The syndrome known in English as Ankle Impingement is an inflammation produced in the anterior or posterior area of the ankle. In this article, the Dr. Almoguera, from the Elgeadi Traumatology team of traumatologists tells us about one of the most frequent pathologies in traumatology, posterior ankle impingement and entrapment of the flexor hallux. Keep reading and don't miss anything about this pathology.
What is posterior ankle impingement?
Posterior ankle pain is a common complaint in trauma clinics. The causes of pain are very diverse, but, in an important part, they are due to a impingement in the posterior region of the ankle, especially of the flexor hallucis longus (flexor hallucis longus [FHL]), while in maximum plantarflexion (on tiptoe). This condition is most commonly found in athletes who participate in sports that involve vigorous or repetitive movements, such as runners, tennis players, and dancers.
Why does ankle impingement occur?
The posterior region of the ankle consists of bony and soft tissue structures located behind the tibia, talus, and calcaneus. The posterior talar process consists of 2 projections, the posteromedial and posterolateral processes. The groove between these posterior processes houses the FHL tendon.
The posterolateral process is the most commonly involved in posterior ankle impingement syndrome.. When this remains an entity not fused with the body of the talus, it is called os trigonum. If the fusion is complete, but results in an elongated posterolateral projection, it is called the Stieda process.
FHL tendinitis, or tenosynovitis, is the result of compression of the tendon within its sheath by friction of the tendon with the os trigonum/Stieda process in plantar hyper-flexion.
What are the symptoms of ankle impingement?
The most common symptoms of patients who come to a trauma clinic with an impingement in the posterior region of the ankle are:
- Pain at first mild, which progresses and is annoying even at rest
- ankle inflammation
- Loss of joint range
- Functional disability and alteration of activities of daily living
Diagnosis and treatment of posterior ankle impingement
What is the diagnosis of posterior ankle impingement?
To diagnose this pathology, the clinical history is essential: patient participation in athletic activities and the specific position of the foot and ankle in sport. Increased pain with weight-bearing and the swing phase of walking is common, as well as discomfort with movement of the first metatarsophalangeal joint. Reproducible pain at maximum plantarflexion of the ankle is known as the “nutcracker sign.”
Lateral ankle x-rays are mandatory. In it you can identify the os trigonum/Stieda process. Magnetic resonance imaging (MRI) will give us the diagnosis of FHL tenosynovitis.
Posterior ankle impingement treatment
Initial nonsurgical treatment should be attempted for all patients: rest, activity modification, ice, elevation, anti-inflammatory medications, and immobilization. Physical therapy can also provide significant benefit.
If conservative treatment fails, we can consider surgical decompression of the FHL.. This can be performed openly, through a posteromedial approach, or arthroscopically; and basically consists of synovectomy of the FHL and resection of the os trigonum/Stieda process.
What is the post-operative period like after posterior ankle impingement?
In general, the ankle should be kept in a neutral position with a splint or CAM boot for approximately 3 weeks. Weight bearing on the limb is allowed from the second week. Almost all patients recover full activity around the sixth-eighth week after the intervention. Most of the results are excellent.
Do you have any questions about this pathology? Do not hesitate to make an appointment with the Elgeadi Traumatoogía team, traumatologists experts in minimally invasive surgeries.
