Anterior Ankle Impingement
What is Anterior Ankle Impingement?
Anterior Ankle Impingement is a condition where an individual experiences pain at the front of the ankle, due to compression of the bony or soft tissue structures during activities that involve maximal ankle dorsiflexion motion.
It can be also known as:
- Ankle Impingement
- Anterior Impingement Syndrome
- Anterior Impingement of the Ankle
- Footballer’s Ankle
What is the Relevant Anatomy of Ankle Impingement?
The ankle joint is comprised of two bones - the tibia and talus, which glide on one another and have articular cartilage that cushions the impact of the tibia on the talus during weight-bearing activity.
During the movement of ankle dorsiflexion (figure 1) the foot and shin move towards one another, meaning the tibia approaches the front of the talus. This places compressive forces on the structures at the front of the ankle joint. If these forces are in excess or beyond what the ankle can withstand, damage and inflammation of these structures can occur.
What Occurs in Anterior Ankle Impingement?
Repeated compression at the front or anterior aspect of the ankle joint results in pinching of the joint capsule and synovium that is responsible for generating pain in patients with anterior ankle impingement.
In some cases, this repeated compression of the anterior ankle joint can lead to bone spurs, otherwise known as osteophytes to form on the front edge of the tibia or talus. It is believed that these spurs can develop to help protect the surface from the repeated pulling of the joint capsule on the front lip of the tibia or just the cumulative repetition of bony contact. This process does not have to be associated with arthritis of the ankle joint, however, it can be accelerated with repeated ankle sprains.
What Causes Anterior Ankle Impingement?
Anterior ankle impingement most commonly occurs as a result of:
- Ankle Sprain
- Recurrent Ankle Sprains
- Activities that require repeated Dorsiflexion of the Ankle - such as landing and deep squatting.
There are several factors that can predispose you to develop anterior ankle impingement. Your Physiotherapist is highly trained in identifying these and correcting them to reduce your risk of developing anterior ankle impingement.
Some of the factors that can contribute to the development of this condition include:
- inadequate rehabilitation following a previous ankle injury
- joint stiffness or swelling
- muscle tightness
- bony anomalies
- poor foot biomechanics (e.g. "flat feet" or high arches)
- poor lower limb biomechanics
- inappropriate training (including technique, footwear or training surfaces)
- excessive training
- inadequate recovery periods from training and games
- inadequate warm-up
- poor core stability
- poor proprioception or balance
Symptoms of Anterior Ankle Impingement
Individuals that suffer from anterior ankle impingement typically present with:
- Dull ache at the front of the ankle with rest, which then becomes sharp pain at the front of the ankle with excessive dorsiflexion or weight bearing
- Increased symptoms following certain activities, including:
- Walking or running excessively (especially up hills or on uneven surfaces)
- Deep squatting or lunging (especially with the knee moving forwards over the toes)
- Landing from a jump (particularly on an incline or an uneven surface)
- Performing a calf stretch (particularly with the knee bent)
- Heavy lifting or twisting activities
- Tenderness on palpation of the front of the ankle joint.
- In some cases, a clicking sensation may be experienced during certain ankle movements.
- Puffiness or swelling of the ankle joint.
How is Anterior Ankle Impingement Diagnosed?
Anterior ankle impingement can be diagnosed by your physiotherapist based on your history and physical assessment findings. In some cases, your physiotherapist may recommend that you obtain some imaging based on your presentation.
Standard ankle radiographs (or X- Rays) can be utilised when imaging anterior ankle impingement. The x-ray view of the ankle from the side (lateral radiograph) shows the ankle in profile and the bone spurs can be seen. Sometimes when the spurs are located on the inside of the ankle (anteromedial), they can be difficult to see on the standard lateral radiograph. Therefore an x-ray taken at a slight angle (oblique radiograph) can be helpful in seeing anteromedial bone spurs.
Magnetic Resonance Imaging or (MRI) is a useful test for a couple of different reasons. First, it can be useful in being sure there is no other cause of foot or ankle pain present that can mimic anterior ankle impingement. Also, an MRI may show signs of swelling in the region of irritation in the front of the ankle. This can help confirm the findings in the patient’s history and physical exam as well as help with surgical planning in the future.
Anterior Ankle Impingement Treatment
PHASE I - Pain Relief, Minimise Swelling & Injury Protection
Managing your pain. Pain is the main reason that you seek treatment for anterior ankle impingement. In truth, it was actually the final symptom that you developed and should be the first symptom to improve.
(Active) Rest: Our first aim is to provide you with some active rest from pain-provoking postures and movements. This means that you should stop doing the movement or activity that provokes the ankle pain.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.
Compression: A compression bandage, Tubigrip compression stocking or kinesiology supportive taping will help to both support the injured soft tissue and reduce excessive swelling.
Elevation: Elevating your injured ankle above your heart will assist gravity to reduce excessive swelling around your ankle.
Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These may include ice, electrotherapy, acupuncture, unloading taping techniques, soft tissue massage and temporary use of a mobility aid (eg brace) to off-load the injured structures.
In severe cases, you may require a period of rest from your aggravating activity. Your physiotherapist will be able to provide you with information in regards to alternative exercise.
Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling.
Phase 2: Restore Full Range of Motion
As soon as it is comfortable, your physiotherapist will start your rehabilitation aiming at regaining full active range of motion of the ankle.
Phase 3: Restore Muscle Strength
Your calf, ankle and foot muscles will require strengthening to recover from the injury and prevent future episodes. It is important to regain normal muscle strength to provide normal dynamic ankle control and function. Your strength and power should be gradually progressed from non-weight bear to partial and then full weight bear and resistance loaded exercises. You may also require strengthening for your other leg, gluteal and lower core muscles depending on your assessment findings. Your physiotherapist will guide you.
Phase 4: Restore High Speed, Power, Proprioception and Agility
Most cases of anterior ankle impingement occur during high-speed activities, which place enormous forces on your ankle and adjacent structures. Balance and proprioception (the sense of the relative position of neighbouring parts of the body) are required to ensure a full recovery and also to prevent re-injury.
Phase 5: Return to Normal Daily Function and Sport
Once you are able to return to normal daily function eg walking, stairs and squatting, your physiotherapist will address your specific needs. If you play sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport. Your physiotherapist will discuss your goals, time frames and training schedules with you.
The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.
Ankle Impingement Surgery
Surgery is not common for those suffering from anterior ankle impingement. However, in persistent cases of anterior ankle impingement operative treatment may be beneficial, particularly for the high-level athlete.
If a patient’s symptoms can be directly attributed to the impingement, rather than ankle arthritis, removing the prominent impinging bone spurs or soft tissue structures can help symptoms.
Surgical treatment involves removing the offending bone or soft tissue either arthroscopically or by opening up the ankle joint with an incision.
If the bone spurs are large it is often more efficient and effective to make a larger incision and open up the ankle joint and remove the bone spurs. It is important to note that surgery to remove impinging bone spurs from the front of the ankle will not typically help symptoms if the pain is due to significant ankle arthritis. In some instances, surgery to remove the bone spurs can contribute to an increase in a patient’s symptoms if it allows the ankle joint to move more and the ankle joint has significant arthritis.
Other Treatment Options
Specific Interventions eg Injection
Corticosteroid injections may be useful in the initial phase of treatment if the patient is having difficulty calming the inflammation and pain in the ankle joint.
Your Physiotherapist is highly trained in identifying whether you will require this adjunct treatment, and will often have you discuss this adjunct treatment option with a Sports Physician. If you have any concerns or have some specific questions regarding your condition, please ask your physiotherapist.