to diagnose, the symptoms being less clear although a forceful downward movement of the foot may cause pain. Anterior impingement can be brought on by kicking a ball in soccer and doing repetitive lunging manoeuvres such as in fencing or ballet. Repeated micro damage to the area leads to chronic injury and the formation of bony spurs at the front edge of the joint.

The investigation of ankle impingement is difficult as the typical methods of imaging lesions may show up little. CT scanning, bone scans and normal x-rays are often reported as normal although there can be bony spur formation on the front lips of the tibia and talus in the case of anterior impingements. Magnetic resonance imaging scanning is used in these cases to attempt to clarify the soft tissue or bony changes responsible.

The initial management of this syndrome is always conservative with activity modification a significant goal as reducing the stresses suffered by the ankle will be likely to relieve the symptoms to some degree. Patients may be prescribed non-steroidal anti-inflammatory drugs to help the pain and attend for physiotherapy. Physiotherapists can perform mobilising techniques on the ankle and foot joints, give ultrasound, perform deep tissue massage and work on joint ranges and muscle strengthening. They also provide ankle braces for lateral support or to limit joint movement and assess and provide in shoe foot orthotics to correct abnormal foot mechanics.

If ankle impingement is not managed successfully by conservative methods then the surgeon may consider operative intervention. Usual operating technique is via an arthroscope to tidy up the joint surfaces and edges and remove any bony spurs or soft tissue obstructions. Early mobilisation after surgery is common and if there has not been major internal work patients can typically walk soon after surgery. Four to six weeks is likely to elapse before patients can resume their typical activities, sometimes with physiotherapy guidance. Scientific results from studies on operated patients show over 80 percent are in the excellent or good outcome categories.

If the surgery is more extensive then patients may be given elbow crutches to protect the ankle joint from full weight bearing for up to two weeks, and they may also wear an ankle brace to reduce joint movement. Once settled to some degree the brace is removed and physiotherapy commenced with encouraging of the ranges of movement of the ankle joint and the foot. Ice and ultrasound may be used to help control pain and inflammation. As the ankle improves the physio will progress to more active exercises without great weight involved, such as cycling on the static bike. Further progression involves weight bearing work to improve joint position sense, coordination, balance and strength.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Edinburgh. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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