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Ankle Impingement Syndrome
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.
Investigations for ankle impingement often do not contribute much to the diagnostic process. Plain x-rays, bone scans and CT scans are typically normal, although patients who have anterior impingement may have bony spurs on the front edge of the tibia and on the talus, the ankle bone. Magnetic resonance imaging or MRI scanning is more useful as it enables the doctor to identify abnormalities in both bony and soft tissue structures.
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, editor of the Physiotherapy Site, writes articles about Physiotherapists, 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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Filed under back pain by on Jan 4th, 2010. 
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