Anterior Ankle Impingement
What is Anterior Ankle Impingement?
Anterior Ankle Impingement is a condition where an individual experiences pain at the front of the ankle, due to compression of the bony or soft tissue structures during activities that involve maximal ankle dorsiflexion motion.
It can also be known as:
- Ankle Impingement
- Anterior Impingement Syndrome
- Anterior Impingement of the Ankle
- Footballer’s Ankle
What is the Relevant Anatomy of Ankle Impingement?
Two bones comprise the “true’ ankle joint – the tibia and talus. These bones glide upon each other and have articular cartilage that cushions the impact of the tibia on the talus during weight-bearing activity.
During the movement of ankle dorsiflexion (figure 1) the foot and shin move towards one another, meaning the tibia approaches the front of the talus. This movement places compressive forces on the structures at the front of the ankle joint. If these forces are in excess or beyond what the ankle can withstand, damage and inflammation of these structures can occur.
What Occurs in Anterior Ankle Impingement?
Repeated compression at the front or anterior aspect of the ankle joint may result in joint capsule or synovium pinching. The subsequent soft tissue inflammation is responsible for generating pain in patients with anterior ankle impingement.
In some cases, this repeated compression of the anterior ankle joint can lead to bone spurs, otherwise known as osteophytes to form on the front edge of the tibia or talus. These spurs can develop to help protect the surface from the repeated pulling of the joint capsule on the front lip of the tibia or just the cumulative repetition of bony contact. This process does not have to be associated with arthritis of the ankle joint. However, it can accelerate with repeated ankle sprains.
What Causes Anterior Ankle Impingement?
Anterior ankle impingement most commonly occurs as a result of:
- Ankle Sprain
- Recurrent Ankle Sprains
- Activities that require repeated ankle dorsiflexion, such as landing and deep squatting movement.
Several factors can predispose you to develop anterior ankle impingement. Your physiotherapist can identify these and correct them to reduce your risk of developing anterior ankle impingement.
Some of the factors that can contribute to the development of this condition include:
- inadequate rehabilitation following a previous ankle injury
- joint stiffness or swelling
- muscle tightness
- bony anomalies
- poor foot biomechanics (e.g. “flat feet” or high arches)
- poor lower limb biomechanics
- inappropriate training (including technique, footwear or training surfaces)
- excessive training
- inadequate recovery periods from practice and games
- inadequate warm-up
- poor core stability
- poor proprioception or balance
Symptoms of Anterior Ankle Impingement
Individuals that suffer from anterior ankle impingement may present with:
- Dull ache at the front of the ankle with rest, which then becomes sharp pain at the front of the ankle with excessive dorsiflexion or weight-bearing
- Increased symptoms following specific activities, including:
- Walking or running excessively (especially up hills or on uneven surfaces)
- Deep squatting or lunging (especially with the knee moving forwards over the toes)
- Landing from a jump (particularly on an incline or a rough surface)
- Performing a calf stretch (particularly with the knee bent)
- Heavy lifting or twisting activities
- Tenderness on palpation of the front of the ankle joint.
- In some cases, a clicking sensation during specific ankle movements.
- Puffiness or swelling of the ankle joint.
How is Anterior Ankle Impingement Diagnosed?
Your physiotherapist can diagnose anterior ankle impingement based on your history and physical assessment findings. In some cases, your physiotherapist may recommend that you obtain some imaging based on your presentation.
The X-ray view of the ankle from the side (lateral radiograph) shows the ankle in profile and the bone spurs. Sometimes when the spurs are on the inside of the ankle (anteromedial), they can be challenging to see on 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 useful test for a couple of different reasons. First, it can help be sure there is no other cause of foot or ankle pain present that can mimic anterior ankle impingement. Also, an MRI may show signs of swelling in the region of irritation in the front of the ankle. Diagnostic imaging can help confirm the findings in the patient’s history and physical exam as well as help with surgical planning in the future.
Anterior Ankle Impingement Treatment
PHASE I – Pain Relief, Minimise Swelling & Injury Protection
You are managing your pain. Pain is the main reason that you seek treatment for anterior 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 you with some active rest from pain-provoking postures and movements. Active rest means that you should stop doing the action or activity that provokes the 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 to both 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 an array of treatment tools to reduce your pain and inflammation. These may include ice, electrotherapy, acupuncture, unloading 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. Your Physiotherapist will be able to provide you with information in regards to alternative exercise.
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 aiming at regaining full active range of motion of the ankle.
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 reasonable 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. You may also require strengthening for your other leg, gluteal and lower core muscles depending on your assessment findings. Your Physiotherapist will guide you.
Phase 4: Restore High Speed, Power, Proprioception and Agility
Most cases of anterior ankle impingement 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 also to 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 program has minimised your chance of future injury.
Ankle Impingement Surgery
Surgery is not typical for those suffering from anterior ankle impingement. However, in persistent cases of anterior ankle impingement, operative treatment may be beneficial, particularly for the high-level athlete.
If a patient’s symptoms can be directly attributed to the impingement, rather than ankle arthritis, removing the prominent impinging bone spurs or soft tissue structures can help symptoms.
Surgical treatment involves removing the offending bone 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 and open up the ankle joint and remove the bone spurs. 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. In some instances, surgery to remove the bone spurs can contribute to an increase in a patient’s symptoms if it allows the ankle joint to move more, and the ankle joint has significant arthritis.
Other Treatment Options
Specific Interventions, e.g. Injection
Corticosteroid injections may be useful in the initial phase of treatment if the patient is having difficulty calming the inflammation and pain in the ankle joint.
Your Physiotherapist is skilled in identifying whether you will require this adjunct treatment, and will often have you discuss this auxiliary treatment option with a Sports Physician. If you have any concerns or have some specific questions regarding your condition, please ask your Physiotherapist.
Common Ankle Injuries
The most common ankle injury is a sprained ankle, but ankle pain can have numerous sources.
Ankle pain that results from a traumatic injury is often a sports-related injury. But you don't necessarily have to be an athlete or even a social sportsperson to twist your ankle.
Something as simple as walking on an uneven footpath can cause a rolled ankle, resulting in an ankle sprain. Ankle injuries can potentially occur at any age. Thousands of people sprain their ankle every day around the world. Just while you've been reading this article, a few hundred people have sprained their ankle. While ankle pain can result from a large number of ankle and foot injuries, the most common ankle injuries are sprains (low and high ankle), which involve ligaments and bones in the ankle. But you can also fracture a bone, tear muscles or over-stress a tendon when you sprain your ankle.
High ankle sprains are generally a more significant injury. These injuries require thorough assessment and treatment to avoid long-term ankle arthritis. If you can't perform a single-leg calf raise within a few weeks of the injury, please seek an early professional ankle assessment.
An ankle fracture occurs when there is a break in one or more of the bones. The most common ankle fractures are avulsion fractures of your distal fibula, which can be a side effect of an ankle sprain. These are generally less troublesome than if you experience a talar dome fracture with your actual ankle joint. Potts fracture is a significant fracture of your tibia and fibula simultaneously. All suspected fractures require medical investigation and professionally managed by your health professional to avoid long-term foot and ankle issues. If your healthcare professional suspects an ankle fracture, you will be referred for at least an Xray and potentially to an orthopaedic surgeon. Related links:
- Ankle Fracture (Broken Ankle)
- Stress Fracture
- Stress Fracture Feet
- Severs Disease
- Heel Spur
- Shin Splints
While muscle strains are more common in your legs, there are important muscles which converge into tendons that wrap around your ankle to stabilise your ankle and foot to protect them from sprains and allow you to walk and run. These muscles and their tendon vitally provide you with a normal foot arch and avoid flat feet.
Your muscles or tendons can become injured or inflamed as a result of overuse or trauma. The inflammation is called tendonitis. They can also tear, completely rupture, or sublux out of place. Medically tendon injuries are known as tendinopathies, and at the ankle may include:
- Achilles Tendinopathy
- Achilles Tendon Rupture
- Peroneal Tendinopathy
- Tibialis Posterior Tendinopathy
- FHL Tendinopathy
- Plantar Fasciitis
Your ankle pain and dysfunction can lead to degenerative conditions such as ankle osteoarthritis. While arthritis usually is a chronic deterioration of your ankle joint, it is crucial to slow the progression of ankle arthritis. Please seek the professional advice of your ankle and foot health practitioner, e.g. physiotherapist or podiatrist.
Biomechanical disorders may result in foot deformation, painful weight-bearing and potentially nerve compression. In simple terms, this is where your foot and ankle do not have normal bone alignment and motion contr. Here are a few possible conditions related to poor ankle biomechanics.
- Anterior Ankle Impingement (Front of Ankle Pain)
- Posterior Ankle Impingement (Back of Ankle Pain)
- Pes Planus (Flat Feet)
- Tarsal Tunnel Syndrome