Impingement of the Ankle
In ankle impingement there is a limitation in the joint mobility of the ankle due to pain from a soft tissue or bony pathology. A common finding to precipitate this pain syndrome is an irritation of the synovial membrane or the joint capsule, typically after an ankle sprain or a repetitive series of such injuries. Chronic pain in the ankle and impingement can result from the ankle being sprained and this can give a persistent pain problem with limitations on involvement in sports. Numbers are unclear but some level of impingement could occur in about ten percent of people who undergo ankle sprains.
An acute ankle sprain which precedes impingement is commonly precipitated by a person stepping into a hole or on to something uneven, forcing the foot inwards and downwards with the body weight on it. Impingent can present as anterior (front of ankle), posterior (back) or as a problem with the tibial and fibular interconnection just above the ankle. Patients with anterior impingement report that the front of the ankle joint feels blocked as they try and pull the foot up. If the ankle is dorsiflexed, especially with some force as in lunging forward whilst standing on the foot, this may point to this diagnosis if painful.
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.
Ankle impingement is treated initially with conservative methods with typical advice to patients to modify their aggravating activities initially so relieving the stresses on the injured areas to allow pain reduction. To limit the pain and any inflammatory local changes a patient may take nonsteroidal anti-inflammatory medications. Physiotherapy referral can involve the use of local ultrasound, friction massages, mobilisations of the local foot and ankle joints, strengthening muscles and increasing ranges of motion. Ankle braces can be useful for joint stability and to limit joint excursion, with assessment and provision of in-shoe insoles by physiotherapists.
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, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in Manchester, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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