Ankle impingent involves a patient suffering a painful limitation of their ankle joint mobility from a bony irritation at the margin or a soft tissue lesion. Inflammation of the synovial membrane or the capsule of the joint after the ankle gets sprained several times is a typical history to bring on this sort of syndrome. Repeated ankle sprains can develop into a chronically painful ankle and interfere with walking as well as sporting endeavours. It is not clear how prevalent impingement is but around 10 percent of ankle sprains could develop persistent pain and joint limitation.
Impingement is often secondary to an acute ankle sprain where the person stands on something uneven or puts their foot into a hole in the ground, forcing the foot over into a downwards and inwards movement with the weight of the body. Anterior impingement occurs at the front of the ankle and posterior impingement behind, with another lesion type involving the connecting joint between the fibula and the tibia just above the ankle joint proper. An anterior blocking feeling is often reported by patients with this impingement as they try and get the foot up in the ankle. Moving the ankle into dorsiflexion with weight on it can bring on the pain.
If the syndesmosis (the connecting joint between the fibula and tibia) has been injured and is causing symptoms, then palpating the local area may be extremely tender and pain elicited on compressing the malleoli together. It is more difficult to diagnose posterior impingement as the symptoms are often not so obvious although a forced downward movement of the foot may be painful. Repeated lunging movements such as in ballet and fencing and kicking a ball in football can bring on anterior impingement as the front of the joint suffers repeated microscopic damage which results in bony spur formation.
Investigations for ankle impingement often do not contribute much to the diagnostic process. Plain x-rays, bone scans and CT scans are typically normal, although patients who have anterior impingement may have bony spurs on the front edge of the tibia and on the talus, the ankle bone. Magnetic resonance imaging or MRI scanning is more useful as it enables the doctor to identify abnormalities in both bony and soft tissue structures.
Ankle impingement is treated initially with conservative methods with typical advice to patients to modify their aggravating activities initially so relieving the stresses on the injured areas to allow pain reduction. To limit the pain and any inflammatory local changes a patient may take nonsteroidal anti-inflammatory medications. Physiotherapy referral can involve the use of local ultrasound, friction massages, mobilisations of the local foot and ankle joints, strengthening muscles and increasing ranges of motion. Ankle braces can be useful for joint stability and to limit joint excursion, with assessment and provision of in-shoe insoles by physiotherapists.
If ankle impingement is not managed successfully by conservative methods then the surgeon may consider operative intervention. Usual operating technique is via an arthroscope to tidy up the joint surfaces and edges and remove any bony spurs or soft tissue obstructions. Early mobilisation after surgery is common and if there has not been major internal work patients can typically walk soon after surgery. Four to six weeks is likely to elapse before patients can resume their typical activities, sometimes with physiotherapy guidance. Scientific results from studies on operated patients show over 80 percent are in the excellent or good outcome categories.
In more serious cases patients may wear an ankle brace and use crutches to reduce the weight borne on the ankle, working up to full weight bearing over a week or two. Physiotherapy may then commence once the brace has been removed, starting with range of motion exercises to the ankle and foot joints. Physiotherapists also use ice and other treatments such as ultrasound to reduce pain and inflammation. Once the ankle has begun to settle the physio will progress the patient onto gym exercises without significant weight such as using a static bike, and then to weight bearing exercises involving power, coordination, joint position sense and balance.
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