Ankle impingement happens when bony or soft tissues within the ankle's joint are pressured exceedingly due to movements, like pointing your foot sharply downwards. It usually affects those who encounter forces in their ankle due to certain "end-range" situations, such as gymnasts, dancers, or individuals whose activities involve kicking. Additionally, those who perform recurrent duties like stair-climbing or squatting are vulnerable to this illness.
Physical therapists assist individuals suffering from ankle impingement in reducing discomfort, healing, and strengthening the affected areas, as well as improving overall balance. At Suarez Physical Therapy in Las Vegas, we have professional physical therapists who improve people's lives by providing hands-on treatment, prescribed mobility, and patient education. You can request an evaluation from a physiotherapist directly.
An Overview of Ankle Impingement
Ankle impingement is categorized into two types:
- Anterior ankle impingement
- Posterior ankle impingement
Anterior Ankle Impingement
This condition, sometimes known as "footballer's ankle" or "athlete's ankle," is caused by repetitive microtrauma, inversion injury, and dorsiflexion, which causes harm to anteromedial tissues like the articular cartilage. It's further subdivided into Anterolateral Impingement and Anteromedial Impingement.
Individuals with anterior ankle impingement could have both osteochondral and chondral lesions. This condition can also be found following non-sporting injuries, particularly foot and ankle fractures. Note that there seems to be a link between an ankle instability and mild cavus foot, well known as a high arched foot.
Anterior intra-articular soft tissues, alone or coupled with bony spurs, could result in ankle impingement. In the anterior joint area, there is a triangular-shaped soft tissue mass made mostly of synovial and adipose components. In asymptomatic people, these tissues are squeezed after 15 degrees of dorsiflexion.
Anterior osteophytes could limit the amount of space accessible for the triangular soft tissue and aggravate its entrapment, leading to synovitis, capsuloligamentous hypertrophy, and chronic inflammation. Range of movement limitations and pain could occur in individuals diagnosed with anterior ankle impingement as a result of the soft tissue impingement.
Hypothesized etiology encompasses repetitive dorsiflexion causing bone spurs, recurring capsular traction leading to the formation of osteophytes, chronic microtrauma on the anterior joint area, and inversion ankle sprains. However, the source remains unknown, despite the above-mentioned suggestions in the literature.
It can be triggered by inverted ankle sprains, which cause scar development or reactive synovitis and inflammation. It could also be caused by forceful supination and plantarflexion, which could rupture anterolateral capsular structures.
Posterior Ankle Impingement
This type of ankle impingement involves pain and distress on the rear side of one's ankle, particularly during activities involving pointing one's toes. The soreness is triggered by bony or soft tissue compression between the heel bone (calcaneus) and the shin bone (tibia.) Some individuals have a little additional bone in their ankle's rear part well known as an Os Trigonum. When your foot is pointed, this small bone could cause posterior impingement due to tension between the heel bone and the shin bone.
Furthermore, excessive levels of strain on the ankle would occasionally lead small fragments to fracture the ankle bone. This in turn could become squeezed when the ankle advances into "end-range plantar flexion," which means moving the toes or feet down towards the foot's sole. Tissue compression triggers edema and inflammation, which results in pain.
Persistent posteromedial pain is caused mainly by scar tissue composed of posterior fibers. When there is an ankle inversion injury, the fibers of the posterior ligament are squeezed while the ankle is in the plantar flexion.
Posteromedial ankle impingement is caused by the tibiotalar ligament's posterior fibers and posteromedial tibiotalar capsule. Their position between the medial malleolus and the talus predisposes them to entrapment throughout supination. The formed fibrosis and thickening of the damaged posteromedial capsule and tibiotalar ligament cause impingement between the medial malleolus' posterior margin and the talus medial wall, leading to fibrous meniscoid wounds, collagenous and synovitis formation at the posteromedial ankle.
This ankle injury is brought about by the Posterior Talofibular Ligament (PTL) also known as a Posterior intermalleolar ligament (PIL.) This ligament, on the other hand, is considered an anatomic variation that affects 56 percent of the overall population. During plantar flexion, the PTL would become entrapped and subsequently ripped.
Signs and Symptoms of Ankle Impingement
The signs and symptoms of the 2 types of ankle impingement differ. You are likely to experience the following symptoms if you have anterior ankle impingement:
- A dull discomfort at the ankle's front side with rest, which develops to an acute pain at the ankle's front part with weight-bearing or severe dorsiflexion
- Increased symptoms as a result of specific activities, such as:
- Excessive running or walking, especially on uneven surfaces or up hills
- Deep squats or lunges, especially when moving your knee forward over your toes
- Getting down from a jump, particularly on a rough or inclined surface
- Stretching the calf muscles, particularly with your knees bent
- Activities requiring twisting or heavy lifting
- Sensitivity at the front part of the ankle's joint on palpation
- In some circumstances, a clicking sensation occurs with specific ankle motions
- Ankle joint puffiness or edema
On the other hand, you could experience the following signs and symptoms as a result of posterior ankle impingement:
- Distress on the rear part of the ankle, particularly while pointing your toes
- Reduced range of movement when pointing the toes
- Soreness at the back of your ankle when in contact with any object
Ankle Impingement Diagnosis
Your assessment will start with a review of your individual health's past and present symptoms. Your physiotherapist will inquire about the onset of your symptoms, the area of your pain, and the activities that trigger your pain. A physical assessment will be performed by the physiotherapist to examine your structural stability, ankle strength, balance, and range of mobility. The physiotherapist will also conduct other tests, like gently moving and/ or twisting your ankle to check if it triggers discomfort.
To evaluate posterior ankle impingement in choreographers or dancers, the evaluation could be tailored to that pursuit. A physiotherapist, for instance, would request a ballet dancer to show the "en pointe" posture, which entails balancing on the tips of one's toes. To deliver a comprehensive assessment, your therapist would engage an orthopedist or any other healthcare professional. The most reliable way to identify ankle impingement is via magnetic resonance imaging (also referred to as MRI) or an X-ray, which the orthopedist can order.
Physical Therapy Treatment for Ankle Impingement
Once you've been given a diagnosis of ankle impingement, your physiotherapist will guide and help you to attain your functional objectives and get you back to doing the things you used to do without suffering.
This type of treatment plan would involve the following:
Your pain management is a top priority. The sole reason you seek therapy for ankle impingement is the discomfort and pain you suffer. In reality, it was the last symptom you got and it should be the first to cure. Managing pain involves:
- (Active) Rest: Your physiotherapist's first goal is to offer you some rest from the painful positions and motions. Active rest entails ceasing the activity or action that is causing ankle pain
- Ice Application: Using ice is an effective and simple method for reducing swelling and pain. Normally, you will be advised to apply the ice on the sore part for 20 to 30 minutes every two to four hours during the early stages or if your injury feels hot or warm
- Compression: Using compression bandages, kinesiology supportive taping or a Tubigrip compression stocking can help in supporting the affected soft tissues and reduce the swelling
- Elevation: Raising an injured ankle over your heart will aid gravity to reduce edema around the ankle
- Physiotherapist Techniques: Your Physical therapist will employ a variety of therapy methods to alleviate your inflammation and pain. Electrotherapy, ice, acupuncture, soft tissue massage, temporary mobility aids like a brace, and unloading taping techniques could be used to discharge the harmed structures
- Medication: Anti-inflammatory medications and natural lotions like arnica can help relieve your discomfort and swelling
A physical therapist would tenderly move the patient's ankle through its available range of movement or teach him or her the right motions to promote mobility and minimize stiffness. If necessary, your physiotherapist will conduct joint mobilization, which is the skillful movement of a joint in a specific direction to enhance its mobility.
It's critical to develop the muscles that function on the ankle, lower leg, and foot to support correct joint mechanics. When your muscles are strong and functioning well, the ankle joint space is maintained, thereby reducing the likelihood of bone or soft tissue compression.
Balance exercises can be prescribed by your physiotherapist to test how your body responds to external pressures. These exercises help you understand more about your body's location in space. Boosting your stability will result in a strong ankle since your body would be able to adapt to challenges more easily.
After your physiotherapist has aided you to reduce your ankle soreness and inflammation, you can advance to greater activity-specific duties. A physiotherapist will help make sure that your ankles can endure the demands of your sport, job, or artistic endeavors.
Surgery is not usually recommended as the first option for those who suffer from ankle impingement. However, in cases of recurrent ankle impingement, the high-level sportsman could benefit from surgical therapy. If the patient's complaints can be traced back to impingement rather than arthritis, eliminating the notable soft tissues or impinging bone overgrowth can alleviate symptoms. The problematic soft or bone tissue is removed surgically, either arthroscopically or by an incision in the ankle joint. The surgical treatment will vary based on the position and severity of the ankle impingement.
Os Trigonum Excision
The purpose of an Os Trigonum excision technique is to gently remove the Os Trigonum to relieve squeezing of the tissues below or above it. The open surgical approach is commonly used, which needs 1 to 2 incisions over the exterior section of the ankle's back. Since there are numerous blood vessels and nerves at the ankle's back part that would be harmed by an arthroscope, it's not often used for removing the Os Trigonum.
The procedure begins with the patient lying on the operating table, facing down. A small incision is made over the lateral side of the ankle's back part, behind the exterior ankle bone. A retractor is made use of to keep adjacent nerves, blood vessels, and tendons out of the way. Once the surgeon traces the Os Trigonum, he or she will use a scalpel to dissect it. However, if a bone bridge connects the talus and the Os Trigonum, the surgeon would use an osteotome or a chisel.
During operation, the medical professional uses a fluoroscope to look for any leftover bony pieces. Once the surgeon is confident that all fragments of bones have been excised, the skin is sewn together. Patients are fitted with a specific splint that protects the ankle and prevents their foot from bending or pointing downward.
Debridement is by far the most commonly used surgical procedure for (AI) anterior impingement. Most surgeons choose to use an arthroscope to do this operation. An arthroscope is a little television camera that is implanted through a very small cut. It enables the operator to view the region in which he or she is operating on a television screen.
To begin, 2 tiny incisions into the skin are made on either side of the operating area. The surgeon then inserts an arthroscope to determine which joint capsules or tendons are inflamed and thickened. The arthroscope allows the practitioner to check if a meniscoid wound (as previously indicated) exists.
A tiny shaver is often used to remove away or debride the inflamed fibers from the damaged ligaments. The medical professional also removes the tissues forming the meniscoid lesion as well as any inflammatory portions of the ankle joint capsule. Small forceps could be used as well to remove irritated or inflammatory tissue.
Small bone overgrowth on the talus or tibia is removed. If the overgrowth is substantial, the surgeon would choose to make a new cutover or near the spur. This facilitates the insertion of a specific device known as an osteotome. The osteotome is used to gently remove the large bone spurs. Before the treatment is completed, the surgeon uses a fluoroscope to inspect the debridement and ensure that no bone fragments remain.
Alternative Treatment Options
If a patient is having problems calming the pain and inflammation in the ankle joint, certain interventions like corticosteroid injections could be helpful in the early stages of treatment.
Acupuncture is useful in the treatment of pain. Most experienced physiotherapists use acupuncture if you're interested in giving it a try. You consider seeking their advice as a treatment option for ankle impingement.
Another treatment option is seeking more information about your condition. You could reach out to a competent physiotherapist if you have any queries or concerns about your ankle impingement.
Can This Injury Be Prevented?
There is no such thing as a completely avoidable injury. However, there are several steps that energetic and at-risk individuals can do to lower their chances of ankle impingement, such as:
- When engaging in physical activity, use proper technique
- Wearing appropriate footwear. For instance, a basketball player can put on high-top shoes to enhance his or her ankle stability)
- Avoiding overtraining since problems such as ankle impingement are often caused by recurrent strains
Which Type of Physiotherapist Would I Need?
Through experience and education, all physiotherapists are trained to handle ankle impingement. However, you would need to consider:
- A physiotherapist who is well-versed in the treatment of ankle impingement. Some physiotherapists specialize in orthopedics or sports medicine
- A physiotherapist who has finished a fellowship or residency in sports or orthopedic physical therapy, or one who is a board-certified specialist in the medical field. Such a professional possesses extensive knowledge, expertise, and skills that can apply to your situation
When looking for a physical therapist (or any other type of health care practitioner), keep the following points in mind:
- Seek advice from friends and family, as well as other healthcare professionals
- When making an appointment with a physiotherapy clinic, inquire about the experience of their physical therapists in treating ankle impingement
- Prepare to describe your condition and symptoms in detail at your ﬁrst appointment. Keep track and note what causes your discomfort to improve or worsen
Find a Physical Therapist Near Me
It is important to get medical assistance once you develop an ankle impingement. Prompt and suitable therapy guarantees that you fully recover. Suarez Physical Therapy is a Las Vegas-based physiotherapy clinic that focuses on personalized care to help patients achieve their health goals. Our sessions include therapeutic modification tactics, patient education, and manual therapy. Our team is committed to providing world-class services so that you can resume your normal activities as soon as possible. If you have any questions or would like to schedule a session with us, please call us at 702-368-6778. We are delighted to provide you with the attention you require.