Anterior Ankle Impingement Lesions
Following on from my previous blog on Footballer’s Ankle, I explore the range of Anterior Ankle Impingement Lesions.
What is Ankle Impingement?
Ankle impingement is defined as pain in the ankle due to impingement commonly affecting two areas: anterior (anterolateral and anteromedial) and posterior (discussed separately):
Anterior ankle impingement refers to pinching/trapping of structures along the anterior (front) margin of the tibiotalar joint in dorsiflexion (when the ankle and toes point upward).
The pain is caused by mechanical obstruction due to osteophytes (bone spurs) or pinching of soft tissue structures due to inflammation, scarring or hypermobility. The condition is common in athletes, especially football players, distance runners and ballet dancers.
Anterior Ankle Impingement (AI)
Anterior Ankle Impingement (also known as Footballer’s Ankle) is caused by repeated dorsiflexion, and repeated inversion injury causing damage to anterior structures such as the ligaments and articular cartilage. It is further classified into Anteromedial & Anterolateral Impingement:
Anteromedial Ankle Impingement
Inversion ankle sprains and repetitive dorsiflexion can cause bone spurs/osteophytes.
Anterolateral Ankle Impingement
Inversion ankle sprains can cause inflammation (synovitis) and ligament scar formation. Palpation over the lateral ligament provokes pain:
A variety of ligaments maybe involved in causing AL Impingement:
The effect is to produce a soft tissue internal lump which can get trapped (impingement):
Examination: After taking a History an examination is performed. The bone and soft tissue structures are systematically palpated to assess for localised tenderness. Anterior or Anterolateral tenderness is often present in anterior impingement. The anterior drawer and Varus Stress tests of the tibiotalar joint are performed to exclude ankle instability.
Imaging: Standard radiographs (X-rays) can show bony impingment but do not show soft tissue lesions. MRI scan is the gold standard for assessing soft tissue pathology such as ligament, tendon and cartilage injuries. Ultrasound (U/S scan) can be useful for looking at anterolateral soft tissue lesions and U/S injections can be used to relieve the symptoms or to aid in the diagnosis.
Surgery: Surgery is considered after conservative treatment has been tried for about 3-6 months. Surgical goals for the treatment of anterior impingement involve removing the offending pathologic lesion contributing to the symptoms. This may involve resection or debridement of bony lesions, soft tissue lesions, or both
In most cases keyhole or arthroscopy is used. The procedure is performed as a day case and in most cases patients can fully weight bear after the operation, although the ankle maybe sore for a few weeks. Results at follow-up show 75-85% improvement.
Complications include infection, neuropraxia/nerve injury, arthrofibrosis (internal scar tissue), complex regional pain syndrome.
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