Anterior Ankle Impingement
Anterior Ankle Impingement
What is Anterior Ankle Impingement?
Anterior Ankle Impingement is when an individual experiences pain at the front of the ankle due to compression of the bony or soft tissue structures during activities involving 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 tibia’s impact on the talus during weight-bearing activity.
The foot and shin move towards one another during the ankle dorsiflexion movement, meaning the tibia approaches the talus’s front. 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
- Repeated loaded ankle dorsiflexion. E.g. 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 bone 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 valuable test for a couple of different reasons. First, it can help ensure no other cause of foot or ankle pain present can mimic anterior ankle impingement. Also, an MRI may show signs of swelling in the irritation region in the front of the ankle. Diagnostic imaging can help confirm the patient’s history and physical exam findings and assist with surgical planning in the future.
Please seek the advice of your ankle physiotherapist or ankle specialist to determine the best assessment and treatment approach for your ankle impingement.
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 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 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 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 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 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 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 anterior 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 program has minimised your chance of future injury.
Other Treatment Options
Specific Interventions, e.g. Injection
Corticosteroid injections may be useful in the initial treatment phase if the patient has difficulty calming the ankle joint’s inflammation and pain.
Ankle Impingement Surgery
Surgery is not typical for those suffering from anterior ankle impingement. However, in persistent anterior ankle impingement cases, operative treatment may benefit 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 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 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 increase a patient’s symptoms if it allows the ankle joint to move more, and the ankle joint has significant arthritis.
Your physiotherapist is skilled in identifying whether you will require this adjunct treatment and will often discuss this additional 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.
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. All suspected fractures require medical investigation and professional management 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 X-ray and potentially an Orthopaedic Surgeon.
- 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 essential muscles that 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 ankle arthritis progression. Would you 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
Nerve-Related Ankle Pain
Children & Youth Conditions
Systemic Conditions That May Cause Ankle Pain
Soft Tissue Inflammation
Other Useful Information
Common Youth Leg Injuries
Why are Children's Injuries Different to Adults?
Adolescent Leg Injuries
Adolescent injuries differ from adult injuries, mainly because the bones are still growing. The growth plates (physis) are cartilaginous (strong connective tissue) areas from which the bones elongate or enlarge. Repetitive stress or sudden large forces can cause injury to these areas.
In the adolescent leg, common injuries include:
Pain at the bump just below the knee cap (tibia tubercle). Overuse injuries commonly occur here. The tibia tubercle is the anchor point of your mighty quadriceps (thigh) muscles. Because of excessive participation in running and jumping sports, the tendon pulls bone off and forms a painful lump that will remain forever. This type of injury responds to reduced activity and physiotherapy.
More info: Osgood Schlatter's Disease
Pain at the lower pole of the knee cap (patella). Overstraining causes Sinding-Larsen-Johansson disease. Because of excessive participation in running and jumping sports, the tendon pulls bone off the knee cap. This type of injury responds to reduced activity and physiotherapy.
More info: Sinding Larsen Johansson Syndrome
Anterior Knee Pain
Anterior knee pain or patellofemoral syndrome frequently gets passed off as growing pains. Cause of this pain includes overuse, muscle imbalance, poor flexibility, poor alignment, or more commonly, a combination of these. Anterior knee pain is one of the most challenging adolescent knee injuries to sort out and treat. Accurate diagnosis and treatment with the assistance of a physiotherapist with a particular interest in this problem usually resolves the condition quickly.
More info: Patellofemoral Pain Syndrome
The cartilage between the leg bones has a better blood supply and is more elastic in adolescents than adults. As adolescents near the end of bone growth, their injuries become more adult-like. Hence more meniscal and ACL (anterior cruciate ligament) injuries are likely. MCL (medial collateral ligament) injuries result from a lateral blow to the knee. Pain felt on the inner side (medially) of the knee. MCL injuries respond well to protective bracing and conservative treatment.
More info: Knee Ligament Injuries
ACL (Anterior Cruciate Ligament) Injuries
This traumatic knee injury is significant. Non-contact injuries of the ACL are becoming more common than contact injuries of the ACL. Adolescent females are at high risk. Combination injuries with MCL or menisci are common. Surgical reconstruction is needed if the adolescent wishes to continue participating in "stop-and-start" sports.
More info: ACL Injury
Your meniscus is crescent-shaped cartilage between the thigh (femur) and lower leg (tibia). Meniscal injuries usually result from twisting. Swelling, catching, and locking of the knee are common. If physiotherapy treatment does not resolve these damages within six weeks, they may require arthroscopic surgery.
Heel pain is commonplace in young adolescents due to the stresses of their Achilles tendon pulling upon its bony insertion point on the heel (calcaneum). It is a common overuse injury due to excessive training and competition, particularly when loads are increased dramatically in a short period. Diminished flexibility and muscle-tendon strength mismatching may predispose you. Physiotherapy, reduced activity, taping and orthotics are the best ways to manage this debilitating condition for the active young athlete.
More info: Sever's Disease
An ankle sprain is probably the most common injury seen in sports. Ankles sprains involve stretching of the ligaments and usually occur when the foot twists inward. Treatment includes active rest, ice, compression and physiotherapy rehabilitation. With the correct treatment, a low ankle sprain usually improves in two to six weeks. Your ankle physiotherapist should check even simple ankle sprains to eliminate high-ankle sprains. A residually stiff ankle post-sprain can predispose you to several other lower limb issues.
More info: Sprained Ankle
Patellar (kneecap) instability can range from partial dislocation (subluxation) to dislocation with a fracture. Partial dislocation treatment is conservative. Dislocation with or without fracture is a much more severe injury and usually will require surgery.
More info: Patella Dislocation
The separation of a bone from its bed in the knee joint is Osteochondritis Dissecans (OCD). This injury is usually due to one major macro event with repetitive macro trauma that prevents complete healing. This injury is potentially severe. Treatment varies from rest to surgery. An Orthopaedic Surgeon's opinion is vital.
Growth Plate Fractures
A fracture through the growth plate can be a severe injury that can stop the bone from growing correctly. These fractures should be treated by an Orthopaedic Surgeon, as some will require surgery.
Image source: https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children
An avulsion fracture occurs when a small segment of bone attached to a tendon or ligament gets pulled away from the main bone. The hip, elbow, and ankle are the most common locations for lower limb avulsion fractures in young sportspeople.
Treatment of an avulsion fracture typically includes active rest, ice and protecting the affected area. This active rest period is followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Your physiotherapist should supervise your post-avulsion exercises. Most avulsion fractures heal very well. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. An avulsion fracture to your foot or ankle may require a cast or walking boot.
An excessive gap between the avulsed bone fragment and main bone may not rejoin naturally in rare cases. Surgery may be necessary to reunite them. In children, avulsion fractures that involve the growth plates also might require surgery. All avulsion fractures should be reviewed and managed by your trusted physiotherapist or an Orthopaedic Surgeon.
For more information regarding your youth sports injury, please consult your physiotherapist or doctor.
Youth Leg Injuries
Pelvis & Hip
- Osgood Schlatter's Disease
- Sinding Larsen Johannson Disease
- Patellofemoral Pain Syndrome
- Patella Dislocation
- Meniscus Tear
- Discoid Meniscus
- Juvenile Osteochondritis Dissecans
Heel & Ankle
Common Youth & Teenager Sports Injuries
Acute Injury Signs
Acute Injury Management.
Here are some warning signs that you have an injury. While some injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop.
For detailed information on specific injuries, check out the injury by body part section.
Don't Ignore these Injury Warning Signs
Joint pain, particularly in the knee, ankle, elbow, and wrist joints, should never be ignored. Because these joints are not covered by muscle, pain here is rarely of muscular origin. Joint pain that lasts more than 48 hours requires a professional diagnosis.
If you can elicit pain at a specific point in a bone, muscle, or joint, you may have a significant injury by pressing your finger into it. If the same spot on the other side of the body does not produce the same pain, you should probably see your health professional.
Nearly all sports or musculoskeletal injuries cause swelling. Swelling is usually quite obvious and can be seen, but occasionally you may feel as though something is swollen or "full" even though it looks normal. Swelling usually goes along with pain, redness and heat.
Reduced Range of Motion
If the swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion. Compare one side of the body with the other to identify major differences. If there are any, you probably have an injury that needs attention.
Compare sides for weakness by performing the same task. One way to tell is to lift the same weight with the right and left sides and look at the result. Or try to place body weight on one leg and then the other. A difference in your ability to support your weight is another suggestion of an injury that requires attention.
Immediate Injury Treatment: Step-by-Step Guidelines
- Stop the activity immediately.
- Wrap the injured part in a compression bandage.
- Apply ice to the injured part (use a bag of crushed ice or a bag of frozen vegetables).
- Elevate the injured part to reduce swelling.
- Consult your health practitioner for a proper diagnosis of any serious injury.
- Rehabilitate your injury under professional guidance.
- Seek a second opinion if you are not improving.
Elite Sports Injury Management
You probably already know that a sports injury can affect not only your performance but also your lifestyle. The latest research continues to change sports injury management considerably. Our challenge is to keep up to date with the latest research and put them to work for you.
How we treated you last year could vary significantly from how we treat you this year. The good news is that you can benefit considerably from our professional knowledge.
What Should You Do When You Suffer a Sports Injury?
Rest from painful exercise or a movement is essential in the early injury stage. "No pain. No gain." does not apply in most cases. The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days. After that, you need to get it moving, or other problems will develop.
Ice or Heat?
We usually recommend avoiding heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early. In traumatic injuries, such as ligament sprains, muscle tears or bruising, ice should help reduce your pain and swelling.
Once the "heat" has come out of your injury, you can use heat packs. We recommend 20-minute applications a few times a day to increase the blood flow and hasten your healing rate. The heat will also help your muscles relax and ease your pain. If you're not sure what to do, please call us to discuss your situation specifically.
Should You Use a Compressive Bandage?
Yes. A compressive bandage will help to control swelling and bleeding in the first few days. In most cases, the compressive dressing will also help support the injury as you lay down the new scar tissue. This early healing should help to reduce your pain. Some injuries will benefit from more rigid support, such as a brace or strapping tape. Would you please ask us if you are uncertain about what to do next?
Gravity will encourage swelling to settle at the lowest point. Elevation of an injury in the first few days is beneficial, especially for ankle or hand injuries. Think where your damage is and where your heart is. Try to rest your injury above your heart.
What Medication Should You Use?
Your Doctor or Pharmacist may recommend pain killers or an anti-inflammatory drug. It is best to seek professional advice as certain medications can interfere with other health conditions, especially asthmatics.
When Should You Commence Physio?
In most cases, "the early bird gets the worm". Researchers have found that the intervention of physiotherapy treatment within a few days has many benefits. These include:
- Relieving your pain quicker via joint mobility techniques, massage and electrotherapy
- Improving your scar tissue using techniques to guide the direction it forms
- Getting you back to sport or work quicker through faster healing rates
- Loosening or strengthening of your injured region with individually prescribed exercises
- Improving your performance when you return to sport - we'll detect and help you correct any biomechanical faults that may affect your technique or predispose you to injury.
What If You Do Nothing?
Research tells us that injuries left untreated take longer to heal and have lingering pain. They are also more likely to recur and leave you with either joint stiffness or muscle weakness. It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve. The sooner you get on top of your symptoms, the better your outcome.
What About Arthritis?
Previously injured joints can prematurely become arthritic through neglect. Generally, there are four main reasons why you develop arthritis:
- An inappropriately treated previous injury (e.g. old joint or ligament sprains)
- Poor joint positioning (biomechanical faults)
- Stiff joints (lack of movement diminishes joint nutrition)
- Loose joints (excessive sloppiness causes joint damage through poor control)
What About Your Return to Sport?
Your physiotherapist will guide you safely back to the level of sport at which you wish to participate. If you need guidance, ask us.
What If You Need Surgery or X-rays?
Not only will your physio diagnose your sports injury and give you the "peace of mind" associated, but they'll also refer you elsewhere if that's what's best for you. Think about it. You could be suffering needlessly from a sports injury. Would you please use our advice to guide you out of pain quicker? And for a lot longer.
If you have any questions regarding your sports injury (or any other condition), don't hesitate to get in touch with your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.