Clinical Evaluation and Treatment of Posterior Impingement in Dancers

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.].

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 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.

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.

What Is the Efficacy of a Nonoperative Program Including a Specific Stretching Protocol for Flexor Hallucis Longus Tendonitis?

BACKGROUND

Diagnosis and treatment of tendonitis/entrapment of the flexor hallucis longus (FHL) has been sporadically described in the evidence, primarily in the context of dancers and other athletes. Although various nonspecific nonoperative treatments have been described, it is not clear how often they achieve a satisfactory amount of symptom improvement.

QUESTIONS/PURPOSES

The present study was designed to address the following questions regarding the nonoperative treatment of FHL tendonitis: (1) In a population of patients where the default management option for FHL tendonitis is a comprehensive nonsurgical approach, what proportion of patients thus treated opted not to have surgery? (2) What factors were associated with a patient's decision to undergo surgery after a period of nonsurgical management?

METHODS

The 656 patients included were all those diagnosed with FHL tendonitis who were initially treated nonoperatively in the foot and ankle division between January 2009 and December 2018. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and final outcome were obtained from the electronic medical record. The primary outcome was the decision to have surgery due to unsatisfactory symptom improvement. We compared patients who opted for surgery with those who did not after nonoperative treatment with univariable and multivariable statistics using demographics, comorbidities, and clinical findings as potential risk factors, with p < 0.05.

RESULTS

Forty-four percent (180 of 409) of patients decided to forgo surgery after the institution of a specific FHL stretching program. Surgery was more likely in patients with clinical hallux rigidus (OR 2.4 [95% CI 1.16 to 4.97]; p = 0.02) or posteromedial ankle pain (OR 1.78 [95% CI 1.12 to 2.83]; p = 0.01) and less likely in those who completed an FHL stretching program (OR 0.15 [95% CI 0.08 to 0.27]; p < 0.001).

CONCLUSION

FHL tendonitis is more common than the previous evidence suggests and frequently occurs in nonathletes. Once it was diagnosed by detection of tenderness anywhere along the tendon, most frequently at the fibroosseous tunnel, nonoperative treatment focused on specific FHL stretching and immobilization in more severe cases reduced the symptoms to the extent that 44% of patients decided that surgery was unnecessary. The key to its diagnosis is awareness that this injury is possible because most patients treated in this study had been previously seen by orthopaedic providers who had not appreciated the presence of the condition, leading to a delay in diagnosis and treatment of more than a year in many patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Os Trigonum Syndrome

This article offers an overview of os trigonum syndrome, complications, operative techniques, and the authors' preferred protocol. Os trigonum is an ossicle like many other ossicles in the foot and ankle. Individuals who require repetitive plantarflexion of the ankle for activity may develop symptoms of an enlarged os trigonum. Usually, symptoms will be isolated to the posteriolateral aspect of the ankle. Because of the normal anatomic route of the flexor hallucis longus tendon, its range of motion may also elicit pain to the posterolateral ankle. Conservative, as well as surgical including both endoscopic and open excision, has been described.

Effects of a "toes-off" modified heel raise on muscle coordination in non-dancers, dancers, and dancers with flexor hallucis longus tendinopathy

BACKGROUND

Tendinopathy of the flexor hallucis longus, commonly called "dancer's tendinitis", is a prevalent injury among female ballet dancers. Limited success of non-surgical interventions leads to many dancers undergoing tenolysis surgeries with risks and recovery times that can be detrimental to a dance career. The purpose of this study was to evaluate lower limb kinematics and muscle coordination during a modified traditional heel raise exercise where the toes hang off the edge of the support surface. We hypothesized this would decrease activation of the flexor hallucis longus and increase activation of larger plantarflexors.

METHODS

Healthy non-dancers (n = 11), healthy dancers (n = 10), and dancers with flexor hallucis longus tendinopathy (n = 9) performed traditional ("toes-on") and modified ("toes-off") heel raises with kinematic and electromyographic instrumentation of the lower leg.

FINDINGS

Participants maintained ankle excursion with the toes-off modification, while metatarsophalangeal joints had reduced excursion and greater excursion variability. Most healthy dancers (9/10) decreased flexor hallucis longus activation as predicted, but dancers with flexor hallucis longus tendinopathy showed a variable response with some decreasing activation (3/9) but others increasing activation up to 4-times. There were no changes in activation of other plantarflexors. Across groups, intrinsic foot muscle activation decreased with the toes-off modification.

INTERPRETATION

The toes-off modification decreased flexor hallucis longus activation in most of the healthy dancers but was insufficient to shift muscle coordination from the flexor hallucis longus to larger plantarflexors in dancers with flexor hallucis longus tendinopathy. Future work should investigate clinical cues or modifications to this "toes-off" heel raise intervention.

Excision of Os Trigonum in Dancers via an Open Posteromedial Approach

An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Surgical excision is indicated on failure of nonoperative management. Options for surgical excision include open excision (via a posterolateral or posteromedial approach), subtalar arthroscopy, and posterior endoscopy. Os trigonum excision via an open posteromedial approach with concomitant FHL tenolysis/tenosynovectomy is a safe and effective method for the operative treatment of a symptomatic os trigonum that allows for identification and treatment of associated FHL pathology. The major steps in the procedure, which are demonstrated in this video article, are: (1) preoperative planning with appropriate imaging; (2) patient is positioned in a supine position with the operative extremity in figure-of-4 position; (3) a 3-cm, slightly curvilinear longitudinal incision is made midway between the posterior aspect of the medial malleolus and the anterior aspect of the Achilles tendon, over the palpated FHL tendon, and the flexor retinaculum is exposed and incised; the neurovascular bundle is retracted anteriorly, exposing the FHL tendon and sheath; (4) FHL tenolysis/tenosynovectomy is performed; (5) the FHL is retracted anteriorly and a capsulotomy is performed over the os trigonum and the os trigonum is excised; (6) the capsule is repaired and closure is performed; and (7) dressings and a CAM (controlled ankle motion) walking boot are applied. The patient begins physical therapy at 2 weeks postoperatively and may return to dance at 4 to 6 weeks postoperatively as tolerated. In our series of 40 cases, 95% of patients who desired to return to dance were able to return to their pre-injury level of dance. There were no major neurovascular complications.

Physical Therapy Rehabilitation of an Adolescent Preprofessional Dancer Following Os Trigonum Excision: A Case Report

Study Design Case report. Background An os trigonum can be a source of pain for dancers due to impingement during repetitive ankle plantar flexion movements. Following excision of an os trigonum, it is important to have a gradual, progressive return-to-dance program for optimal recovery. The purpose of this case report is to describe the postoperative management and return-to-dance progression of an adolescent dancer post os trigonum excision. Case Description An adolescent preprofessional female dancer had an extensive history of left posterior heel pain, beginning at age 8, that led to surgical removal of an os trigonum at age 15. Post surgery, the patient was seen for a total of 22 visits over the course of 20 weeks. Treatment included therapeutic exercises, neuromuscular re-education, and manual therapy. Return-to-dance tests and guidelines were used to safely progress to full, unrestricted dance participation. Outcomes The dancer had a full return of ankle range of motion, strength, and balance, improved patient-reported outcome scores, and was able to fully return to dance participation. Discussion Treating a dancer following os trigonum excision should involve a screen for hypermobility, clear communication with the dance instructor, awareness of dance-specific biomechanics, and proper reintegration into dance participation. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2018;48(3):194-203. Epub 7 Nov 2017. doi:10.2519/jospt.2018.7508.

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.

Common Foot and Ankle Injuries: What Not to Miss and How Best to Manage

Injuries to the foot and ankle are commonly encountered, especially among athletes, and can lead to morbidity if not managed appropriately. Health care professionals must have a firm understanding of injury anatomy, diagnoses, and management. This article provides a review of lateral talus process fractures, os trigonum injuries, Lisfranc injuries, turf toe, navicular stress fractures, and syndesmotic injuries.

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

Disorders of the Flexor Hallucis Longus and Os Trigonum

Os trigonum syndrome with disease of the flexor hallucis longus tendon, so-called stenosing flexor tenosynovitis, is a common cause of posterior ankle impingement. Conservative treatment is the recommended first line of treatment, with secondary treatment options of either open or arthroscopic os trigonum excision with flexor hallucis longus retinaculum release. The arthroscopic approaches have gained popularity in the past decade because of less scarring, less postoperative pain, minimal overall morbidity, and earlier return to activities. However, comprehensive understanding of the anatomy of the posterior ankle is crucial to warrant successful outcomes and minimizing complications.

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

A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Forty-seven papers have reported on the surgical outcomes of 905 procedures involving both open and artho-endoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers.

Os trigonum syndrome

Os trigonum syndrome is the result of an overuse injury of the posterior ankle caused by repetitive plantar flexion stress. It is predominantly seen in ballet dancers and soccer players and is primarily a clinical diagnosis of exacerbated posterior ankle pain while dancing on pointe or demi-pointe or while doing push-off maneuvers. Symptoms may improve with rest or activity modification. Imaging studies, including a lateral radiographic view of the ankle in maximal plantar flexion, will typically reveal the os trigonum between the posterior tibial lip and calcaneus. If an os trigonum is absent on radiography, an MRI may reveal scar tissue behind the posterior talus, a condition associated with similar symptoms. Os trigonum syndrome is often associated with pathology of the flexor hallucis longus tendon. Treatment begins with nonsurgical measures. In addition to physical therapy, symptomatic athletes may need surgical excision of os trigonum secondary to unavoidable plantar flexion associated with their sport. This surgery can be performed using open or arthroscopic approaches.

The incidence of complications after posterior hindfoot endoscopy

PURPOSE

The purpose of this systematic review was to determine the incidence of complications after posterior hindfoot endoscopy.

METHODS

Ovid/Medline and Google Scholar were systematically searched for pertinent references to be included. In addition, we hand-searched common American and European orthopaedic and podiatric surgical journals for relevant articles. Articles considered for inclusion were published in peer-reviewed journals, described complications after posterior hindfoot endoscopy using a standard 2-portal technique, and involved 25 or more patients treated.

RESULTS

We identified 335 potentially relevant publications, of which 5 met our inclusion criteria. A total of 452 ankles (452 patients) were included in this study. Overall, 17 complications (3.8%) occurred, with only 8 (1.8%) requiring additional treatment or operative intervention.

CONCLUSIONS

The endoscopic approach for the treatment of hindfoot and ankle pathology is safe with a low incidence of complications. However, additional studies with prospective designs should be undertaken to determine the long-term patient outcomes using validated scoring systems.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Posterior ankle impingement in dancers and athletes

The diagnosis of posterior ankle impingement requires an accurate history and specific examination. Computed tomography is a useful investigation to diagnose bony impingement, especially where plain radiography and/or magnetic resonance imaging are sometimes inconclusive. Accurate ultrasound-guided steroid/anesthetic injections are useful interventions to locate the symptomatic lesions and reduce symptoms and occasionally prove curative. If surgical debridement or excision is deemed necessary, arthroscopic surgery via a posterior approach is recommended to excise impingement lesions with a quicker return to sport expected and minimal complications. Open surgical excision, however, remains a viable treatment option.

Musculoskeletal injuries in young ballet dancers

PURPOSE

The aim of this study was to examine the incidence of musculoskeletal injuries, site and type of injury, and the most common injury diagnoses in young ballet dancers at the Royal Swedish Ballet School, a public school in Stockholm.

METHODS

This retrospective study of 476 students (297 girls and 179 boys) aged 10-21 years was based on medical records for the period August 1988 to June 1995. Data on diagnosis, site of injury and type of injury were collected, and the injuries were classified as traumatic or due to overuse.

RESULTS

In total, 438 injuries were recorded. The injury incidence rate was 0.8 per 1,000 dance hours in both female and male dancers and tended to increase with increasing age. Most injuries occurred as the result of overuse. Seventy-six per cent of all injuries occurred in the lower extremities. Ankle sprain was the most common traumatic diagnosis, while the most common overuse-related diagnosis was tendinosis pedis. A few gender differences were noted.

CONCLUSIONS

The findings of this study suggest that there is a need to apply primary injury prevention in young ballet dancers. Future studies could aim to identify (1) injury risk factors and (2) injury prevention programmes that are effective at reducing injury rates in young dancers.