Posterior Ankle Impingement Injuries: Paving the Path to Recovery and Optimal Ankle Health
▫️Written by John Keller
✅ Reviewed by Dr. Jenny Hynes on JULY 28, 2023
Imagine the excruciating pain that shoots through your ankle every time you take a step, hindering your every move and compromising your quality of life. This is the harsh reality for individuals suffering from posterior ankle impingement injuries. Whether you're an athlete striving to push your physical limits or an individual seeking everyday comfort, understanding this condition is crucial for effective treatment and long-term recovery.
Keilor Road Physio is a team of physiotherapists who are experts in their field. Book an appointment to see an ankle physio today.
Recent research has provided valuable insights into the causes, symptoms, and management of posterior ankle impingement, reinforcing the significance of early diagnosis and appropriate intervention for optimal healing and long-term ankle health.
Posterior ankle impingement occurs when the soft tissues and bony structures at the back of the ankle become compressed, resulting in pain, limited range of motion, and functional impairments. Activities involving repetitive ankle motion, such as ballet, soccer, and high-impact sports, are common contributing factors to the development of this condition (Ribbans et al., 2015). Additionally, degenerative changes and traumatic events can also lead to posterior ankle impingement (Sugimoto et al., 2021).
By exploring the latest research and evidence-based strategies surrounding posterior ankle impingement injuries, we can empower individuals and healthcare professionals alike to pave the path to recovery and ensure long-term ankle health, freeing individuals from the constraints of ankle pain and dysfunction.
What Is Posterior Ankle Impingement?
Posterior ankle impingement is a clinical condition defined by pain and discomfort experienced at the back of the ankle, primarily during movements involving plantarflexion - the downward motion of the foot. This is due to the compression, or impingement, of structures within the posterior aspect of the ankle (Ribbans et al., 2015).
The anatomy of the is complex, consisting of several bones including the tibia, fibula, and the talar bone of the foot. Soft tissues such as tendons, ligaments, and cartilage also occupy this space, with the most prominent being the Achilles tendon, flexor hallucis longus tendon, and the posterior talofibular ligament. Impingement typically occurs when the bony structures compress against the soft tissues, especially during excessive plantarflexion (Saxena & Eakin, 2011).
Causes of posterior ankle impingement are often multifactorial. Repetitive activities that involve recurrent forced plantarflexion, such as ballet dancing or soccer, are commonly implicated. Other factors include previous ankle sprains, which can lead to scar tissue formation that contributes to impingement. Anatomical anomalies, like the presence of an accessory bone known as the os trigonum or a prominent posterior talar process, can also predispose an individual to the condition (Saxena & Eakin, 2011).
By understanding the nature of posterior ankle impingement and its causes, healthcare professionals can better diagnose, manage, and treat this condition, restoring individuals to their full functional capacity.
Signs and Symptoms
Posterior ankle impingement manifests through a series of characteristic signs and symptoms. A prominent indicator is pain localized to the posterior aspect of the ankle, which tends to exacerbate during activities involving plantarflexion such as running, jumping, or walking on uneven surfaces. Swelling may also be present, particularly after strenuous activity (Ribbans et al., 2015).
Additionally, individuals may experience a restricted range of motion in the ankle, particularly during plantarflexion. The condition may also generate discomfort during specific positions, like standing on tiptoe or downhill walking, which induce a stretch or compression at the back of the ankle (Sman et al., 2013).
It is crucial for individuals experiencing these symptoms to seek medical attention promptly. Timely intervention can prevent the progression of the condition, enhance the effectiveness of treatment, and reduce the risk of future complications such as chronic pain or instability.
A thorough clinical examination is of paramount importance for accurate diagnosis. Keilor Road Physiotherapy assessment of the posterior ankle typically involves maneuvers to reproduce the pain and assess the range of motion at the ankle. Advanced imaging techniques like MRI or ultrasound may be employed to identify soft tissue changes, while radiographic studies such as X-rays or CT scans can detect associated bony abnormalities (Sman et al., 2013).
Thus, an in-depth understanding of the signs and symptoms, the importance of seeking medical attention, and the significance of a comprehensive examination are all pivotal aspects in the successful management of posterior ankle impingement.
Types and Mechanisms of Posterior Ankle Impingement
Posterior ankle impingement can materialize in various ways, commonly differentiated into two primary types: osseous (bony) and soft tissue impingement.
Osseous impingement involves the compression of bony structures during ankle movements. It often manifests due to the presence of an os trigonum or a prominent posterior process of the talus, anatomical variations that can be ascertained through imaging studies. This condition frequently presents among athletes engaged in activities demanding excessive plantarflexion, such as ballet and soccer (Peace et al., 2004). These athletes may experience a 'pinching' sensation at the back of the ankle during plantarflexion as the bony structures compress the surrounding soft tissues.
Contrastingly, soft tissue impingement involves the compression or entrapment of soft tissues, often attributable to the formation of scar tissue following an injury. A prominent example includes impingement of the flexor hallucis longus tendon, a condition also known as "dancer's tendinitis" due to its prevalence among ballet dancers. It's postulated that extreme plantarflexion movements in ballet contribute to this condition, as they can strain the tendon, causing inflammation and potential scarring (Vosseller et al., 2019).
Recognizing these variants of posterior ankle impingement is crucial in the diagnosis and management of the condition, facilitating the development of targeted and effective treatment plans. The ultimate goal remains to alleviate discomfort, restore functional mobility, and minimize recurrence.
Treatment Options
Management of posterior ankle impingement encompasses a broad range of treatment options, often divided into conservative (non-surgical) and surgical approaches. The choice of treatment hinges on several factors, including the severity of impingement, patient symptoms, functional limitations, and the response to initial therapy.
Conservative treatment often serves as the first line of management. This may involve rest, modification of activities to avoid exacerbating pain, non-steroidal anti-inflammatory drugs (NSAIDs) to control inflammation and pain, and physiotherapy (Russell et al., 2010). At Keilor Road Physiotherapy, a tailored rehabilitation program can be created, incorporating targeted exercises to strengthen the muscles around the ankle, improve balance, and enhance joint proprioception. Manual therapy techniques may also be utilized to improve joint mobility and alleviate discomfort.
Importantly, Keilor Road Physiotherapy tailored rehabilitation programs consider broader biomechanical factors, such as lumbopelvic and dynamic hip weakness, which can contribute to altered gait and increased stress on the ankle (McCann et al, 2021). Addressing these higher-level biomechanical issues can significantly improve lower limb function and help prevent the recurrence of impingement symptoms.
For patients who do not respond adequately to conservative management, surgical intervention may be considered. This typically involves removing the source of impingement, such as an os trigonum or excessive bone growth. It can be performed as open surgery or arthroscopically, with the latter often preferred due to lesser post-operative pain and a quicker return to activity (Saxena & Eakin, 2011).
Keilor Road Physiotherapy plays an instrumental role in the post-operative rehabilitation process through the provision of targeted exercises to restore strength, mobility, and function, alongside modifications to activity levels and footwear to prevent recurrence. It's this multidimensional approach that ensures optimal patient outcomes, facilitating a return to pain-free activity and enhancing overall ankle health.
Rehabilitation and Recovery
The path to recovery from posterior ankle impingement is a multi-phase process, involving various stages of rehabilitation. Each stage is vital, encompassing range of motion (ROM) exercises, strengthening activities, proprioception training, and functional exercises.
In the early stages of recovery, restoring normal ankle ROM is paramount. ROM exercises help to reduce joint stiffness and enhance mobility. These exercises, such as gentle ankle circles and pumps, are progressively intensified as the patient's discomfort lessens (Feger et al., 2015).
Once ROM is reinstated, attention turns to strengthening exercises, which aim to bolster the muscles supporting the ankle. This reduces the risk of future instability and impingement. Exercises often involve resistance training, calf raises, and other theraband exercises (Valderrabano et al., 2006).
Proprioception, or body awareness training, constitutes the next critical rehabilitation phase. It's designed to improve balance and bodily spatial orientation, thereby reducing the risk of reinjury. Balance-centric exercises like single-leg stands, wobble board exercises, or activities involving a Bosu ball are usually incorporated (Wikstrom et al., 2017).
Eventually, functional exercises are introduced to simulate day-to-day or sport-specific movements. This ensures that the ankle is conditioned to handle the strains of regular activities or sporting events (Hunt et al., 2017).
Keilor Road Physiotherapy plays a vital role in these stages, guiding patients through each step of the process. Regular attendance at physiotherapy sessions and adherence to prescribed home exercise programs form the backbone of optimal recovery.
During this process, managing pain and swelling is critical. Traditionally, the RICE (Rest, Ice, Compression, Elevation) approach has been utilized, but recent guidelines suggest a shift towards the POLICE principle (Protection, Optimal Loading, Ice, Compression, Elevation) for acute soft tissue injuries (Bleakley et al., 2012). Additionally, some health professionals advocate for the PRICE method (Protection, Rest, Ice, Compression, Elevation), which merges traditional rest and modern optimal loading strategies (van den Bekerom et al., 2012). Usage of prescribed pain medications under expert guidance also aids in managing symptoms. Swift recognition and management of potential complications, such as excessive swelling or pain, significantly contribute to successful recovery.
Preventing Posterior Ankle Impingement
Effective prevention of posterior ankle impingement is a multifaceted endeavor requiring attention to mobility, strength, and lifestyle modifications.
Maintaining and enhancing ankle mobility and flexibility is crucial. Contemporary research highlights the significance of targeted stretching exercises to improve ankle flexibility and decrease impingement risk (Malliaras et al., 2015). Warm-up routines featuring dynamic stretches and functional movements, followed by cool-down exercises, can prepare the body for activity and minimize post-exercise stiffness (McGowan et al., 2015).
Overuse or repetitive stress are major contributors to posterior ankle impingement. Current evidence underscores the importance of varied, balanced training programs, incorporating sufficient rest and progressive overload principles to help prevent such injuries (Gabbett et al., 2016).
Appropriate footwear choice remains critical. Modern studies recommend footwear that provides adequate support, aligns with the foot type and suits the specific demands of the activity, thus reducing potential biomechanical stressors leading to impingement (Debasio et al., 2013).
Ankle-strengthening exercises, such as heel raises, theraband resistance exercises, and balance exercises, have evolved to incorporate more functional and sports-specific movements, augmenting ankle strength and stability to mitigate future injury risks (Silbernagel et al., 2012).
At Keilor Road Physiotherapy, tailored programs addressing these elements are provided, focusing on the individual's specific needs and activities. Patient education regarding activity modifications, progression principles, and technique correction is emphasized, reinforcing preventive measures.
Conclusion
Posterior ankle impingement, characterized by the compression of the posterior ankle's anatomical structures, is a prevalent condition that can significantly impact daily life. Research shows that up to 17% of sports-related ankle pain may be due to posterior impingement syndrome (Peace et al., 2004). This condition can be triggered by a range of causes, including repetitive activities, previous injuries, or bony abnormalities.
Timely diagnosis and appropriate management are paramount in achieving optimal healing and long-term ankle health. Treatment plans encompass both conservative approaches, including targeted exercises, activity modifications, and manual therapy, as well as surgical options when necessary.
The multidimensional nature of rehabilitation includes range of motion exercises, strengthening exercises, proprioception training, and functional exercises, guided by professionals like those at Keilor Road Physiotherapy. The clinic's therapists assess biomechanical factors and individual needs to provide targeted, effective treatment plans.
Effective prevention strategies involve maintaining good ankle mobility, avoiding overuse, and wearing appropriate footwear. In essence, living an active lifestyle while incorporating these measures into daily routines is achievable and promotes ankle health.
With proper understanding, treatment, and rehabilitation, the recovery rates from posterior ankle impingement are incredibly high. Posterior ankle impingement isn't the end of an active lifestyle—it's a hurdle that can be overcome with the right approach and support.
References
Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), 220-221.
Debiasio JC, Russell ME, Butler RJ, Nunley JA, Queen RM (2013). Changes in plantar loading based on shoe type and sex during a jump-landing task.. J Athl Train, Sep-Oct;48(5):601-9.
Feger, M. A., Herb, C. C., Fraser, J. J., Glaviano, N. R., Hertel, J. (2015). Supervised rehabilitation versus home exercise in the treatment of acute ankle sprains: a systematic review. *Clinical Sports Medicine*, 36(2), 329-355.
4. Gabbett, T. J., Hulin, B. T., Blanch, P., & Whiteley, R. (2016). High training workloads alone do not cause sports injuries: how you get there is the real issue. *British Journal of Sports Medicine*, 50(8), 444-445.
Hunt, K. J., Hurwit, D., Robell, K., Gatewood, C., Botser, I. B., & Matheson, G. (2017). Incidence and Epidemiology of Foot and Ankle Injuries in Elite Collegiate Athletes. *The American Journal of Sports Medicine*, 45(2), 426-433.
Lumbopelvic Stability and Trunk Muscle Contractility of Individuals with Chronic Ankle Instability. McCann RS, Johnson K, Suttmiller AMB.Int J Sports Phys Ther. 2021 Jun 2;16(3):741-748.
Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. *Journal of Orthopaedic & Sports Physical Therapy*, 45(11), 910-922.
McGowan, C. J., Pyne, D. B., Thompson, K. G., & Rattray, B. (2015). Warm-Up Strategies for Sport and Exercise: Mechanisms and Applications. *Sports Medicine*, 45(11), 1523-1546.
Peace, K.A., Hillier, S., Healy, J.C., & Thompson, B.J. (2004). MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. *Clinical Radiology*, 59(11), 1025-1033.
Ribbans, W.J., Ribbans, H.A., Cruickshank, J.A., & Wood, E.V. (2015). The management of posterior ankle impingement syndrome in sport: a review. *The Foot and Ankle Online Journal*, 8(2), 1-7.
Russell, J. A., Kruse, D. W., Koutedakis, Y., McEwan, I. M., & Wyon, M. A. (2010). Pathoanatomy of posterior ankle impingement in ballet dancers. *Clinical Anatomy*, 23(6), 613-621.
Saxena, A., & Eakin, C. (2011). Articular talar injuries in athletes: Results of microfracture and autogenous bone graft. *The American Journal of Sports Medicine*, 39(11), 2331-2340.
Silbernagel, K. G., Steele, R., & Manal, K. (2012). Deficits in heel-rise height and Achilles tendon elongation occur in patients recovering from an Achilles tendon rupture. *The American Journal of Sports Medicine*, 45(12), 2874-2881.
Sugimoto K, Isomoto S, Samoto N, Matsui T, Tanaka Y. Arthroscopic Treatment of Posterior Ankle Impingement Syndrome: Mid-Term Clinical Results and a Learning Curve. Arthrosc Sports Med Rehabil. 2021 May 15;3(4):e1077-e1086.
Valderrabano, V., Hintermann, B., Horisberger, M., & Fung, T. S. (2006). Ligamentous posttraumatic ankle osteoarthritis. *The American Journal of Sports Medicine*, 34(4), 612-620.
van den Bekerom, M. P., Struijs, P. A., Blankevoort, L., Welling, L., van Dijk, C. N., & Kerkhoffs, G. M. (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training, 47(4), 435-443.
Vosseller JT, Dennis ER, Bronner S.J Am Acad Orthop Surg. 2019 Aug 15;27(16):582-589. Ankle Injuries in Dancers.
Wikstrom, E. A., Song, K., Pietrosimone, B. G., Blackburn, J. T., & Padua, D. A. (2017). Visual utilization during postural control in anterior cruciate ligament deficient and patient-reported functionally unstable individuals. *Gait & Posture*, 67, 37-41.
William J. Ribbans, Hannah A. Ribbans, James A. Cruickshank, Edward V. Wood, The management of posterior ankle impingement syndrome in sport: A review, Foot and Ankle Surgery, Volume 21, Issue 1, 2015, Pages 1-10.
Article by
John Keller
Clinical Director | Sports & Musculoskeletal Physiotherapist
John graduated as a Physiotherapist from the Auckland University of Technology with the John Morris memorial prize for outstanding clinical practise in 2003. John has since completed Post Graduate Diplomas in both Sports Medicine and Musculoskeletal Physiotherapy with distinction, also collecting the Searle Shield for excellence in Musculoskeletal Physiotherapy.
Reviewed by
Dr. Jenny Hynes FACP
Clinical Director | Specialist Musculoskeletal Physiotherapist
Jenny sat extensive examinations to be inducted as a fellow into the Australian College of Physiotherapy in 2009 and gain the title of Specialist Musculoskeletal Physiotherapist, one of only a few physiotherapists in the state to have done so.