The management of posterior ankle impingement syndrome in sport: a review

Beyond the needle: How nonsurgical management transforms foot and ankle ability in male footballers with posterior ankle impingement- a longitudinal study

Purpose

Posterior ankle Impingement (PAI) is a condition commonly affecting athletes and individuals engaged in activities involving repetitive ankle plantar flexion. This study aimed to evaluate the impact of nonsurgical management, excluding corticosteroid injections, on the functional outcomes of football players diagnosed with PAI.

Materials and methods

Twenty male football Players between age group of 18-30 years, clinically diagnosed of PAI, were included in this longitudinal study. Nonsurgical management was implemented over 8 weeks, including exercises. Players were assessed for pain, tenderness, range of motion(ROM), Foot and Ankle Ability Measure (FAAM), vertical and broad jump height at baseline, after 4 weeks and 8 weeks.

Results

Significant improvements were observed in pain levels (p < 0.001), tenderness (p < 0.001), ROM (p < 0.001), and functional abilities measured by FAAM ADL (p < 0.001) and Sports subscales (p < 0.001) after 8 weeks of nonsurgical management. Horizontal jump performance significantly improved (p = 0.02), while vertical jump did not (p = 0.15) after 8 weeks. Tenderness and ROM showed significant changes after 4 and 8 weeks. The FAAM% score significantly increased (p < 0.001) after 8 weeks, reflecting enhanced overall functional ability.

Conclusions

Nonsurgical management of 8 weeks is an effective approach for ameliorating symptoms and enhancing functionality in football players with PAI as compared to 4 weeks.

Safety and clinical efficacy of double posterolateral coaxial portals for endoscopic management of posterior ankle impingement syndrome

Background

This study aims to analyze the safety and clinical efficacy of using double posterolateral coaxial portals for endoscopic treatment of posterior ankle impingement syndrome (PAIS), a procedure that has gained popularity in recent times.

Methods

Six fresh foot samples were randomly selected to measure the distances of two posterolateral portals to the sural nerve in different positions (plantar flexion 10°, dorsiflexion 30°, and plantar flexion 30°) for safety evaluation. A prospective analysis was conducted on the clinical efficacy of the operative approach for endoscopic management of posterior ankle impingement syndrome, including evaluation of effectiveness and complications.

Results

In this study, the mean distances of the first and second portals to the sural nerve were measured in different ankle positions. The distances were found to be 2.26 ± 0.22 cm and 1.59 ± 0.12 cm in the plantar flexion 10° position, 2.21 ± 0.21 cm and 1.55 ± 0.12 cm in the dorsiflexion 30° position, and 2.46 ± 0.29 cm and 1.73 ± 0.19 cm in the plantar flexion 30° position, demonstrating a significant safety margin from the nerve. A total of 38 patients underwent endoscopic treatment for posterior ankle impingement syndrome using double posterolateral coaxial portals between January 2012 and December 2017. This surgical approach provided access to the subtalar joint and posterior ankle region. The patients were followed up for an average of 38.2 months (24-72 months), with a satisfaction rate of 94.7%. There were no reported complications, and significant improvements were observed in both visual analogue scale (VAS) and The American Orthopedic Foot and Ankle Society Score (AOFAS) scores postoperatively. The VAS score decreased from 5.68 to 0.51 (P < 0.001), while the AOFAS score increased from 71.68 to 92.34 (P < 0.001), resulting in an excellent/good rate of 97.3%.

Conclusion

The use of double posterolateral coaxial portals in the treatment of posterior ankle impingement syndrome offers several advantages, including improved safety, reduced risk of nerve injury, enhanced visualization of the posterior ankle and subtalar joint, favorable clinical outcomes, and minimal complications.

Os Trigonum Syndrome: A Cause of Posterior Ankle Pain

BACKGROUND

Os trigonum syndrome represents a cause of posterior ankle pain that is predominantly seen in athletes. The os trigonum ossicle forms from a secondary ossification center of the talus and is located at its posterior aspect in an interval between the posterior lip of the tibial plafond and calcaneus. The os trigonum ossicle is often an incidental finding and asymptomatic. However, repetitive plantarflexion and push-off maneuvers can cause symptoms and lead a patient to pursue orthopedic care.

MATERIALS AND METHODS

A review of the literature was conducted using the PubMed search engine with the following keywords: "os trigonum", "os trigonum ossicle", "os trigonum syndrome", "posterior ankle impingement", and "Stieda process".

RESULTS

The pertinent anatomy, clinical presentation, diagnostic evaluation, and treatment of os trigonum syndrome were reviewed in the literature and are extensively discussed in this article.

CONCLUSION

Os trigonum syndrome represents a potential cause of posterior ankle pain that needs thorough evaluation regarding history, physical examination, and imaging. Once diagnosed, treatment ranges from conservative to surgical interventions depending on surgeon preference and specific case presentation. [Orthopedics. 2024;47(2):e67-e72.].

Posterior Ankle Impingement: It's Not Only About the Os Trigonum

Background

Os trigonum and Stieda process are common etiologies for posterior ankle impingement syndrome (PAIS), and diagnosis is typically made by radiographs, computed tomographic, or magnetic resonance imaging. However, these static tests may not detect associated soft tissue and bony pathologies. Posterior ankle and hindfoot arthroscopy (PAHA) is dynamic, providing at least ×8 magnification with full anatomical visualization. The primary aim of this study was to report the prevalence of associated conditions seen with trigonal impingement treated with PAHA.

Methods

In this retrospective comparative study, patients who underwent PAHA for PAIS due to trigonal impingement, from January 2011 to September 2016, were reviewed. Concomitant open posterior procedures and other indications for PAHA were excluded. Demographic data were collected with pre- and postoperative diagnosis, arthroscopic findings, type of impingement, location, associated procedures, and anatomical etiologies. Trigonal impingements were divided in os trigonal or Stieda and subgrouped as isolated, with flexor hallucis longus (FHL) disorders, with FHL plus other impingement, and with other impingement lesions.

Results

A total of 111 ankles were studied-74 os trigonum and 37 Stieda. Isolated trigonal disorders accounted for 15.3% of PAIS (n = 17). Cases having associated conditions had a mode of 3 additional pathologies. FHL disorders were found in 69.4%, subtalar impingement in 32.4%, posteromedial ankle synovitis in 25.2%, posterolateral ankle synovitis in 22.5%, and posterior inferior tibiofibular ligament impingement in 19.8% of cases. Associated pathologies were observed in 58.6% of cases when FHL was not considered. Significant differences were noted comparing os and Stieda (isolated: 20.3% to 5.4%, P = .040; FHL plus others: 35.1% to 59.5%, P = .015).

Conclusion

Trigonal bone (os trigonum or Stieda) was found to cause impingement in isolation in a small proportion of cases even when the FHL was considered part of the same disease spectrum. This should alert surgeons when considering removing trigonal impingement. Open approaches may limit the visualization and assessment of associated posterior ankle and subtalar pathoanatomy, thus possibly overlooking concomitant causes of PAIS.

Level of Evidence

Level III, retrospective comparative study.

Arthroscopic treatment of ankle impingement syndrome

Arthroscopic treatment of ankle impingement syndrome (AIS) is a minimally invasive surgical procedure used to address symptoms caused by impingement in the ankle joint. This syndrome occurs when there is abnormal contact between certain bones or soft tissues in the ankle, leading to pain, swelling, or limited range of motion. Traditionally, open surgery was the standard approach for treating AIS. However, with advancements in technology and surgical techniques, arthroscopic treatment has become a preferred method for many patients and surgeons. With improved visualization and precise treatment of the arthroscopy, patients can experience reduced pain and improved functionality, allowing them to return to their daily activities sooner. In this paper, we reviewed the application and clinical efficacy the of arthroscopic approach for treating AIS, hoping to provide a reference for its future promotion.

Dance-related musculoskeletal injury leading to forced time-loss in elite pre professional dancers - a retrospective study

OBJECTIVES

Describe the epidemiology of dance-related musculoskeletal injury leading to forced time-loss in elite pre-professional dancers and provide descriptive data on the prevalence concerning diagnoses, location, and injury type, stratified by gender and skill level.

METHODS

Retrospective cohort, over a 3-year period on a full-time pre-professional Portuguese dance school featuring 70 both gender students with a mean age of 14.87 years. A total of 110 injuries were analyzed. Non-parametric statistics were used.

RESULTS

The most prevalent diagnosis leading to forced time-loss in female dancers were Medial Tibial Stress Syndrome (MTSS), 14.29%, and Posterior Ankle Impingement Syndrome (PAIS), 7.14%, whereas in male dancers these were Hallux Sprain, 17.50%, and Lumbar Spine Joint Injuries, 7.50%. Differences were found in injuries' anatomical location between genders and in Incidence Proportion and Clinical Incidence between skill levels. 72.20% of the chronic injuries and 50.00% of the acute injuries occurred in Level III students.

CONCLUSIONS

With respect to forced time-loss injuries, male dancers were found to sustain more acute traumatic injuries and female dancers overuse, respectively, sprains and MTSS and PAIS. Identifying which injuries are most likely to lead to forced time-loss may be useful for helping health-care professionals in clinical decision-making and in developing more effective injury prevention and management strategies.

Posterior Ankle Impingement

This article is devoted to managing posterior ankle impingement syndrome and its management using endoscopic to arthroscopic surgical instrumentation. The authors explore the critical anatomy, pathogenesis, and clinical examination. Operative techniques, including the approach, and instrumentation used, are outlined. The postoperative protocol is discussed. Finally, a literature review is provided, which also defines known complications.

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.

Dance-Related Foot and Ankle Injuries and Pathologies

Dancers are highly vulnerable to injuries due to high dynamic overload, extreme positions and motions, and excessive use. Increased load at the forefoot with jumping and high-impact lands can cause sesamoiditis and stress fractures of the metatarsals. Significant plantarflexion can lead to posterior joint impingement and flexor hallucis longus tendonitis, whereas forced dorsiflexion can cause anterior joint impingement. Most pathologies can be diagnosed on physical examination and various imaging modalities. Treatment should be tailored to the dancers' needs and should begin with a course of conservative therapy with immobilization, physical therapy, and activity cessation.

Posterior Ankle Impingement Syndrome

Posterior ankle impingement is typically seen in athletes, primarily dancers and soccer players, secondary to dynamic and repetitive push-off maneuvers and forced hyperplantarflexion. Posterior ankle impingement results from chronic, repetitive trauma to the posterior ankle capsule, flexor hallucis longus tendon, and/or os trigonum. It is important to perform a thorough workup by isolating and testing the posterior compartment muscles and obtaining proper imaging with radiographs to identify any osseous abnormalities and MRI to evaluate the soft tissue structures. Nonsurgical treatment includes activity modification, physical therapy, and steroid injections.

The Stieda process of the talus: the anatomical knowledge and clinical significance of an overlooked protrusion

Background

The Stieda process (SP) is an extended lateral tubercle of the posterior process of the talus. Although there are different classifications for SP in the literature, it is essential to know the differential diagnosis of SP from fractures and accessory ossicles. This review aims to classify the SP and to guide the formation, prevalence, etiopathology, symptoms, differential diagnosis, and treatment.

Main body of the abstract

The authors conducted a literature review that lasted up to September 2022 and used the databases PubMed, Web of Science, and Google Scholar to explore the SP of the talus in all of its aspects. Out of 3802 publications, only 34 could be included, and most of them were studies on posterior ankle impingement syndrome (PAIS). The occurrence, prevalence, etiopathology, clinical significance, symptoms, differential diagnosis, and treatment methods of SP were investigated based on the literature. SP is formed by the fusion of a secondary ossification center at the posterolateral side of the talus with an incidence of 12–36.5%. It is frequently observed in males. It causes reduced plantar flexion, impairment in the inversion of the foot, pain, and swelling in the posterior ankle joint, PAIS, and SP fractures after trauma.

Short conclusion

SP can be diagnosed by lateral ankle radiography or MRI in patients complaining of PAIS. The initial treatment of the SP should include reducing inflammation, swelling, pain, and limiting activities. If neither modality affects the patient, surgical treatment will be performed, and SP will be resected until the impingement disappears.

Posterior Ankle Impingement Syndrome Clinical Features Are Not Associated With Imaging Findings in Elite Ballet Dancers and Athletes

OBJECTIVE

To assess the association between clinical features and magnetic resonance imaging (MRI) findings in posterior ankle impingement syndrome (PAIS) and to compare the prevalence of imaging findings between participants with and without a clinical diagnosis of PAIS.

DESIGN

Case-control study.

SETTING

Elite ballet and sport.

PARTICIPANTS

Eighty-two male (54%) and female participants comprising ballet dancers (n = 43), cricket fast bowlers (n = 24), and football (soccer) players (n = 15).

INDEPENDENT VARIABLES

Clinical: posterior ankle pain on body chart, passive plantarflexion pain provocation test. Patient-reported outcome measures: Oslo Sports Trauma Research Center Overuse Injury Questionnaire, Foot and Ankle Ability Measure Sports subscale.

MAIN OUTCOME MEASURES

Imaging findings including posterior ankle bone marrow edema, os trigonum (± bone marrow edema, and increased signal at synchondrosis), Stieda process (± bone marrow edema), talocrural and subtalar joint effusion-synovitis size, flexor hallucis longus tendinopathy, and tenosynovitis identified as present or absent on 3.0-Tesla MRI.

RESULTS

Imaging findings were not associated with posterior ankle pain or a positive ankle plantarflexion pain provocation test. Imaging findings were not associated with patient-reported outcome measures. Imaging findings did not differ between PAIS-positive and PAIS-negative groups. Os trigonum and Stieda process were prevalent despite clinical status.

CONCLUSIONS

The lack of association between imaging findings and clinical features questions the role of imaging in PAIS. Clinicians should rely primarily on clinical assessment in the diagnosis and management of patients with PAIS.

The double posteromedial portals endoscopy for posterior ankle impingement syndrome in athletes

Background

Posterior ankle impingement syndrome (PAIS) may result from flexor hallucis longus tendinopathy, compression of the posterior process of the talus from the presence of an os trigonum, soft-tissue impingement, or a combination of these. Posterior extra-articular endoscopy performed with the patient supine through the double posteromedial portals, with excision of adhesions, excision of the posterior process of the talus or an os trigonum, and decompression of the tendon of the flexor hallucis longus (FHL), can be used in athletes with PAIS.

Methods

Thirty-four athletes with PAIS in whom conservative management had failed underwent posterior ankle endoscopy in the supine position using the double posteromedial portals. The patients were assessed pre- and postoperatively using the American Orthopaedic Foot and Ankle Society hindfoot scale score, the Tegner scale, and the simple visual analogue scale. Time of surgery, return to sports, patient satisfaction, and complications were recorded and analysed. The average length of postoperative follow-up was 26.7 ± 12.6 (range 24 to 72) months.

Results

The mean Tegner activity scale score improved to 9 ± 0.2 postoperatively (p < 0.05), while the mean American Orthopaedic Foot and Ankle Society scale score improved to 96 ± 5.1 (range 87 to 100) postoperatively, with 29 of 34 patients (85.3%) achieving a perfect score of 100 (p < 0.05). The mean time to return to sports was 8.7 ± 0.7 (range 8 to 10) weeks. The complication rate was low, with no superficial wound infections or venous thromboembolism events; only two patients (5.9%) reported pain and tenderness by 3 months after the index procedure.

Conclusion

Posterior ankle endoscopy for the resection of a posterior process of the talus or an os trigonum and decompression of the tendon of FHL is safe and allows excellent outcomes with low morbidity in athletes with PAIS.

Associations between clinical and imaging findings in posterior ankle impingement syndrome: a systematic review

BACKGROUND

Posterior ankle impingement syndrome (PAIS) is a common and debilitating condition, commonly affecting people who participate in activities that involve repetitive ankle plantarflexion. The relationship between clinical and imaging findings in PAIS has not been established.

PURPOSE

To investigate the relationship between clinical and imaging features in PAIS by reviewing the literature comparing symptomatic patients to asymptomatic controls.

MATERIAL AND METHODS

A systematic literature search was performed to identify all English-language articles that compared imaging features in patients diagnosed with PAIS to imaging in an asymptomatic control group.

RESULTS

A total of 8394 articles were evaluated by title and abstract, and 156 articles were read in full text. No articles compared imaging findings to an asymptomatic control group, thus no articles met the inclusion criteria.

CONCLUSION

This systematic review found no published research that compared the imaging findings of people diagnosed with PAIS to asymptomatic people. Until this information is available, imaging features in people with posterior ankle impingement should be interpreted with caution.

Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement: A Meta-analysis

BACKGROUND

Surgical treatment of symptomatic posterior ankle impingement consists of resection of the bony impediment and/or debridement of soft tissue. Historically, open techniques were used to perform surgery with good results. However, since the introduction of endoscopic techniques, advantages attributed to these techniques are shorter recovery time, fewer complications, and less pain.

PURPOSE

The primary purpose was to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcome (American Orthopaedic Foot & Ankle Society [AOFAS] score). The secondary aim was to determine differences in return to full activity, patient satisfaction, and complications.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE (Classic), and CINAHL databases were searched. Publication characteristics, patient characteristics, surgical techniques, AOFAS scores, time to return to full activity, patient satisfaction, and complication rates were extracted. The AOFAS score was the primary outcome measure. Data were synthesized, and continuous outcome measures (postoperative AOFAS score and time to return to full activity) were pooled using a random-effects inverse variance method. Random-effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients who were satisfied and who experienced complications.

RESULTS

A total of 32 studies were included in this review. No statistically significant difference was found in postoperative AOFAS scores between open surgery (88.0; 95% CI, 82.1-94.4) and endoscopic surgery (94.4; 95% CI, 93.1-95.7). There was no difference in the proportion of patients who rated their satisfaction as good or excellent, 0.91 (95% CI, 0.86-0.96) versus 0.86 (95% CI, 0.79-0.94), respectively. No significant difference in time to return to activity was found, 10.8 weeks (95% CI, 7.4-15.9 weeks) versus 8.9 weeks (95% CI, 7.6-10.4 weeks), respectively. Pooled proportions of patients with postoperative complications were 0.15 (95% CI, 0.11-0.19) for open surgery versus 0.08 (95% CI, 0.05-0.14) for endoscopic surgery. Without the poor-quality studies, this difference was statistically significant for both total and minor complications, 0.24 (95% CI, 0.14-0.35) versus 0.02 (95% CI, 0.00-0.06) and 0.14 (95% CI, 0.09-0.20) versus 0.03 (95% CI, 0.01-0.05), respectively.

CONCLUSION

We found no statistically significant difference in postoperative AOFAS scores, patient satisfaction, and return to preinjury level of activity between open and endoscopic techniques. The proportion of patients who experienced a minor complication was significantly lower with endoscopic treatment when studies of poor methodological quality were excluded.

Anterior ankle impingment syndrome is less frequent, but associated with a longer absence and higher re-injury rate compared to posterior syndrome: a prospective cohort study of 6754 male professional soccer players

PURPOSE

To study the epidemiology and return to play characteristics of anterior and posterior ankle impingement syndromes (AAIS and PAIS) over 18 consecutive seasons in male professional soccer players.

METHODS

Between the 2001-2002 and 2018-2019 seasons, 120 European soccer teams were followed prospectively for various seasons. Time loss injuries and player exposures were recorded individually in 6754 unique players. Injury incidence and burden were reported as the number of injuries and days absence per 1000 h with 95% confidence intervals (CIs). Injury severity was reported as median absence in days with the interquartile range (IQR).

RESULTS

Out of 25,462 reported injuries, 93 (0.4%) were diagnosed as AAIS (38%) or PAIS (62%) in 77 players. AAIS and PAIS were similar regarding injury characteristics except for a greater proportion of AAIS having a gradual onset (69% vs.47%; P = 0.03) and being re-injuries (31% vs. 9%; P = 0.01). Impingement syndromes resulted in an overall incidence of 0.03 injuries (95% CI 0.02-0.03) per 1000 h and an injury burden of 0.4 absence days per 1000 h. PAIS incidence was significantly higher than that for AAIS [0.02 (95% CI 0.002-0.03) vs. 0.01 (95% CI 0.005-0.01) injuries per 1000 h (RR = 1.7). The absence was significantly longer in AAIS than in PAIS [10 (22) vs. 6 (11) days; P = 0.023]. Impingement syndromes that presented with a gradual onset had longer absences in comparison to impingement with an acute onset [8 (22) vs. 5 (11) days; P = 0.014]. Match play was associated with a higher incidence and greater injury burden than training: 0.08 vs. 0.02 injuries per 1000 h (RR 4.7), respectively, and 0.9 vs. 0.3 days absence per 1000 h (RR 2.5).

CONCLUSION

Ankle injuries are frequent in men's professional soccer and ankle impingement is increasingly recognized as a common source of pain, limited range of motion, and potential time loss. In our study, ankle impingement was the cause of time loss in less than 0.5% of all injuries. PAIS was more frequently reported than AAIS, but AAIS was associated with more absence days and a higher re-injury rate than PAIS. The findings in this study can assist the physician in best practice management on ankle impingment syndromes in professional football.

LEVEL OF EVIDENCE

II.

Magnetic resonance imaging findings associated with posterior ankle impingement syndrome are prevalent in elite ballet dancers and athletes

OBJECTIVE

To report the prevalence of MRI features commonly associated with posterior ankle impingement syndrome in elite ballet dancers and athletes and to compare findings between groups.

MATERIALS AND METHODS

Thirty-eight professional ballet dancers (47.4% women) were age- and sex-matched to 38 elite soccer or cricket fast bowler athletes. All participants were training, playing, and performing at full workload and underwent 3.0-T standardised magnetic resonance imaging of one ankle. De-identified images were assessed by one senior musculoskeletal radiologist for findings associated with posterior ankle impingement syndrome (os trigonum, Stieda process, posterior talocrural and subtalar joint effusion-synovitis, flexor hallucis longus tendon pathology and tenosynovitis, and posterior ankle bone marrow oedema). Imaging scoring reliability testing was performed.

RESULTS

Posterior talocrural effusion-synovitis (90.8%) and subtalar joint effusion-synovitis (93.4%) were common in both groups, as well as the presence of either an os trigonum or Stieda process (61.8%). Athletes had a higher prevalence of either os trigonum or Stieda process than dancers (74%, 50% respectively, P = 0.03). Male athletes had a higher prevalence of either os trigonum or Stieda process than male dancers (90%, 50% respectively, P = 0.01), or female athletes (56%, P = 0.02). Posterior subtalar joint effusion-synovitis size was larger in dancers than athletes (P = 0.02). Male and female dancers had similar imaging findings. There was at least moderate interobserver and intraobserver agreement for most MRI findings.

CONCLUSION

Imaging features associated with posterior impingement were prevalent in all groups. The high prevalence of os trigonum or Stieda process in male athletes suggests that this is a typical finding in this population.

Endoscopy for the treatment of posterior ankle impact syndrome: Learning curve

BACKGROUND

This study aimed to demonstrate our learning curve of endoscopy for the treatment of Posterior Ankle Impact Syndrome (PAIS), assessing the operative time and evolution of the outcomes.

METHODS

We conducted a retrospective review of 39 patients submitted to endoscopic treatment by a single surgeon over a period of ten years. We divided the study population into four blocks of ten consecutive patients and compared the mean operative time and outcomes between the four blocks. For the learning curve model, we performed linear regression analysis and logarithmic transformation.

RESULTS

We found a decrease in the surgery duration over time (P = .0273). All patients had an improvement in the AOFAS Scale (P < .0001), regardless of the group (P = .07). The learning rate was estimated at 83%, indicating a 17% reduction of the operative time as the cumulative cases doubled.

CONCLUSIONS

This study showed a decrease in the operative time of the posterior ankle endoscopy over the years, with an estimated learning rate of 83%. The outcomes and incidence of complications showed no relationship with operative time and the number of cases operated.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Treatment of Posterior Ankle Impingement Syndrome: Mid-Term Clinical Results and a Learning Curve

Purpose

To report mid-term clinical results of posterior ankle arthroscopy in the treatment of posterior ankle impingement syndrome (PAIS) and to assess the learning curve and its influence on the results.

Methods

This was a retrospective evaluation of the clinical outcomes of posterior ankle arthroscopy and its learning curve in a series of patients with PAIS. Demographic and clinical data, surgical time, the American Orthopaedic Foot Ankle Society (AOFAS) ankle/hindfoot scores, and time to resumption of sports were recorded.

Results

Fifty-nine patients with 72 posterior ankle arthroscopies were evaluated at a mean follow-up period of 60 months (24-133 months). Causes of PAIS were an os trigonum (50), a large posterior talar process (14), and soft-tissue impingement (8). There were 29 male and 30 female patients. The average age was 21.8 years (12-74 years). The average preoperative AOFAS score improved significantly from 79.6 to 97.6 postoperatively (P < .0001). The average time taken to resume training was 5.3 weeks, and the time to return to a competitive condition was 13.4 weeks. The times to resumption of training were shorter in elite athletes than local competitive athletes. The learning curve of the posterior ankle arthroscopy was detected and determined by a logarithmic trendline and moving averages. An experience of 26 cases was required to be proficient in posterior arthroscopies. The postoperative AOFAS scores were not statistically different between the initial and the latest 10 series each.

Conclusions

The mid-term follow-up results of endoscopic treatment for the PAIS were good, with a high success rate in returning to sports activities. Although a learning curve effect was detected in our series of arthroscopic treatment for the PAIS due to os trigonum, a low volume of experience did not affect the results.

Level of Evidence

Level IV, therapeutic case series.

Ankle Impingement: A Critical Analysis Review

Ankle impingement presents with painful and limited range of motion with dorsiflexion or plantar flexion, originating from pathological contact between bone and/or soft-tissue structures. Diagnosis is made primarily through clinical examination with adjunct radiographs and magnetic resonance imaging, with care taken to rule out a plethora of similarly presenting pathologies. Arthroscopic surgical approaches bring satisfactory short, mid, and long-term outcomes, with the current body of evidence dominated by Level-IV studies. Minimally invasive techniques offer improvements in time to return to play and complication rates relative to open approaches. Recent advances in the arthroscopic management of ankle impingement include long-term outcome studies, novel prognostic classification systems, and strategies for concomitant lesion management.

Posterior Ankle Decompression With Os Trigonum or Stieda Process Resection in Dancers: Case Series Report and Review of the Literature

This case series reports the outcome of posterior ankle decompression and os trigonum or Stieda process resection utilizing an open posterolateral approach in 54 professional, pre-professional, and dedicated recreational dancers. All procedures were performed by a single surgeon at the same facility between 2008 and 2018. The surgical technique is described in detail. Data related to results of the surgery were gathered via follow-up questionnaire and verified by referencing the patients' medical records. Outcomes were self-assessed in terms of categories ranging from excellent through moderate to poor. Eighty-nine percent of the dancers (N = 48 of 54) chose excellent or good, 11% (N = 6) chose moderate, and none selected poor. These results were compared with those achieved in 17 previous studies reporting the use of both open (posterolateral and posteromedial) and arthroscopic/endoscopic techniques in dancers. This comparison found similarly favorable reported outcomes, but also great variation in methodology for determining patient reported outcomes (PROs). While the preferred surgical technique for posterior ankle decompression remains controversial, the open posterolateral approach utilized in this series resulted in high expectation of return to dance with minimal complications. The need for a dancer-specific PRO tool is discussed.

Chronic Fracture of the Posteromedial Tubercle of the Talus Masquerading as Os Trigonum Syndrome

Posterior ankle impingement syndrome (PAIS) can be caused by osseous pathology from the posterior aspect of the talus. The commonest cause is an os trigonum, an accessory ossicle arising from the lateral tubercle of the posterior talus. We have observed cases where the osseous impingement is due to a chronic fracture nonunion of the medial tubercle of the posterior talus with unique symptoms, differentiating this clinical syndrome from the more common os trigonum syndrome. These can be readily overlooked on imaging and confused with an often coexisting os trigonum. Awareness of these lesions is paramount to ensure appropriate management and safe surgery. We describe a series of patients presenting to the senior author with this clinical syndrome, discuss its unique clinical and radiological features, and describe our surgical technique.

Causes of delayed diagnosis of posterior ankle impingement in the pediatric and adolescent population

PURPOSE

The purpose of this study was to identify and characterize various causes of delay in the diagnosis of posterior ankle impingement syndrome (PAIS) in pediatric patients.

METHODS

IRB approved prospective study of patients under 18 years who underwent arthroscopic surgery for the diagnosis of posterior ankle impingement after failed conservative treatment at a tertiary children's hospital. Radiographic findings were compared with an age-matched control group. Descriptive and inferential statistics were employed.

RESULTS

47 patients (61 ankles), mean age 13 years, had an average 14 months delay in diagnosis of PAIS from the initial presentation. 33 (70%) patients had seen multiple medical providers and given other diagnoses. 9 (19%) patients participated in ballet or soccer, and 16 (34%) patients had unrelated associated foot and ankle diagnoses. 25 (41%) of 61 ankles did not have pain on forced plantar flexion; all 61(100%) ankles had tenderness to palpation over the posterior ankle joint line. Radiographs were reported to be normal in 37/52 (71%) ankles, while MRI report did not mention the diagnosis in 20/41 (49%) studies. There was a significant difference in the MRI findings in the patient population when compared to the control group. Indication for surgery was failed conservative treatment. All 61 ankles had posterior ankle impingement pathology confirmed visually during arthroscopy. At average 15 months follow-up, there was significant improvement pre- to post-operatively (p<0.001) for both pain VAS (6.9-0.9) and AOFAS ankle-hindfoot scores (65-94).

CONCLUSION

Multiple clinical and imaging factors can lead to delayed diagnosis of posterior ankle impingement. An increased awareness about the features of PAIS is needed amongst medical providers involved in treating young patients.

Role of Arthroscopy in Various Ankle Disorders

INTRODUCTION

Ankle arthroscopy has come a long way since it was thought, it is not feasible because of tight joint and anatomical characteristics of ankle joint. The same anatomical features like capsular attachment and safe accessory portals are used to access the whole joint even with a rigid arthroscope. Ankle distraction method was routinely used to access the anterior ankle. However, nowadays, anterior arthroscopy is done in dorsiflexion as this increases the anterior ankle joint volume, and thereby easy access to various anatomical structures. On the other hand, intermittent traction is used to access the posterior ankle. Initially used as a diagnostic tool, ankle arthroscopy is now used extensively as a therapeutic and reconstruction tool. New evidence is published for all inside ligament reconstructions, effective management of impingement syndromes, and osteochondral lesions. The indications are being extended to fracture management and arthrodesis.

METHODOLOGY

This narrative review was performed following a literature search in the Pubmed database and Medline using the following keywords: ankle arthroscopy, portals, ankle OCD, functional outcome. Related articles were then reviewed.

CONCLUSION

Complications rate is reduced with a better understanding of the relative anatomy of surrounding neurovascular structures and tendons with regard to the position of ankle joint. This review on ankle arthroscopy focuses on anatomy, indications, and complications. Ankle arthroscopy is a safe and elegant tool as any other joint arthroscopy.

Surgical Outcomes of Os Trigonum Syndrome in Dancers: A Case Series

Background

Management of ankle pain in dancers can be challenging because of the repetitive stress and complex demands placed on this region. Despite the prevalence of ankle injuries in this population, literature on surgical outcomes and return to dance is limited.

Purpose

To retrospectively evaluate the efficacy and functional outcomes after surgical excision of a symptomatic os trigonum in dancers.

Study Design

Case series; Level of evidence, 4.

Methods

Between June 2006 and June 2016, a total of 44 dancers underwent surgical excision of a symptomatic os trigonum at a single institution and by a single surgeon. All patients presented with symptoms of posterior ankle impingement syndrome and subsequently failed nonsurgical treatment. Clinical analysis was conducted using various pre- and postoperative patient-reported outcome questionnaires, including the Veterans RAND 12-Item Health Survey (VR-12), Foot Function Index-Revised (FFI-R), and visual analog scale (VAS) for pain, as well as subjective patient satisfaction.

Results

A total of 44 patients (54 ankles; mean age, 18.2 years) were retrospectively evaluated at a mean follow-up of 33.4 months. The VR-12 Physical Health score improved from a mean score of 37.8 ± 11.9 to 51.2 ± 10.5 (P < .001). The cumulative FFI-R score improved from 46.45 ± 13.8 to 31.2 ± 9.7 (P = .044), with the subcategory of "activity limitation" representing the highest-scoring FFI-R subcategory at 65.28 ± 13.4 preoperatively and improving to 34.47 ± 12.4 at follow-up (P < .001). The mean VAS score for subjective pain improved significantly from 5.39 ± 2.84 to 1.73 ± 2.10 (P < .00044).

Conclusion

Overall, the findings of the present study demonstrate that dancers of varying style and level improved significantly according to various clinical measures. Patients included in this study reported that they returned to their previous level of dance upon completion of physical therapy and maintained thriving postoperative careers, which for several meant dancing at the professional level.

Endoscopic Treatment of Posterior Ankle Impingement Secondary to Os Trigonum in Recreational Athletes

Background:

The os trigonum (OT)—the most common accessory bone of the foot—although usually asymptomatic, may cause posterior ankle impingement syndrome (PAIS), which may be a severely debilitating problem for recreational or competitive athletes. The aim of the present study was to evaluate effectiveness of posterior ankle arthroscopy and to assess the outcome in the treatment of PAIS secondary to OT impingement or OT fractures within a group of young athletes and their return to previous sports level.

Methods:

From 2011 to 2018, a retrospective review of 81 recreational athletes of mean age 27.8 years was performed. All patients were diagnosed with PAIS due to OT pathology and were operated on endoscopically with resection of the OT. Pre- and postoperative clinical evaluation were performed at 3 months, 1 year, and 2 years based on visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the Foot & Ankle Disability Index (FADI) scores, in a follow-up of at least 2 years.

Results:

VAS score was significantly improved from an average of 7.5 (5-9) preoperatively to 1.9 (1-3) at 3 months postoperatively and to 0.6 (0-2) and 0.3 (0 -1) at 1 and 2 years postoperatively. Ankle ROM was significantly improved from an average of 24.8 (10-35) preoperatively to 58.0 (50-65) at 3 months postoperatively and to 64.0 (50-65) at 1 year and 64.7 (60-65) at 2 years postoperatively. AOFAS and FADI scores were significantly improved from 39.4 (18-55) and 49.7 (42.3-62.5) preoperatively to 85.2 (74-89) and 87.3 (81.7-88.5) postoperatively at 3 months to 97.7 (85-100) and 97.9 (93.3-100) postoperatively at 1 year, respectively (P < .001). Only 5 patients dropped to a lower activity level. There were 5 complications (4 transient).

Conclusion:

Endoscopic treatment of PAIS due to OT pathology demonstrated excellent results. Posterior ankle arthroscopy was an effective treatment and allowed for a prompt return to a high activity level of their athletic performance.

Level of Evidence:

Level IV, therapeutic study / retrospective case series.

Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role?

BACKGROUND

Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.

OBJECTIVE

To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.

MATERIALS AND METHODS

Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.

RESULTS

Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).

CONCLUSION

PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.

A literature review of the complications following anterior and posterior ankle arthroscopy

INTRODUCTION

There is a wealth of studies reporting the complications of anterior and posterior ankle arthroscopy. The aim of this study is to summarise and review the complication rate(s) associated with both anterior and posterior ankle arthroscopy, as described in the literature.

MATERIAL AND METHODS

The authors carried out a comprehensive review of the literature up until March 2018. An extensive search of the MEDLINE, Cochrane library and EMBASE databases was undertaken using the following keywords: complications of ankle arthroscopy, anterior ankle arthroscopy, and posterior ankle arthroscopy.

RESULTS

A total of 107 papers were identified and 55 were deemed appropriate for analysis. The overall complication rate of ankle arthroscopy was found to be between 3.4- 9%.

CONCLUSIONS

No life threatening complications were identified in the literature with both anterior and posterior ankle arthroscopy. The commonest complication after anterior and posterior ankle arthroscopy is superficial peroneal nerve injury and temporary Achilles tendon tightness, respectively.

Ankle Injuries in Dancers

The term dance encompasses a broad range of different styles; much of the orthopaedic literature has focused on ballet dancers. Injury is common in dancers at all levels, and many serious dancers sustain multiple injuries as they progress through their career. Foot and ankle injuries are among the most common injuries experienced by dancers. These injuries include those that are specific to dancers because of the unique physical maneuvers required to effectively perform, but they can also include common injuries that may require relatively different treatment because of the physical demands of the dancer. Os trigonum syndrome and flexor hallucis longus tenosynovitis generally fall into the former category as they are injuries that are more prevalent in dancers due to the extreme plantarflexion involved in dancing, especially ballet, and the relative demand placed on the toe flexors, most notably the flexor hallucis longus. On the other hand, anterior ankle impingement occurs both in dancers and in the general public. In many cases, a team approach to treatment with knowledgeable physical therapists can obviate the need for surgical treatment. If surgical treatment proves necessary, good results can be achieved with sound surgical technique and a well thought-out rehabilitation program.

A Preliminary Study of Ankle Single Photon Emission Computed Tomography/Computed Tomography in Patients With Bony Impingement Syndrome: Association With the Visual Analogue Scale Pain Score

Both osteoarthritis and impingement syndrome are the disorders commonly observed in sports medicine. However, failure in pain alleviation by surgical intervention introduces challenges in the diagnosis and decision-making for orthopedists. Hybrid single photon emission computed tomography/computed tomography (SPECT/CT) provides both functional and structural information of ankle pathology. The purpose of this retrospective study was to evaluate whether bone tracer uptake by ankle SPECT/CT is related to the lesion type and visual analog scale (VAS) pain score for patients with osteoarthritis and bony impingement. Fifty individuals with chronic ankle pain who underwent pretreatment ankle SPECT/CT were included in the current study. The median follow-up period was 2.5 (range 1.8 to 3.2) years. The lesion types were categorized by the positions of anatomical changes and bone tracer uptake. The VAS pain score was recorded 2 weeks before and 1.5 year after surgical intervention. Twenty-nine (58%) of 50 patients had osseous impingement. Among them, 16 (55.2%), 4 (13.8%), and 9 (31%) patients had anterior, posterior, and both types of ankle impingement, respectively. The uptake grade of bone tracer was significantly related to the lesion type of ankle impingement (p < .001). The VAS pain score was significantly correlated with bone tracer uptake before treatment (p < .001). Bone tracer uptake was related to the lesion type of impingement detected by SPECT/CT and was confirmed by surgical findings. The VAS pain score was significantly correlated with the bone tracer uptake. Preoperative ankle SPECT/CT may be helpful to clinically correlate the VAS pain score in the pre- and postsurgical periods for patients with osteoarthritis and bony impingement syndrome.

Evaluation of the Prevalence of Os Trigonum and Talus Osteochondral Lesions in Ankle Magnetic Resonance Imaging of Patients With Ankle Impingement Syndrome

The prevalence of os trigonum and osteochondral lesions of talus (OCLT) have been presented in different prevalences among different groups in the literature for the patients with ankle impingement syndrome. Our main objective in the study was to determine the possible relationship between the impingement syndrome and the prevalence of os trigonum and OCLT in specific groups. The presence of anterior ankle impingement syndrome (AAIS), posterior ankle impingement syndrome (PAIS), os trigonum, OCLT, and the location of OCLT were evaluated in a blinded manner on magnetic resonance imaging from patients clinically considered to be diagnosed with ankle impingement syndrome from January 2014 to July 2017. The patients were separated into specific groups according to the confirmation of their clinical diagnosis of ankle impingement syndrome on magnetic resonance imaging . A total of 333 patients were included. The prevalence of os trigonum was found to be 1.3% in patients with PAIS(-) AAIS(+), 7.7% in patients with PAIS(-) AAIS(-), 63.3% in patients with PAIS(+) AAIS(-), and 81.1% in patients with PAIS(+) AAIS(+) (p < .001). The prevalence of OCLT was found to be 41.3% in patients with PAIS(-) AAIS(+), 23.1% in patients with PAIS(-) AAIS(-), 18.3% in patients with PAIS(+) AAIS(-), and 27% in patients with PAIS(+) AAIS(+) (p= .005). Our study showed that, for patients with isolated PAIS and AAIS combined with PAIS, the prevalence of os trigonum was 63.3% and 81.1%, respectively, which is more common than previously reported. For patients with isolated AAIS and PAIS, the prevalence of OCLT was 41.3% and 18.3%, respectively. Of the OCLTs combined with ankle impingement syndromes, 87.1% were medially located.

Management of foot and ankle injuries in pediatric and adolescent athletes: a narrative review

In this review, we focus on the treatment of injuries to the foot and ankle in the adolescent athlete. While many injuries in the adolescent foot and ankle are similar to or overlap with their counterparts in the adult population, the anatomy of the adolescent ankle, especially the presence of growth plates, results in different injury patterns in many cases and calls for specific management approaches. We discuss the unique anatomy of the pediatric patient as well as the diagnostic evaluation and treatment of common injuries in the young athlete.

Quantification of the Learning Curve for Arthroscopic Os Trigonum Excision

The purpose of the present study was to quantify the learning curve for arthroscopic os trigonum excision using the log-linear model. Twenty-three consecutive feet underwent arthroscopic os trigonum excision and release of the flexor hallucis longus. The required time from the beginning of shaving of the soft tissue until completion of os trigonum excision and release of the flexor hallucis longus (van Dijk time) was recorded. Regression analysis was applied to predict the required time on the basis of the cumulative case volume after logarithmic transformation of both statistics. The mean required time was 35.2 (range 9 to 90) minutes. After logarithmic transformation, a significant linear correlation was observed between the required time and the cumulative case volume (p = .0043). The best-fit linear equation was calculated as log (y, estimated required time)  = -0.41 log (x, case volume) + 1.86, resulting in an estimated learning rate of 75.3% (= 2^-0.41). The results showed an overall time reduction in arthroscopic os trigonum excision in support of a learning curve effect with an ~75% learning rate, indicating that the required time for arthroscopic os trigonum excision can decrease by ≤25% when the cumulative volume of cases has doubled.

Endoscopic treatment for posterior ankle impingement: high patient satisfaction and low recurrence rate at long-term follow-up

Objectives

Good short-term outcomes have been described for endoscopic treatment of posterior ankle impingement. However, long-term outcome is unknown. The aim of this study is to determine the long-term patient satisfaction after endoscopic treatment and evaluate the recurrence rate of posterior ankle impingement. In addition, the aim of this study is to identify factors associated with favourable long-term outcome.

Methods

A consecutive series of patients treated endoscopically for posterior ankle impingement between 2000 and 2011 in the Academic Medical Centre in Amsterdam were retrospectively reviewed. Primary outcome was patient satisfaction. Secondary outcome measures were function, pain, recurrence rate and Foot Ankle Outcome Scores. In addition, factors associated with long-term outcome were identified.

Results

Two-hundred and three patients with 5–15 years of follow-up were included. Median satisfaction score was 8/10 and for 9/10 for function . Patients had no pain at follow-up. Outcome was similar for different types of impingement and type or level of sport participation. Symptoms recurred in 5% of the patients. In a multivariable analysis, additional flexor hallucis longus (FHL) tendinopathy was associated with lower satisfaction and a higher recurrence rate.

Conclusion

Long-term outcome of endoscopic treatment for posterior ankle impingement demonstrated good results, with high patient satisfaction, good functional outcome scores and a low rate of recurrence for all types of posterior ankle impingement. Type and level of sports did not influence outcome. Only the presence of FHL tendinopathy was associated with lower satisfaction and a higher recurrence rate.

Level of evidence

Level IV.

Endoscopic management of posterior ankle impingement syndrome-A case report

Posterior ankle impingement syndrome (PAIS) is a clinical condition characterized by pain in the posterior aspect of ankle on performing activities requiring extreme plantar flexion. The impinging lesion could be bony and/or soft tissue. The operative treatment aims at removing the impinging lesion either by open or endoscopic surgery. The later has been shown to have benefits of early return to sports, better cosmesis, less wound complications. We report a case of a 19 year old footballer with PAIS secondary to Os Trigonum. The patient complained of pain on performing running and on kicking football. Conservative treatment in form of NSAIDS, rest, physiotherapy modality use could not ensure pain free return to sports.The patient was managed using endoscopic excision of the Os Trigonum followed by aggressive rehabilitation. The patient returned to competitive football at the end of 14 weeks after surgery. There were no wound complications. AAFOS score had changed from 73 to 100 and NPS scale showed pain score reduce from 7/10 to 1/10. We concluded that endoscopic management of PAIS to remove the impinging lesion is a minimally invasive technique that ensures early return to sports, good cosmesis, less risk of wound complications and good patient satisfaction.

MR Imaging of Impingement and Entrapment Syndromes of the Foot and Ankle

Impingement is a clinical syndrome of chronic pain and restricted range of movement caused by compression of abnormal bone or soft tissue within the ankle joint. It usually occurs following a sprain injury or repetitive microtrauma causing haemorrhage, synovial hyperplasia, and abnormal soft tissue interposition within the joint. MR imaging is particularly valuable in being able to detect not only the soft tissue and osseous abnormalities involved in these syndromes, but also a wide variety of other potential causes of ankle pain and instability that also may need to be addressed clinically.

Treatment of hindfoot and ankle pathologies with posterior arthroscopic techniques

The two-portal hindfoot arthroscopy is an effective procedure enabling direct visualisation of posterior ankle pathology with low invasiveness.

An important stage of the hindfoot endoscopy is localisation of the flexor hallucis longus (FHL) tendon to protect the neurovascular bundle which is located just medial to it.

Posterior ankle impingement syndrome and FHL tenosynovitis are common causes of posterior ankle pain and frequently occur together.

Posteriorly localised talar osteochondral lesions, Achilles tendon disorders, osteoarthritis, talar bone cysts and talar fractures are among the other pathologies that can be treated with hindfoot arthroscopy.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160055. Originally published online at www.efortopenreviews.org

Endoscopic Versus Open Excision of Os Trigonum for the Treatment of Posterior Ankle Impingement Syndrome in an Athletic Population: A Randomized Controlled Study With 5-Year Follow-up

BACKGROUND

Open surgical excision of the os trigonum has been the traditional treatment for posterior ankle impingement syndrome (PAIS). However, the endoscopic excision has recently become quite popular. Purpose/Hypothesis: The purpose of our study was to compare the results of endoscopic versus open excision of a symptomatic os trigonum for the treatment of PAIS in an athletic population. It was hypothesized that the endoscopic technique would be superior to the open technique regarding functional outcomes, pain, and time to return to training and the previous sports level.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

From 2008 to 2011, 52 athletes underwent a symptomatic os trigonum excision; 26 athletes had an open procedure (group A) and 26 had an endoscopic procedure (group B). The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the Visual Analog Score-Foot and Ankle (VAS-FA) were obtained, and the time to return to training and to previous sports level was recorded.

RESULTS

Patients in group B appeared to have significant improvement of AOFAS hindfoot score compared with those in group A ( P < .05), whereas no statistical significance was found for the postoperative VAS-FA scores between the 2 groups. The mean ± SD time to return to training was 9.58 ± 3.98 weeks for group A and 4.58 ± 1.47 weeks for group B ( P < .001). The time to return to previous sports level was 11.54 ± 3.89 weeks for group A and 7.12 ± 2.25 weeks for group B ( P < .001). The overall complication rate was 23% for group A (6 cases) and 3.8% for group B (1 case).

CONCLUSION

Both the open procedure and the endoscopic approach yielded acceptable outcomes in terms of function and pain. However, complication rates were remarkably lower with endoscopic treatment, and the time to return to full activities was much shorter. Endoscopic excision of the os trigonum is a safe and effective treatment option for athletes who require early return to their previous sports level.

Os Trigonum Excision in Dancers via an Open Posteromedial Approach

BACKGROUND

An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Options for operative excision include open excision, subtalar arthroscopy, and posterior endoscopy. The purpose of this paper was to present a series of dancers who underwent excision of a symptomatic os trigonum via an open posteromedial approach.

METHODS

This study is a retrospective case series of 40 ankles in 38 dancers who underwent os trigonum excision via an open posteromedial approach with FHL tenolysis between 2000 and 2013. All patients were interviewed and charts retrospectively analyzed. Collected variables included pre- and postoperative pain level, time to return to dance, and subjective satisfaction. The average age was 19.2 years; ballet was the primary dance form in 36 (95%) of patient-cases. Eight (20%) of the patient-cases were professional dancers, and 30 (75%) were students or preprofessional dancers.

RESULTS

Average preoperative pain level was 7.7/10, which decreased to 0.6/10 postoperatively. Seventeen (42.5%) experienced concurrent preoperation-associated FHL symptomatology, all of whom experienced relief postoperatively. The average time to return to dance was 7.9 weeks, and time to pain-free dance was 17.7 weeks. Of the 37 patient-cases desiring to return to dance, 35 (94.6%) returned to their preoperative level of dance. There were no neurovascular or other major complications. Four (10%) had minor wound complications that resolved, and 38 cases (95%) considered the procedure a success.

CONCLUSION

Open posteromedial excision of an os trigonum in dancers provided satisfactory pain relief, return to dance, and complication rates compared to other approaches, and allowed for identifying and treating any associated FHL pathology.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes

Objective

To describe a clinical treatment algorithm for posterior ankle impingement (PAI) syndrome in professional football players.

Material and methods

A case series of 26 elite professional football players diagnosed and treated for posterior ankle impingement syndrome were included for the study. All of the athletes received conservative treatment with physical therapy modalities initially. If the first line medical treatment and rehabilitation was ineffective to alleviate the symptoms, ultrasound-guided corticosteroid injection was proposed and thereafter the patients underwent posterior ankle arthroscopy if the complaints are still unresolved. The pain scores (AOFAS, VAS), and time to return to play were the main outcome measures.

Results

The complaints of 18 (69.2%) players were subsided with non-surgical treatment whereas three of acute cases and five of the chronic cases did not respond to medical treatment and arthroscopic surgery was performed for eight athletes. Eighteen players returned to training for a mean time of 36.3 days (24–42 days) after conservative treatment. The patients who underwent arthroscopic surgery returned to training for a mean time of 49.8 days (42–56 days) after the surgery. All athletes returned to their previous level of competition after treatment without any complications or recurrence in a mean follow-up 36.5 months (19–77 months).

Conclusion

Non-surgical treatment modalities were effective in 2/3 of posterior ankle impingement syndrome in elite football players. On the other hand, posterior ankle arthroscopy is safe and effective treatment option for posterior ankle impingement syndrome if the conservative treatment fails.

Level of evidence

Level IV, Therapeutic study

Posterior ankle impingement syndrome: A systematic four-stage approach

Posterior ankle impingement syndrome (PAIS) is a common injury in athletes engaging in repetitive plantarflexion, particularly ballet dancers and soccer players. Despite the increase in popularity of the posterior two-portal hindfoot approach, concerns with the technique remain, including; the technical difficulty, relatively steep learning curve, and difficulty performing simultaneous anterior ankle arthroscopy. The purpose of the current literature review is to provide comprehensive knowledge about PAIS, and to describe a systematic four-stage approach of the posterior two-portal arthroscopy. The etiology, clinical presentation, diagnostic strategies are first introduced followed by options in conservative and surgical management. A detailed systematic approach to posterior hindfoot arthroscopy is then described. This technique allows for systematic review of the anatomic structures and treatment of the bony and/or soft tissue lesions in four regions of interest in the hindfoot (superolateral, superomedial, inferomedial, and inferolateral). The review then discusses biological adjuncts and postoperative rehabilitation and ends with a discussion on the most recent clinical outcomes after posterior hindfoot arthroscopy for PAIS. Although clinical evidence suggests high success rates following posterior hindfoot arthroscopy in the short- and mid-term it may be limited in the pathology that can be addressed due to the technical skills required, but the systematic four-stage approach of the posterior two-portal arthroscopy may improve upon this problem.

Arthroscopic Approach to Posterior Ankle Impingement

Posterior ankle pain can occur for many reasons. If it is produced by forced plantarflexion of the foot, it is often a result of impingement from an enlarged posterior talar process or an os trigonum. This condition may present in an acute or chronic state. Management is initially nonoperative, but surgical treatments are available. This condition is often seen in athletes, so procedures that limit surgical trauma and allow early return to activity are ideal. An arthroscopic approach for this disorder produces good outcomes with limited complications. Understanding the indications, local anatomy, and surgical technique, allows good, reproducible outcomes.

Ankle impingement

Ankle impingement is a syndrome that encompasses a wide range of anterior and posterior joint pathology involving both osseous and soft tissue abnormalities. In this review, the etiology, pathoanatomy, diagnostic workup, and treatment options for both anterior and posterior ankle impingement syndromes are discussed.

Combined Anterior and Dual Posterolateral Approaches for Ankle Arthroscopy for Posterior and Anterior Ankle Impingement Syndrome

BACKGROUND

We introduce a novel method of combining the standard anteromedial and anterolateral approaches and dual posterolateral approaches in the arthroscopic treatment of posterior and anterior ankle impingement syndrome and compare the postoperative outcomes with conventional anteromedial/anterolateral and posteromedial/posterolateral approaches.

METHODS

From January 2013 to January 2015, we treated 28 patients with posterior and anterior ankle impingement syndrome by arthroscopy. The patients were divided into the conventional group (n = 13) and the modified group (n = 15) according to the surgical approaches used in the operation. Preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score, range of ankle motion, and operation time were recorded. The average follow-up was 16 months (range 6-24 months).

RESULTS

Posterior and anterior ankle impingement syndrome was confirmed arthroscopically in all patients. After the operation, the range of ankle motion in all patients was restored. There was no significant difference in postoperative AOFAS score, VAS score, dorsiflexion, and plantarflexion between the conventional group and the modified group. Moreover, the operation time was significantly reduced in the modified group compared with the conventional group. There was no recurrence of osteophyte and no complications such as infection, neurovascular injury, or delayed healing of surgical incision in the modified group.

CONCLUSIONS

Dual posterolateral approaches combined with standard anteromedial and anterolateral approaches was a novel method for arthroscopic treatment of posterior and anterior ankle impingement syndrome. It proved to be safe and effective, and significantly reduced the operation time. Reposition, repeated prep and drape, and limb distraction were avoided.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Foot and Ankle Injuries in Professional Soccer Players: Diagnosis, Treatment, and Expectations

Soccer is one of the most popular sports in the world. It has undergone many changes in recent years, mainly because of increased physical demands, and this has led to an increased injury risk. Direct contact accounts for half of all injuries in both indoor and outdoor soccer and ankle sprains are the most common foot and ankle injury. There is a spectrum of foot and ankle injuries and their treatment should be individualized in these high-demand patients. An injury prevention program is also important and should the players, the trainer, responsible physician, and physical therapists.