Posterior Ankle Impingement

Posterior Ankle Impingement

Article by Zoe Russell

What is Posterior Ankle Impingement?

Posterior Ankle Impingement is a condition where an individual experiences pain at the back of the ankle due to compression of the bone or soft tissue structures during activities that involve 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 have an increased likelihood of developing 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 upon your presentation.

Diagnostic Imaging

Standard ankle radiographs (or X-rays) can help when imaging posterior ankle impingement. The X-ray view of the ankle from the side (lateral radiograph) shows the ankle in profile, and the 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 present 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 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, 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 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 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. 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 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 choice for those suffering from posterior ankle impingement. However, in persistent posterior ankle impingement cases, operative treatment may be beneficial, particularly for the high-level athlete.

If a patient’s symptoms are directly attributed to the impingement, removing the prominent impinging bone spurs or soft tissue can help symptoms rather than ankle arthritis. 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 and open up the ankle joint and remove the bone spurs.

Removal of all bone spurs is not required, rather 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. 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.

Other Ankle Impingement Treatment Options

Specific Interventions, e.g. Injection

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

Acupuncture

Acupuncture can be effective pain relief. If you are interested in trying some acupuncture, many of our physiotherapists utilise 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 what is appropriate and inappropriate.

More Advice

If you have any concerns or have some specific questions regarding your posterior ankle impingement, please ask your physiotherapist.

Common Ankle Injuries

ankle pain

Sprained Ankles

The most common ankle injury is a sprained ankle, but ankle pain can have numerous sources.

Ankle Fractures

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 Tendinopathies

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:

Ankle Arthritis

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 Conditions

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.

Muscle Injuries

Nerve-Related Ankle Pain

Children & Youth Conditions

Systemic Conditions That May Cause Ankle Pain

Soft Tissue Inflammation

Other Useful Information

Article by John Miller

Common Youth Leg Injuries

Why are Children's Injuries Different to Adults?

youth sports injuries

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:

Osgood-Schlatter's Disease

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

Sinding-Larsen-Johansson 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

Knee Ligaments

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

Meniscal Injuries

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.

More info: Meniscus Tear, Discoid Meniscus

Sever's Disease

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

Ankle Sprain

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 Instability

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

Osteochondritis Dissecans

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.

More info: Juvenile Osteochondritis Dissecans (JOCD)

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.

Avulsion Fractures

youth pelvis hip avulsion

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

Knee

Heel & Ankle

Common Youth & Teenager Sports Injuries

Common Youth Neck & Back Pain

Common Youth Arm 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

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.

Tenderness

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.  

Swelling

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.

Weakness

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.