Posterior ankle impingement:
Dance is a demanding sport that places a heavy toll on the body. This leads to many injuries, especially around the foot and ankle. To dance in en-pointe and demi-pointe positions, dancers require significant amounts of flexibility at the ankle to get into a plantarflexed (foot pointing downward) position. The extreme position of maximal plantar flexion can lead to excessive pressure behind the ankle joint leading to pain, limited mobility and difficulty with performance. This condition is referred to as posterior ankle impingement (1,2)
Causes:
- Osseus (bony) causes:
- Os trigonum: An Os Trigonum is an accessory bone that sometimes develops behind the talus/ankle bone. This may occur in adolescent dancers where repeated maximal plantar flexion inhibits proper closure of the bone growth center.
- Stieda process: This refers to an elongated portion of the talus/ankle bone. This causes a bony block with plantar-flexion which causes pain in the back of the ankle in dancers.
- Soft tissue causes:
- Ganglion cysts and synovial hypertrophy:
Soft tissue masses, hypertrophic masses or synovial hypertrophy may contribute to posterior ankle impingement. Due to repetitive and excessive plantar-flexion, ganglion cysts form. The soft tissue becomes inflamed and repeated entrapment and eventually thickens and hardens. - Tendon: Excessive plantarflexion in the demi-pointe and en-pointe positions and with subsequent movement through the plie or grand plie positions can cause inflammation of the Flexor Hallucis Longus (FHL) tendon and the tendon sheath. The FHL is part of the spectrum of impingement given its close approximation with the talus and its bony ‘growth’.
- Ligament causes: Ligamentous structures situated adjacent to the heel bone and ankle joint have been speculated to be risk factors for impingement.
- Ganglion cysts and synovial hypertrophy:
What are the signs and symptoms of posterior ankle impingement?
- Pain behind the ankle
- Increased pain with releve position, demi-pointe and pointe.
- Increased pain with the foot in a push-off position.
- Swelling in acute cases
Diagnosis:
A diagnosis can be made based on clinical presentation in conjunction with radiological and MR imaging. These images will look at the foot and ankle complex from different views with the ankle placed in different weight-bearing positions. An MRI is indicated if further evaluation of the causative factor is needed or if a soft tissue cause is suspected (2,4).
Treatment:
- Application of the POLICE principle – Protect, Optimal loading, Ice, Compression and elevation.
- Avoidance of plantar flexion for a period of time, if possible.
- Casting, in severe acute cases.
- Inner soles where applicable
- Progressive strengthening of foot muscles as well as the entire lower limb
- Graduated mobility exercises.
- In severe cases where conservative management fails to optimally alleviate symptoms, surgery may be indicated.
If you or your kid battle with what you think may be posterior ankle impingement, do not hesitate to book an appointment for a thorough assessment with one of our experienced physiotherapists at Floyd Lebatie Physiotherapy.
References:
- Hamilton, W. (2008). Posterior Ankle Pain in Dancers. Clinics in Sports Medicine, 27, 263-277.
- Moser, B. (2011). Posterior Ankle Impingement in the Dancer. Current Sports Medicine Reports, 10(6), 371-377.
- Ribbans, W., Ribbans, H., Cruickshank, J., & Wood, E. (2014). The Management Of Posterior Ankle Impingement Syndrome In Sport: A Review. Foot and Ankle Surgery, 1-10.
- van Dijk, N. (2006). Anterior and Posterior Ankle Impingement. Foot and Ankle Clinics, 11, 663-683.
- Yasui, Y., Hannon, C., Hurley, E., & Kennedy, J. (2016). Posterior ankle impingement syndrome: A systematic four-stage approach. World Journal of Orthopedics, 7(10), 657-663.
