Impingement of the Ankle

Ankle impingement is a condition whereby the patient suffers from a restriction in their ankle movement due either to a bony or soft tissue problem. The typical causes of this condition are usually irritation of the capsule or synovial membrane of the ankle secondary to a single or a repeated series of accidents or incidents. Ankle sprains, especially if repetitive, can lead to chronic pain and impingement syndromes. This gives the patient continual pain on weightbearing and limits their mobility and sporting activities. Estimates vary but 10% of people suffering ankle sprains may develop some degree of impingement.

Impingement is often secondary to an acute ankle sprain where the person stands on something uneven or puts their foot into a hole in the ground, forcing the foot over into a downwards and inwards movement with the weight of the body. Anterior impingement occurs at the front of the ankle and posterior impingement behind, with another lesion type involving the connecting joint between the fibula and the tibia just above the ankle joint proper. An anterior blocking feeling is often reported by patients with this impingement as they try and get the foot up in the ankle. Moving the ankle into dorsiflexion with weight on it can bring on the pain.

If the intervening joint between the tibia and fibula is involved then there will be tenderness and pain on palpating that area firmly and on pressing the two sides of the ankle together. Posterior impingement may be harder to diagnose, the symptoms being less clear although a forceful downward movement of the foot may cause pain. Anterior impingement can be brought on by kicking a ball in soccer and doing repetitive lunging manoeuvres such as in fencing or ballet. Repeated micro damage to the area leads to chronic injury and the formation of bony spurs at the front edge of the joint.

Ankle impingement is difficult to investigate with the usual imaging methods as little may be apparent. Normal x-rays, bone scanning and computed tomography (CT) scanning often show little abnormal, although people with a diagnosis of anterior impingement may show spurs of bone on the front surfaces of the ankle bone (talus) and the tibia. MRI scanning (magnetic resonance imaging) is more helpful to show bony or soft tissue problems.

Conservative management is the mainstay of treatment for this condition and patients can reduce their symptoms if they modify the activity levels they are performing or alter their techniques and methods. Non-steroidal anti-inflammatory drugs can be prescribed to counter the pain and inflammatory changes. Referral to physiotherapy is common to attempt joint mobilisation methods on the foot and ankle, apply ultrasound, give deep friction massage and work on muscle power and joint motion. An ankle brace can be fitted to support the joint laterally or to restrict the range of motion and physiotherapists can also assess and fit orthotics in the shoes.

Conservative treatment methods may not settle impingement pain and then consideration turns towards surgical intervention. Modern operation is usually performed arthroscopically, any loose tissue cut away, and bony spurs or soft tissue abnormalities removed. Patients can rapidly mobilise after surgery and almost normal walking can start a few hours after operation provided minor work has been performed. Patients may need to wait 4 to 6 weeks before fully resuming their normal routines, in some cases guided by physiotherapists. Results from trials of surgery for this condition have shown that eighty percent have good to excellent outcomes.

In more serious cases patients may wear an ankle brace and use crutches to reduce the weight borne on the ankle, working up to full weight bearing over a week or two. Physiotherapy may then commence once the brace has been removed, starting with range of motion exercises to the ankle and foot joints. Physiotherapists also use ice and other treatments such as ultrasound to reduce pain and inflammation. Once the ankle has begun to settle the physio will progress the patient onto gym exercises without significant weight such as using a static bike, and then to weight bearing exercises involving power, coordination, joint position sense and balance.

Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in London visit his website.