Posterior Ankle Impingement Syndrome

Posterior ankle impingement syndrome refers to a pathology that is characterised by pain and mechanical limitation in the posterior ankle joint caused as a result of repetitive plantarflexion. This explains its common occurrence in individuals involved in activities such as ballet dancing or playing football.

The etiology of the condition can be associated with both osseous and/or soft tissue lesions and anatomical variations. Compression of structures that are posterior to the tibiotalar and talocalcaneal articulations during terminal plantar flexion can also lead to posterior ankle impingement.

As described by Lavery et al., pathology associated with the lateral process of the posterior talus is the most common cause of posterior impingement. This can result from acute fracture, chronic injury due to repetitive microtrauma, or mechanical irritation of the surrounding soft tissues.

For instance, posterior capsuloligamentous injury due to repetitive or acute hyper-plantar-flexion can lead to inflammation, scarring and thickening of the capsule, posterior inferior tibiofibular ligament, and posterior fibers of the deltoid ligament. The flexor hallucis longus tendon is known to be commonly affected by tenosynovitis and tendinosis.

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Other sources of impingement can also include anatomic soft tissue variants such as the posterior intermalleolar ligament and several anomalous muscles.

With a clinical presentation that is similar to Achilles or peroneal tendon pathology, a physical examination should be conducted to inspect abnormal alignment, joint effusion, or soft tissue edema. In addition, the bone and soft tissue structures need to be palpated to assess for localised tenderness.

Yasui et al. recommend a complete neurovascular examination as well as strength and range of motion assessment. According to the authors, if the patient is tender during passive or active range of motion, it may indicate pathology involving the flexor hallucis longus tendon.

While discussing the management of posterior ankle impingement syndrome in sports, Ribbans et al. outline conservative treatment options that are available for the condition as rest, cessation of activity, modification of technique, physical therapy, orthotics/footwear modification, non-steroidal anti-inflammatory drugs and injections.

Out of these, injections were found to be curative for soft-tissue pathologies and can be used to temporarily ameliorate symptoms during sporting schedules. Studies have shown that ultrasound-guided injections can help high-level athletes return to sports quicker. 

Physical therapy should be implemented with a focus on improving ankle stability and optimising proprioception. The purpose of an orthotic inclusion in a comprehensive treatment programme for posterior ankle impingement syndrome would be for preventing dorsiflexion.

Postural stability is crucial to boost optimal articulation alignment which, in turn, facilitates optimal arthrokinematics of the foot and ankle.

An advantage of using MASS4D® customised orthotics is the enhancement of proprioceptive action through the foot and lower limbs, proximally to the central nervous system, throughout all types of movement.

These orthotics can also help in reducing any load on the soft tissue supportive structures around the ankle in order to improve ankle range of motion. There is also a marked reduction in compensation as the orthotics help to provide a stable base of support for resistance of body sway and improved ambulation.

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References:

1. Yasui, Y., Hannon, C. P., Hurley, E., Kennedy, J. G. (2016) Posterior Ankle Impingement Syndrome: A Systematic Four-Stage Approach. World Journal Of Orthopedics: October 18, 2016, Vol. 7, No. 10, pp. 657-663
2. Lavery, K. P., McHale, K. J., Rossy, W. H., Theodore, G. (2016) Ankle Impingement. Journal Of Orthopaedic Surgery And Research: 2016, Vol. 11, No. 97, DOI 10.1186/s13018-016-0430-x
3. Ribbans, W. J., Ribbans, H. A., Cruickshank, J. A., Wood, E. V. (2015) The Management Of Posterior Ankle Impingement Syndrome In Sport: A Review. Foot And Ankle Surgery: 2015, Vol. 21, pp. 1-10

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