Impingement syndromes of the ankle

Update on Ankle and Foot Impingement

Ankle impingement syndromes are a well-recognized cause of chronic ankle symptoms in both the elite athletic and general population. They comprise several distinct clinical entities with associated radiologic findings. Originally described in the 1950s, advances in magnetic resonance imaging (MRI) and ultrasonography have allowed musculoskeletal (MSK) radiologists to further their understanding of these syndromes and the range of imaging-associated features. Many subtypes of ankle impingement syndromes have been described, and precise terminology is critical to carefully separate these conditions and thus guide treatment options. These are divided broadly into intra-articular and extra-articular types, as well as location around the ankle. Although MSK radiologists should be aware of these conditions, the diagnosis remains largely clinical, with plain film or MRI used to confirm the diagnosis or assess a surgical/treatment target. The ankle impingement syndromes are a heterogeneous group of conditions, and care must be taken not to overcall findings. The clinical context remains paramount. Treatment considerations are patient symptoms, examination, and imaging findings, in addition to the patient's desired level of physical activity.

Anterior and Posterior Ankle Impingement Syndromes: Arthroscopic and Endoscopic Anatomy and Approaches to Treatment

Ankle impingement refers to a chronic painful mechanical limitation of ankle motion caused by soft tissue or osseous abnormality affecting the anterior or posterior tibiotalar joint. Impingement can be associated with a single traumatic event or repetitive microtrauma. These syndromes are a possible etiology of persistent ankle pain. An arthroscopic approach to this pathology, when indicated, is considered as ideal treatment with its high safety and low complication rate. We describe the clinical and potential imaging features, and the arthroscopic/endoscopic management strategies, for the 4 main impingement syndromes of the ankle: anterolateral, anterior, antero-medial, and posterior.

[Impingement syndrome of the ankle]

Impingement syndrome of the ankle is a clinical diagnosis caused posttraumatically by overuse due to repetitive mechanical loading or the presence of predisposing anatomical variants. Ankle impingement syndrome is characterized by chronic pain and limited range of movement caused by mechanical compression of bony or soft tissues within the joint compartments. Ankle impingement syndrome is classified according to the various anatomical locations around the tibiotalar joint as anterior, anterolateral, anteromedial, posterior or posteromedial. Various imaging modalities are helpful in confirming the clinical diagnosis of ankle impingement. Radiography and computed tomography are used to identify bony abnormalities and intra-articular loose bodies. Magnetic resonance imaging is the modality of choice to demonstrate pathological soft tissue changes, bone marrow edema and osteochondral lesions. Dynamic sonography can identify the anatomical structures leading to impingement during movement.

[MRI diagnostics of bone marrow oedema and its significance for the forensic medical evaluation of the injuries to bones and articulations]

The objective of the present study was the analysis of the publications in the literature dealing with radiological methods employed for the diagnostics of injuries to and diseases of the bones and articulations as well as the role of bone marrow oedema in the development of these conditions in the specific context of the problems facing forensic medical expertise. The main results of the domestic and foreign authors concerning MRI-based investigations into the nature of injuries and other pathological changes in bones and articulations during different periods after their development are discussed with the major emphasis placed on diagnostics of bone marrow oedema. Magnetic resonance visualization of this diagnostic feature and the related manifestations of the above conditions in many cases provides an indisputable evidence of the damage whereas the discovery of its distribution to and localization in the bone structures makes it possible to elucidate the sources of this condition, such as a blow, torsional stress, stretching, etc., and its underlying mechanisms. The character and the mode of distribution of the signal from a bone marrow oedema under various conditions of visualization allow to carry out differential diagnostics of the damage prescription period of up to 1.5 months.

Anatomic Relationship and Imaging Relevance of the Perforating Branches of the Peroneal Vessels to the Anterior Talofibular Ligament

BACKGROUND

Patients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging.

OBJECTIVE

Our aim was to estimate prevalence of perforating branches (PBs) of the peroneal vessels and determine their most frequent position relative to the ATFL. If these vessels are located in a predictable position at the level of the ATFL, they may serve as a sonographic landmark for the correct imaging plane.

METHODS

Magnetic resonance imaging (MRI) scans of 105 ankles were reviewed to determine the PB prevalence and location at the ATFL. Inter-observer agreement was determined. Additionally, 16 ankles from 8 asymptomatic subjects were scanned using a high-frequency linear transducer and PB prevalence and location were noted.

RESULTS

By MRI, PBs were detected in 85% of the ankles and 93% of ankles after consensus. In 73% of cases with agreed PB visualization, vessels assumed a medial position with respect to the ATFL. By US, PBs could be seen in 100% of cases, with the arterial PB seen in 81% of cases and assuming a medial position in 88%.

CONCLUSIONS

PBs are often present, have a predictable course, and may be useful to help optimize US probe positioning when assessing the ATFL.

Imaging of Common Arthroscopic Pathology of the Ankle

Arthroscopy of the ankle is used in the treatment and diagnosis of a spectrum of intra-articular pathology including soft tissue and osseous impingement, osteochondral lesions, arthrofibrosis, and synovitis. To help identify the correct pathology, imaging techniques are often used to aid the surgeon in diagnosing pathology and determining best treatment options. This article discusses the use of imaging in various ankle pathologies.

Posterior ankle and hindfoot endoscopy: A cadaveric study

BACKGROUND

The list of indications of posterior ankle endoscopy is expanding and includes various soft tissue and bony pathologies of the posterior ankle. Some of the indications, e.g. release of frozen ankle, debridement of posteromedial soft tissue impingement of the ankle and debridement or fixation of the posteromedial osteochondral lesion of the talus, require approach to the posterior ankle medial to the flexor hallucis longus tendon. The purpose of this study was to assess the risk of injury to the posterior tibial neurovascular bundle during posterior ankle endoscopy.

METHODS

Fourteen fresh frozen foot and ankle specimens were used. A metal rod was inserted into the posteromedial, posterolateral and modified posteromedial portals and touched the medial border of the posterolateral talar tubercle and the posteromedial corner of the ankle mortise in turn. The neurovascular bundle and FHL tendon were examined for any kink.

RESULTS

The neurovascular bundle was kinked in all specimens (100%) with the rod at the posteromedial corner of the ankle mortise through the posteromedial portal and was kinked in 11 specimens (79%) with the rod through the modified posteromedial portal. The neurovascular bundle was kinked in 1 specimen (7%) with the rod through the posterolateral portal.

CONCLUSIONS

The neurovascular bundle was at risk during instrumentation of the posteromedial ankle through the posteromedial portal but was safe through the posterolateral portal.

Ankle Impingement Caused by an Intra-articular Plica: A Report of 2 Cases

Entrapment of soft tissues in the anterolateral gutter of the ankle can cause impingement. When symptomatic, patients complain of chronic ankle pain exacerbated with dorsiflexion. Symptoms of instability and a history of recurring ankle sprains are common findings. Plain radiographs and magnetic resonance imaging may assist clinicians in identifying associated pathology. We present 2 cases of ankle impingement occurring in the setting of equivocal examination and imaging findings. In both cases, arthroscopy revealed a likely congenital, intra-articular plica.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Study.

US in ankle impingement syndrome

Ankle impingement is a common condition occurring secondary to sprain or repeated microtrauma. Clinical symptoms are chronic pain located in the affected region and limited range of ankle motion. There are three types of ankle impingement syndrome: anterior impingement, which can be subdivided into anterolateral, anteromedial and purely anterior impingement; posterior impingement, which can be subdivided into posterior and posteromedial impingement; and calcaneal peroneal impingement which is secondary to planovalgus foot deformity. This paper evaluates physiological and clinical elements of these three types of ankle impingement syndrome as well as the role of ultrasound (US) imaging and US-guided treatment.

Intra-articular plica causing ankle impingement in a young handball player: a case report

Ankle sprains are common injuries that respond well to rehabilitation. In the case of persisting symptoms, the differential diagnosis should include osteochondral defects, tendon injury, mechanical instability, and ankle impingement. In the present case report, we describe a 16-year-old male handball player who presented with persisting pain and locking in the right ankle 3 years after having sustained multiple minor inversion trauma. The clinical examination and conventional radiography showed no abnormalities. On magnetic resonance imaging, a flake fracture at the anteromedial talar dome and/or loose body was assumed. Arthroscopic examination revealed an intra-articular plica originating from an osteochondral fossa at the anteromedial tibial plafond. The plica was debrided. Retrospectively, the arthroscopic findings matched the radiographs and magnetic resonance images. The postoperative protocol consisted of early mobilization. At 6 weeks of follow-up, the patient had no pain and had returned to his sports activities. The present case report illustrates, to the best of our knowledge, the first case of ankle impingement due to a, most likely congenital, intra-articular plica arising from an osteochondral fossa at the anteromedial tibial plafond. This rare clinical condition can be diagnosed with magnetic resonance imaging. Arthroscopic debridement will effectively relieve the symptoms.

Diagnostic imaging of ankle impingement syndromes in athletes

The chronic ankle pain is a very frequent clinical problem, which is often characterized by a painful mechanical limitation of full-range ankle movement. A large amount of causes are involved in its pathogenesis, but the most common forms are secondary to an osseous or soft tissue abnormality. Especially for professional athletes, impingement lesions are the most important causes of chronic pain; however, this symptomatology can also affect ordinary people, mostly in those who work in environments that cause severe mechanical stress on the joints. This group of pathologies is characterized by a joint conflict secondary to an abnormal contact among bone surfaces or between bones and soft tissues. Diagnosis is mainly clinic and secondly supported by imaging in order to localize the critical area of impingement and determine the organic cause responsible for the joint conflict. Treatments for different forms of impingement are similar. Usually, the first step is a conservative approach (rest, physiotherapy, ankle bracing, shoe modification and local injection of corticosteroids), and only in case of unsuccessful response, the second step is the operative treatment with open and arthroscopic techniques. The aim of the study is to describe different MR imaging patterns, comparing our data with those reported in the literature, in order to identify the best accurate diagnostic protocol.

Arthroscopic treatment of patients with anterolateral impingement of the ankle with and without chondral lesions

Anterolateral impingement syndrome is defined as chronic pain in the ankle secondary to soft tissue impingement, hypertrophy, or tearing of the lateral and anterolateral ligaments of the ankle. The purpose of the present study was to evaluate the results of arthroscopic treatment of anterolateral impingement syndrome and its association with chondral lesions. In this case series study, 23 patients with anterolateral impingement syndrome underwent arthroscopic debridement of the ankle. Simple radiography and magnetic resonance imaging were applied for all the patients to diagnose the spur condition and to exclude patients with other possible lesions. All the patients were evaluated preoperatively and at interval visits of 2, 4, and 6 weeks and 3 and 6 months postoperatively according to the American Orthopaedic Foot and Ankle Society criteria and Meislin score. The mean patient age was 38.13 ± 6.85 years. Significant differences were seen between the mean American Orthopaedic Foot and Ankle Society scores, which was 59.21 before surgery and 83.56 and 88.13 at 3 and 6 months postoperatively, respectively. No significant differences were seen between the American Orthopaedic Foot and Ankle Society scores of the patients with or without chondral lesions. Arthroscopic treatment of anterolateral impingement syndrome is recommended as the treatment of choice and is still considerably effective in patients with chondral lesions.

Update on anterior ankle impingement

Anterior ankle impingement results from an impingement of the ankle joint by a soft tissue or osteophyte formation at the anterior aspect of the distal tibia and talar neck. It often occurs secondary to direct trauma (impaction force) or repetitive ankle dorsiflexion (repetitive impaction and traction force). Chronic ankle pain, swelling, and limitation of ankle dorsiflexion are common complaints. Imaging is valuable for diagnosis of the bony impingement but not for the soft tissue impingement, which is based on clinical findings. MR imaging and MR arthrography are helpful in doubtful diagnoses and the identification of associated injuries. Recommended methods for initial management include rest, physical therapy, and shoe modification. If nonoperative treatment fails, arthroscopic bony or soft tissue debridement both offer significant symptomatic relief with long-term positive outcomes in cases that have no significant arthritic change, associated ligament laxity, and chondral lesion.

Radiological interventions for soft tissue injuries in sport

Injection therapy has played an integral role in the rehabilitation of sports injuries for many years. The athlete's primary goal is a rapid return to sporting activity. This may be achieved by a combination of either a temporary or permanent reduction in pain, and by a pharmacological or physiological effect that promotes or accelerates a healing response. A wide variety of pharmacological agents are used. However, there is often a lack of good evidence that quantifiable effects can be achieved. There are restrictions on the use of some pharmaceutical agents. This article reviews the various pharmacological agents and bioactive substrates that are available, and discusses the current evidence base of their use in common sports injuries.

Ankle impingement syndromes: a review of etiology and related implications

Ankle injuries are common occurrences in athletics involving and requiring extreme ranges of motion. Ankle sprains specifically occur with a 1 in 10,000 person rate in active individuals each day. If trauma is repetitive, the ankle structures have potential to experience secondary injury and dysfunction. Included in this category of dysfunction are both anterior and posterior ankle impingement syndromes where disruption of the bony structures, joint capsule, ligaments, and tendons typically occurs. Ankle impingement is described as ankle pain that occurs during athletic activity, with recurrent, extreme dorsiflexion or plantar flexion with the joint under a load. Ankle impingements can be classified according to what structures become involved both anteriorly and posteriorly. Osseous impingement, soft tissue impingement, impingement of the distal fascicle of anterior inferior tibiofibular ligament, and meniscoid lesions are all documented causes of ankle impingement. These changes tend to be brought about and exacerbated by extreme ranges of motion. Understanding various impingement types will better enable the clinician to prevent, identify, treat, and rehabilitate affected ankles. Acknowledging activities that predispose to ankle impingement syndrome will enhance prevention and recovery processes. Description of ankle impingement etiology and pathology is the objective of the current review.

Stieda process versus Haglund’s deformity: An uncommon presentation of posterior ankle impingement

Posterior ankle impingement syndrome represents an important cause of chronic ankle pain and has been extensively described in the orthopaedic and radiology literature. A rare case of this painful hindfoot disorder that resulted from two concurrent developmental anomalies is presented herein.

MR imaging of deltoid ligament pathologic findings and associated impingement syndromes

Injuries of the deltoid ligament of the ankle are increasingly recognized with the widespread use of magnetic resonance (MR) imaging. The use of higher magnetic field strengths requires familiarity with the anatomic substructure of the deltoid ligament to better localize and characterize pathologic findings. Specifically, improved image resolution allows components of the superficial (tibiocalcaneal, tibionavicular, posterior superficial tibiotalar, and tibiospring ligaments) and deep (anterior tibiotalar and posterior deep tibiotalar ligaments) portions of the ligament to be evaluated separately. Awareness of the deltoid ligament substructure and associated injury patterns can guide the radiologist in defining underlying mechanical derangement, such as that seen in various impingement disorders. In this review article, the MR imaging technique for the deltoid ligament is summarized, and the normal and abnormal MR imaging appearances of various components of the deltoid ligament and associated impingement syndromes are presented.

Imaging of impingement lesions in the ankle

Ankle impingement and instability are well-recognized complications of ankle sprain. Ankle impingement is an important cause of chronic ankle pain in active populations, particularly in the professional athlete. Depending on anatomical location and the structures involved, impingement syndromes are classified into anterolateral, anterior, posterior, posteromedial, and anteromedial types. Clinically, impingement syndromes are characterized by painful limitation of full-ankle movement. Ankle impingement results from repetitive subclinical trauma due to overuse injuries, which, in the subacute or chronic situation, lead to abnormal osseous and soft-tissue thickening within the ankle joint. Various imaging techniques can be used in the diagnosis of ankle impingement. Usually, radiography is the initial imaging technique performed to rule out bony trauma and identify potential anatomical bony abnormalities. Use of computed tomography and isotope bone scanning is largely superseded by magnetic resonance imaging, although with variable sensitivity and specificity. Arthrographic techniques, using computed tomography or magnetic resonance, are useful for exquisite demonstration of capsular recesses and synovial abnormalities. Imaging-guided injection techniques can be used in the management of impingement for pain ablation and to aid clinical diagnosis, especially in hind foot pain.

Persistent symptoms following non operative management in low grade MCL injury of the knee - The role of the deep MCL

Incomplete injuries (grade I or II) to the medial collateral ligament (MCL) of the knee are common and usually self limiting. Some patients complain of chronic medial knee pain following injury. We highlight the importance of anatomical investigation of these patients and evaluate a successful treatment technique. A consecutive case series of 34 patients with chronic pain following grade I/II MCL injury were reviewed. Injury prevented sporting activity, and examination revealed thickening and tenderness of the MCL. The knee was assessed by MRI. All patients had radiological evidence of injury to the superficial and deep MCL, with thickening, scarring and tearing. Patients were treated with ultrasound guided injection of local anaesthetic and steroid into the deep MCL and clinically reassessed. They were allowed to return to sport immediately. They were assessed for recurrence of symptoms with a postal questionnaire. Four were excluded from follow up. Four were lost. All patients reported an immediate and sustained resolution their medial knee pain. At mean follow up of 20.4 months (range 11-38 months) all were back to their pre-injury level of work. Twenty five (96%) had immediate and sustained return to sporting activity. Twenty one (81%) reported no change in level of sporting function. In patients with persistent medial joint pain following grade I/II MCL sprain, pain from the deep MCL must be considered. MRI will confirm the diagnosis, exclude coexistent pathology and localise the lesion within the deep MCL. A single corticosteroid injection provides an excellent clinical outcome 20 months post injection.