What is Posterior Ankle Impingement?

Posterior Ankle Impingement is when an individual experiences pain at the back of the ankle due to compression of the bone or soft tissue structures during activities involving maximal ankle plantarflexion motion.

It can also be known as:

• Ankle Impingement
• Posterior Impingement Syndrome
• Posterior Impingement of the Ankle
• Os Trigonum Syndrome

What is the Relevant Anatomy of the Ankle?

The ankle joint comprises the tibia and talus, which glide on one another and have articular cartilage on the surface that cushions the tibia’s impact on the talus during weight-bearing activity.

During the plantar flexion movement, where the foot and ankle point maximally away from the body, the ankle compresses. This compression may result in tissue damage and pain if the compressive forces are too repetitive or forceful.

What Causes Posterior Ankle Impingement?

Posterior ankle impingement commonly presents in the following athletes:

• Gymnasts
• Ballet dancers
• Footballers
• Cricket Fast Bowlers (front or landing leg)

Posterior ankle impingement often occurs due to inadequate rehabilitation following an acute ankle injury. In some cases, an individual may have an anatomical variant in their talus bone, known as an os trigonum, which is quite normal. However, it may be more likely to develop this condition, particularly in the very active.

What are the Symptoms of Posterior Ankle Impingement?

Individuals that suffer Posterior Ankle Impingement typically present with:

• Sharp pain at the back of the ankle joint. Especially during activities that require maximal plantar flexion (pointing).
• Ache at rest or following provocative activities

Examples of provocative actions include:

• Kicking a ball
• Pointe work (dancing)
• Walking or running (especially downhills)
• Jumping or hopping
• Activities on ‘tippy-toes.’

How is Posterior Ankle Impingement Diagnosed?

Posterior ankle impingement diagnosis includes your history and physical assessment findings. In some cases, your physiotherapist may recommend that you obtain some imaging based on your presentation.

Diagnostic Imaging

Standard ankle radiographs (or X-rays) can help image posterior ankle impingement. The X-ray view of the ankle from the side (lateral radiograph) shows the ankle in profile, and bone spurs may occur. Sometimes when the spur location is on the inside of the ankle (anteromedial), it can be challenging to see the standard lateral radiograph. Therefore an X-ray taken at a slight angle (oblique radiograph) can help see anteromedial bone spurs.

Magnetic Resonance Imaging or (MRI) is a valuable test for a couple of different reasons. First, it can help ensure there is no other cause of foot or ankle pain that can mimic posterior ankle impingement or additional symptom generators. Also, an MRI may show signs of swelling in the irritation region in the front of the ankle. MRI can help confirm the findings in the patient’s history and physical exam and help with surgical planning in the future.

Please consult your ankle physiotherapist for specific information regarding your posterior ankle impingement.

Posterior Ankle Impingement Treatment

PHASE I – Pain Relief, Minimise Swelling & Injury Protection

Managing your pain is a priority. Pain is the main reason that you seek treatment for Posterior ankle impingement. In truth, it was the final symptom that you developed and should be the first symptom to improve.

(Active) Rest: Our first aim is to provide active rest from pain-provoking postures and movements. Active rest means you should stop doing the action or activity that provokes ankle pain.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Compression: A compression bandage, Tubigrip compression stocking or kinesiology supportive taping will help support the injured soft tissue and reduce excessive swelling.

Elevation: Elevating your injured ankle above your heart will assist gravity in reducing excessive swelling around your ankle.

Your physiotherapist will use various treatment tools to reduce your pain and inflammation. These may include ice, electrotherapy, acupuncture, de-loading taping techniques, soft tissue massage and temporary use of a mobility aid (e.g. brace) to off-load the injured structures. In severe cases, you may require a period of rest from your aggravating activity. However, your physiotherapist will be able to provide you with information in regards to alternative exercises.

Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling.

Phase 2: Restore Full Range of Motion

As soon as it is comfortable, your physiotherapist will start your rehabilitation to regain the ankle’s full active range of motion.

Phase 3: Restore Muscle Strength

Your calf, ankle and foot muscles will require strengthening to recover from the injury and prevent future episodes. It is essential to regain normal muscle strength to provide standard dynamic ankle control and function. Your strength and power should gradually progress from non-weight bear to partial, and then full weight bear and resistance-loaded exercises. Depending on your assessment findings, you may also require strengthening your other leg, gluteal and lower core muscles. Your physiotherapist will guide you.

Phase 4: Restore High Speed, Power, Proprioception and Agility

Most posterior ankle impingement cases occur during high-speed activities, which place enormous forces on your ankle and adjacent structures. Balance and proprioception (the sense of the relative position of neighbouring parts of the body) are required to ensure a full recovery and prevent re-injury.

Phase 5: Return to Normal Daily Function and Sport

Once you can return to normal daily function, e.g. walking, stairs and squatting, your physiotherapist will address your specific needs. If you play sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport. Your physiotherapist will discuss your goals, time frames and training schedules with you. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation programme has minimised your chance of future injury.

Ankle Impingement Surgery

Surgery is not the initial treatment for those suffering from posterior ankle impingement. However, operative treatment may be beneficial in persistent posterior ankle impingement cases, particularly for the high-level athlete.

Removing the prominent impinging bone spurs or soft tissue can help symptoms rather than ankle arthritis if a patient’s symptoms are directly attributed to the impingement. Surgical treatment involves removing the prominent bone spurs or soft tissue either arthroscopically or by opening up the ankle joint with an incision. If the bone spurs are significant, it is often more efficient and effective to make a larger incision, open up the ankle joint, and remove the bone spurs.

Removal of all bone spurs is not required, but only those causing impingement at the time of surgical inspection. It is important to note that surgery to remove impinging bone spurs from the front of the ankle will not typically help symptoms if the pain is due to significant ankle arthritis. Surgery to remove the bone spurs can sometimes increase a patient’s symptoms if it allows the ankle joint to move more, and the ankle joint has significant arthritis.

Other Ankle Impingement Treatment Options

Specific Interventions, e.g. Injection

Corticosteroid injections may help the initial treatment phase if the patient has difficulty calming the inflammation and pain in the ankle joint. Your physiotherapist is identifying whether you require this adjunct treatment and will often discuss this additional treatment option with a Sports Physician.

Acupuncture

Acupuncture can be effective pain relief. Many of our physiotherapists utilise acupuncture if you are interested in trying some acupuncture. Please ask for their advice.

General Exercise

General exercises are essential to keeping your body fit. Your physiotherapist will be able to advise you best on what is appropriate and inappropriate.

More Advice

Please ask your physiotherapist if you have any concerns or specific questions regarding your posterior ankle impingement.

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