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.
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 I there is involvement of the connecting joint between the shin bone and the fibula then it will be very sensitive to firm palpation and respond with pain to malleolar compression. Impingement at the back of the ankle is much harder to establish as a diagnosis with its less clear presentation, with a strong toe-pointing movement of the foot bringing on symptoms potentially. In ballet and fencing people may perform repetitive lunge type movements which can give many small instances of damage to the joint lip which can result in the formation of bony outgrowths in that area.
The investigation of ankle impingement is difficult as the typical methods of imaging lesions may show up little. CT scanning, bone scans and normal x-rays are often reported as normal although there can be bony spur formation on the front lips of the tibia and talus in the case of anterior impingements. Magnetic resonance imaging scanning is used in these cases to attempt to clarify the soft tissue or bony changes responsible.
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.
If conservative management of ankle impingement is not successful then surgical intervention may be attempted. The typical operative method is to undergo excision of any bony or soft tissue obstructions and debridement of the local tissues via arthroscopy. Patients can mobilise very soon after ankle arthroscopy provided major work has not been done and be walking about later the same day. It may take four to six weeks for patients to return to their normal activities under the guidance in some cases of a physiotherapist. Results from trials of surgical care in these cases have indicated over 80% of patients fall into the excellent or good result groups.
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, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Edinburgh. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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