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Sports Injury Prevention & Rehabilitation

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Posterior Ankle Impingement
(Also known as Ankle Impingement, Posterior Impingement Syndrome, Posterior Impingement of the Ankle)
What is posterior ankle impingement?
The ankle joint primarily comprises of the articulation of two bones, the tibia (shin bone) and a small bone which lies directly beneath it called the talus.
When the foot and ankle are pointed maximally away from the body (plantarflexion), the ankle is compressed at the back of the joint. This may result in tissue damage and pain if the compressive forces are too repetitive or forceful. This condition is known as posterior ankle impingement.

Causes of posterior ankle impingement

Posterior ankle impingement is commonly found in gymnasts, ballet dancers and soccer players, all of whom maximally plantarflex their ankles during their activities. It is also often seen following acute ankle injuries. Sometimes, patients with anatomical variants in their talus bone may have an increased likelihood of developing this condition.

Signs and symptoms of posterior ankle impingement
Patients with posterior ankle impingement typically experience pain during activities requiring maximal plantarflexion of the ankle or after these activities with rest (especially at night or first thing in the morning). Symptoms are typically felt at the back of the ankle, or in the achilles region and may present as a dull ache or a more acute / sharper pain. Occasionally symptoms may be referred into other regions such as the calf or foot.

Diagnosis of posterior ankle impingement
A thorough subjective and objective examination from a doctor may be all that is necessary to diagnose posterior ankle impingement. X-Ray investigation may assist with diagnosis.

Treatment for posterior ankle impingement
Many patients with posterior ankle impingement heal well with an appropriate physical therapy program. The success rate of the physical therapy program is largely dictated by patient compliance with the program. One of the key components of the program is that the patient rests sufficiently from ANY activity that increases their pain until they are symptom free. This allows their body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence. Immediate appropriate treatment is essential to ensure a speedy recovery.
Patients with this condition should follow RICE in the initial phase of injury. The RICE is beneficial in the first 72 hours following injury or when inflammatory signes are present (i.e. morning pain or pain with rest). RICE involves rest from aggravating activities (crutches may be required), regular icing, the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
A graduated and pain-free flexibility, strength and return to activity program under direction from a physical therapist is vital to ensure an optimal outcome.

Contributing factors to the development of posterior ankle impingement
There are several factors which can predispose patients to developing posterior impingement of the ankle. These need to be assessed and corrected with direction from a physical therapist. Some of the factors which may contribute to the development of this condition include:
  • joint stiffness
  • muscle tightness
  • poor foot mechanics
  • inappropriate training technique (especially in dancers)

Physical therapy for posterior ankle impingement
Physical therapy treatment is vital to hasten the healing process and ensure an optimal outcome in all patients with this condition. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • stretches
  • joint mobilization
  • taping
  • bracing
  • the use of crutches
  • ice or heat treatment
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • biomechanical correction
  • a gradual return to activity program
Other intervention for posterior ankle impingement
Despite appropriate physical therapy management, some patients with posterior ankle impingement do not improve. When this occurs, the treating doctor can advise on the best course of management. This may include corticosteroid injection, X-rays or other investigations, or for those patients with prominent bony spurs, surgical intervention may be indicated to remove the bony prominence at the back of the talus.