Updated: Nov 13
Our feet can take a beating depending on our sport of choice. Between practice, cross-training, and performance, athletes with repetitive foot movements or recurring ankle injuries may develop a syndrome called ankle impingement. The pain or mobility issues caused by ankle impingement may have serious implications for participation in your sport. In this blog, we break down this condition and learn how to handle it best… with a skilled physical therapist ;)
ANKLE ANATOMY: Let's orient ourselves!
The ankle joint is a synovial (fluid-filled) hinge joint comprised of 3 bones: the tibia, the fibula, and the talus. The top portion of the ankle joint is made of the bottom surface of the tibia as it brackets together with the fibula. The bottom portion of the ankle joint is made from the top surface of the talus. The surfaces of the ankle are covered with hyaline cartilage. The ankle bones are held together firmly by ligaments on both the inner and outer borders, with a joint capsule surrounding it all. The many muscles controlling the actions of the foot and ankle originate above the tibia and fibula. Their tendons course around either side of the ankle, reaching the insertion points on the foot. As you can see, there are many structures congesting this area.
WHAT IS ANKLE IMPINGEMENT?
Ankle Impingement is the abnormal interaction of bones, ligaments, and or other soft tissue structures of the ankle joint. The result is symptoms of pain, inflammation, and stiffness or restricted movement.
Risk Factors for Ankle Impingement:
-sports with repetitive movements requiring extreme ranges of ankle plantarflexion (stretching your foot away from your head as performed in a calf raise) or dorsiflexion (bending your ankle so that your foot moves towards your head as performed in a deep squat)
-a history of ankle injury that has not been properly rehabilitated, commonly inversion sprains (rolling your ankle)
-individuals with bony abnormalities making bone-on-bone contact more likely
-lack of proper warmup before athletic performance will put the structures of our ankle at risk
Types of Ankle Impingement: Anterior vs. Posterior
The ankle can be impinged either on the front border, anterior impingement, or on the back side, posterior impingement. Each situation has a unique presentation, causes, and limitations.
1. Anterior Ankle Impingement: aka ”Athletes Ankle,” “Footballers Ankle”
Anterior ankle impingement presents as pain in the front of the ankle. It is commonly seen in athletes who repetitively dorsiflex the ankle, like kicking a ball, or have repetitive inversion injuries. An association has also been seen in individuals with a high-arched foot or that suffer repeated sprains (ankle instability) positively correlate with the development of anterior ankle impingement. The articular cartilage of the ankle may be found to have a lesion, bony spurs may develop from the repetitive dorsiflexion, or soft tissues may become entrapped in the anterior joint space, resulting in chronic inflammation.
Some common complaints from athletes with anterior ankle impingement:
a “blocking sensation” in dorsiflexion (ex: squat, stepping down)
limited ankle motion
swelling along the front of the ankle joint
symptoms of instability (giving way, frequent rolling of the ankle)
pain in the top of the ankle with squatting, sprinting, stair climbing, and hill-climbing
2. Posterior Ankle Impingement: aka “Dancers Heel”
Posterior ankle impingement presents as pain in the back of the ankle. It is associated with athletes performing repetitive plantar flexion of the ankle as performed while dancing elevated on the toes, jumping, and kicking. This can come on slowly from repetitive movement, or it is also associated with inversion trauma to the ankle while the ankle is in plantarflexion or toe pointing. This impingement may be bony from a hypertrophy of the os trigonum, soft tissue compression, or irritation of flexor hallucis longus.
Some common complaints from athletes with Posterior Ankle Impingement:
pain at the inner back border of the ankle when the ankle is stretched both down and inward (plantarflexion/inversion), with palpable tenderness
reports of “ankle locking"
DIAGNOSIS OF ANKLE IMPINGEMENT:
Your medical provider will screen you, looking for common complaints of chronic ankle pain, swelling, and limited motion. Imaging can provide some value, x-ray may be able to visualize bony impingement, while MRI or ultrasound are best to visualize soft tissue impingements. Ultimately, a good physical examination checking your walking gait, functional activities, and range of motion assessments aimed at provoking more extreme ankle ranges and palpation will help the clinician gather a full picture.
TREATMENT OF ANKLE IMPINGEMENT:
Your Physical Therapist will help guide your care, including:
Activity Modification: Avoidance of activities that exacerbate the pain to allow the affected structures time to heal. This does not mean stop exercising. Get guidance on working in shorter ranges or reducing the volume to keep up the development of your athletic abilities while simultaneously allowing for healing.
Flexibility and Mobility: Targeted exercises to address both the soft tissue and joint limitations to gain either Dorsiflexion or Plantarflexion.
Progressive Strengthening: Open chain exercises to target the strength of each individual ankle muscle presenting with strength deficits. Also, loading the ankle joints in compound lower extremity-driven movements of varied stances. At the beginning of care, these positions start in shorter ranges. As the patient progresses, the goal is to strengthen throughout the full available range of motion, incorporating positions mimicking the demands of the athletes’ sport.
Ankle Stability: Learning about correct posturing of the foot in weight bearing, emphasis is placed on maintaining a “tripod foot.” The practice of balance and proprioceptive drills (awareness of the body in space) will help the ankle to challenge this tripod for stability in more dynamic situations.
Plyometrics: Jump and agility training plays a large role in joint and tendon health. Plyometrics will also aide in stability as they will increase the responsiveness of the ankle joint to changes in direction and velocity. The use of plyometrics for this condition is crucial for full healing, especially if the athlete performs running and or jumping in their sport.
Surgery: Typically, surgery is an option if conservative care in physical therapy is unsuccessful. Surgical procedures to help ankle impingement may consist of bone spur removal, repairing damaged tissues, or helping improve structural abnormalities.
Ankle Impingement CAN be PREVENTED with:
participation in a proper warm-up
emphasis on technique and form when training
completion of rehab/physical therapy for ankle injuries
If your ankle is painful and has limited motion, get it checked, reach out, and we would love to help you! We work with clients on-site and virtually through Telehealth. Click here if you are interested in booking a session or getting more information! https://www.physicaltherapysanpedro.com/sports
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The PTSP Docs
Dr. Brown, Dr. Bay, Dr. Daisuke & Dr. Sandoval