Posterior ankle impingement–an underdiagnosed cause of ankle pain in pediatric patients

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.

Endoscopic Approach to Posterior Ankle via Lateral Portals

Posterior ankle pain is a common foot and ankle problem faced by orthopaedic surgeons. It can have many causes, including posterior ankle joint pathologies (synovitis or osteochondral lesion), ankle impingement (posterior, posterolateral, or posteromedial), flexor hallucis longus pathologies, peroneal tendon problems, posterior tibial tendinopathy, Achilles tendon pathology, posterior subtalar tarsal coalition, or tarsal tunnel syndrome. Most of these pathologies can be managed effectively by an endoscopic approach. The classic endoscopic approach is the 2-portal posterior ankle endoscopy with the portals at the medial and lateral side of the Achilles tendon. This is performed with the patient in prone position. In this technical note, we describe the details of endoscopic approach to the posterior ankle via lateral portals. This allow flexibility of patient positioning (supine, prone, or lateral). It is particularly effective for the management of posteromedial ankle impingement without the risk of injury to the posterior tibial neurovascular bundle. Moreover, any concomitant peroneal tendon pathology can be managed via the same lateral portals.

Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes - a case report

Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.