Ankle impingement – improving range of motion without surgery
Ross Hauser, MD, Caring Medical Florida, Fort Myers
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Ankle impingement non-surgical treatment options
Over the years we have seen many people with an ankle impingement syndrome. Some of these patients come into our clinics with a surgical date or a promise that they can get a surgery one day in the future. When we ask, “why are you going to wait for the surgery,” they will say, “because I need the ankle surgery.” When we ask, “why do you need the surgery?” “Because,” they will say, “I have tried everything else. I am here to see if you can help me. I am nervous about the surgery, I am looking for one last chance.”
People with ankle impingement syndrome are typically very frustrated people. They are frustrated that they cannot run or even walk without significant pain. If you are reading this article it is likely that you are one of these frustrated people.
When extra strength anti-inflammatories, painkillers, heel lifts and other shoe inserts and weeks, maybe months of rest did not fix your problems
Some people do get great success with a program of conservative treatments for their ankle impingement problems. These programs includes physical therapy for their range of motion problems and limitations, ankle strengthening exercises, and exercises to help restore balance and gait. We usually do not see these patients at our clinics. We see the patient exploring surgery and/or waiting for a surgical date because in addition to the treatments above, the extra strength anti-inflammatories, painkillers, heel lifts and other shoe inserts and weeks maybe months of rest did not fix their problems.
The one thing that may have worked was a cortisone injection. For some people the injection did the trick and they, the patient, got back on their way back to their activities. We usually do not see these patients at our clinics. We see the patient for whom cortisone provided short-term relief but whose effects eventually “wore off.”
The point we stress is that what we see in our clinics are the people who did not benefit from these treatments and for them, arthroscopy of the ankle is recommended.
Why did these treatments fail these people?
If you are reading this article “these people,” probably includes you. Maybe this treatment program did not address what was really wrong with your or their ankle. Ankle impingement syndrome is an umbrella term to describe soft tissue getting pinched, caught or impinged upon by bone. The bone compressing on the soft tissue causes pain, reduced mobility, and range of motion. But why is the bone pinching in the first place? How come the bone has moved to a point in your ankle that comes into contact with your soft tissue, and instability?
In this article, we will look at the different types of ankle impingements, why the standard and conservative care treatments did not work for you. What do the surgeons say about surgery and finally what you can do non-surgically to get back to a sport?
The different types of ankle impingement have a common source – ankle instability
For most people, where there is no traumatic injury to the ankle, you have ankle impingement because you have ankle instability. Ankle instability in the simplest terms is a loose, wobbly ankle that gives way sometimes. You recognize that you have ankle instability because you have the sleeves, braces, and tapes in your sports drawer to stabilize your ankle. Many times you do not even use these things because you found out during your course of self-management these things are really not a benefit.
Let’s understand what is going on in your ankle. We hope that this information will help you make sense of your treatment choices. We are going to avoid rehashing information that you have probably viewed on many different websites already.
There are different types of ankle impingement syndromes.
If you have been diagnosed with one of the types of ankle impingement syndrome you were likely told that this is a common problem and your problem was probably the result of chronic ankle instability caused by a history of ankle sprains and/or microtrauma, that is repetitive motion and wear and tear injury.
Going through the list of impingements:
For the background of this section of our article we are going to refer to the descriptions of the varying types of ankle impingement syndrome supplied by sports specialists in France who wrote in the Journal of Ultrasound, (1) of the different type of ankle impingements and suggested treatments.
There are three types of ankle impingement:
- Anterior impingement, which can be subdivided into anterolateral, anteromedial and purely anterior impingement.
- Posterior impingement, which can be subdivided into posterior and posteromedial impingement; and
- Calcaneal peroneal impingement which is secondary to planovalgus foot deformity (a flat foot that roles inwards because of structural deformity).
Anterior ankle impingement and ankle instability treatment
Here is a typical patient medical history we see with in someone with a diagnosis of Anterior Ankle Impingement, see how this matches up to yours.
You had a lot of pain and swelling or inflammation at the front of your ankle. You are a runner, someone who does a lot of walking or you are an athlete involved in organized sports. You went online and started researching this pain and realized that you have “athlete’s ankle” or “footballer’s ankle.” “Footballer’s,” is a reference to someone who does a lot of kicking and while prevalent in football you may be reading this article because you are a soccer player.
As your own medical treatment program of anti-inflammatories and tape, brace and ice have not helped. You finally made the decision to see a health care provider. The health care provider saw the swelling in your ankle and that was obvious enough that something is wrong. They may have asked you to point your toes upward towards your nose, to test the dorsiflexion of your ankle. Likely you could not without significant restricted movement or pain. A prescription for an x-ray is given to make sure nothing is broken, fractured or displaced.
Your x-ray came back and may have shown osteophytes, or “bone spurs” on standard x-rays of the ankle. You may have been sent to get an MRI because bone spurs mean a chance that you will need surgery to shave down the bone spur. Hopefully, you did not get to that point yet.
Understanding anterolateral, anteromedial or simply anterior impingement and 30 years of research
Anterior impingement means something at the front of the ankle. Patients are typically diagnosis simply as having anterior impingement, sometimes a patient will get a diagnosis a little more specific, either Anterolateral impingement or Anteromedial impingement. The differential in the diagnosis is where the impingement is in the front of the ankle.
Anterolateral impingement: This is the “outer side” of the front ankle. We like to stay current with our research and provide the latest in findings, however every once in a while we find an old study that is just as relevant today. In this 1992 study, doctors at the Hughston Orthopaedic Clinic reported in the Journal of the Medical Association of Georgia,(2) the following:
- “Anterolateral impingement syndrome of the ankle is caused by entrapment of the hypertrophic soft tissue in the lateral gutter. The impingement process begins when an inversion sprain tears the anterior talofibular, and/or the calcaneofibular ligament. The ligamentous injury is not severe enough to cause chronic instability; however, inadequate immobilization and rehabilitation may lead to chronic inflammation in the ligament, resulting in the formation of scar tissue. This tissue then becomes trapped between the talus (heel) and the lateral malleolus (the outer ankle bone), causing irritation, pain, and further synovitis. The end result is chronic lateral ankle pain. Initial treatment involves physical therapy modalities and nonsteroidal anti-inflammatory medications. Those patients refractory to conservative treatment require arthroscopic debridement.” This study from 1992 sounds like 2019.
- In this description above we have a typical patient with a history of ankle sprains of the anterior talofibular, and/or the calcaneofibular ligament.
- This typical patient did not tear the ligament enough to be considered an acute injury but began the processes of micro-tearing and weakening of these ligaments becuause of chronic inflammation.
- Eventually, not enough rest, not enough anti-inflammatories will require surgery.
- This does sound like 2020. Below we will discuss options to treatments beyond the traditional conservative care often self-managed and prescribed.
“New inversion injuries after the arthroscopic procedure”
In 2010, writing in The Journal of foot and ankle surgery (3) discussed the surgical implication outlined in this 1992 study. Here they wrote: “ankle arthroscopy is useful in the diagnosis and treatment of anterolateral ankle impingement. Factors that negatively affect final outcome are associated chondral lesions of the talus, associated syndesmotic lesions, and new inversion injuries after the arthroscopic procedure.”
The key to this is that if you have more degenerative disease of the ankle, the surgery will be less helpful, further, there is a risk for injury after the surgery. Those would be the “new inversion injuries after the arthroscopic procedure”
In a 2015 study in the medical journal Arthroscopy, (4) surgeons think that surgery may be okay, maybe for some, not for others. They write “arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome.”
So in Anterolateral impingement, you have pain in the outer side of your ankle. If it does not respond to anti-inflammatories or physical therapy, surgery is recommended.
Anteromedial impingement – a pathway to surgery
Anteromedial impingement: Over the years there has been some controversy as to whether “anteromedial impingement of the ankle,” is actually a real diagnosis.” If you have received this diagnosis it is certainly real to you. This is an impingement that is occurring at the front “inner side,” of the ankle. As opposed to AnteroLATERAL impingement where the outer “shin” bone, the fibula, is part of the vice-like squeeze on the soft tissue, in AnteroMEDIAL impingement, the inner “shin” bone, the tibia, is part of the vice-like squeeze on the soft tissue.
Why the controversy? It is a matter of labels, some doctors like to call this problem simply anterior impingement, others tibiotalar impingement (it is the tibia and talus (ankle bone) that is trapping the soft tissue), others call this Anteromedial impingement. The labeling is important because it provides a pathway to surgery. Calling this problem anterior impingement requires a long list of conservative care options which will not work for most athletes within a time frame that they desire. Which is always getting back to the game faster.
Making the patients wait out theses conservative care options prevents them from getting back to the game. Anteromedial impingement does not always require surgery, however, there are times when the bone spurs at the bottom of the tibia present a situation where surgery is recommended. When we discuss surgery, as we do not perform it, it is always best to bring in a surgical opinion.
In the publication, Arthroscopy: The Journal of Arthroscopic & Related Surgery (5), surgeons wrote:
“The typical presentation of anteromedial impingement is medial ankle joint pain while running, kicking, or stair climbing and is explained by the entrapment of soft tissue inflammation between the osteophytes during dorsiflexion (pointing your ties up towards your nose) of the ankle. In the current authors’ experience, the diagnosis of anteromedial impingement is often delayed, caused prolonged time lost to injury in athletes.
When medial ankle joint pain is present, the diagnosis of Anteromedial impingement should be considered until proven otherwise. The poor results of conservative treatment therapies for impingement syndromes of the ankle have led the current authors to advocate arthroscopic debridement as a first line treatment to expedite return to competitive sport.
Anteromedial impingement is a common condition seen in athletes and when treated arthroscopically can be expected to do well and return to sport at previous levels.”
Sometimes those bone spurs have to be dealt with surgically, sometimes not. We will discuss more surgical options below. However in our opinion, we have to address the problem of ankle instability because you can shave down bone spurs but if you do not fix the instability, the bone spurs will return and put the patient into a repeated surgery scenario. Repeated surgery scenario is not what a young athlete can afford timewise.
Functional ankle instability – a pathway to surgery that may fail
We want to reiterate, there are times when bone spurs become so problematic to the function of the ankle that the athlete will need to measure the advantages and disadvantages of the surgical option. Our contention is whether or not a patient gets surgery, they will have to address the problem of chronic ankle instability. We will discuss surgery below at greater detail but we want to emphasize that the long-term problem is not the bone spurs. Here we ask for help explaining this from surgeons.
A French team writing in the December 2017 issue of Orthopaedics & Traumatology, Surgery & Research, (6) give strong opinions on the use of surgery to correct ankle impingement syndrome. Here is what they said:
- Anterolateral ankle impingement syndrome is a well-established clinical entity that is a common consequence of ankle sprains. Injury to the anteroinferior tibiofibular ligament plays a key role in the genesis of Anterolateral ankle impingement syndrome.
- Arthroscopic anterolateral synovectomy is the standard of care. (In this surgery, doctors remove some or all of the synovial membrane of the ankle, as this is the stuff getting pinched by the bones of the ankle joint.)
Here is where the doctors disagree:
“However, this treatment approach may deserve to be challenged, as it does not include any procedure on the ligaments, despite the presence in some patients of lateral rotational micro-instability of the ankle, without objective laxity.”
What the doctors are saying is that surgery is being recommended in patients with ankle instability without a clear examination of ligament laxity. This as they say, needs to be challenged.
Adding more to the surgery to address ankle instability
In the above research, surgeons contend that they must address the problem of ankle instability coming from the anteroinferior tibiofibular ligament. Let’s look at a new study.
In the January 2019 issue of the Journal of Foot and Ankle Surgery, (7) surgeons reported that while functional ankle instability and anterior ankle impingement are two conditions that are likely to occur simultaneously, it is not really known how anterior ankle impingement affects ankle instability. Knowing this, they contend, would give a better picture of who surgery would help and who surgery would not help.
So the surgeons of this study looked at people who had a surgery:
- Those with functional ankle instability and anterior ankle impingement who had a surgery
- Those who had functional ankle instability alone, no impingement, and who had a surgery.
Then they followed these patients to see how they did following an arthroscopic synovectomy (removal of the inflamed synovial tissue as explained above) combined with the modified Broström procedure. (Modified Brostrom procedures are a group of surgical procedures that seeks to stabilize the ankle by repairing the anterior talofibular ligament. The main stabilizer ligament of the outer ankle. Brostrom procedure and its variants are the most popular surgery for ankle instability. There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability. One of the appeals of the arthroscopic Brostrom procedure is that it is an “outpatient,” or same day surgery. But as many have learned, same day surgery can mean months of rehabilitation.)
The results of this study?
Patients with combined functional ankle instability and anterior ankle impingement showed a relatively poorer outcome in comparison with those suffering from functional ankle instability alone, probably because of hypertrophic (abnormal thickness) of the anteroinferior tibiofibular ligament.
Abnormal thickness of a ligament is a ligaments response to injury from instability.
Surgeons challenge the idea of posterior ankle impingement syndrome
Doctors at university hospitals in Turkey have published their research on posterior ankle impingement syndrome in soccer players. Posterior ankle impingement syndrome is pain in the back of the ankle caused by compression in the ankle joint when the toe of the foot is pointed forward to maximum length. This occurs in certain ballet and gymnastic moves and frequently in soccer players who point their toes downward upon striking the ball.
In the case of the soccer players, the Turkish researchers found:
- All (26) of the athletes received conservative treatment with physical therapy modalities initially.
- If the first line medical treatment and rehabilitation was ineffective to alleviate the symptoms, ultrasound-guided corticosteroid injection were given and thereafter the patients underwent posterior ankle arthroscopy if the complaints are still unresolved.
- Eighteen of the 26 players responded well to the conservative treatments
- three of acute cases and five of the chronic cases did not respond to medical treatment and arthroscopic surgery was performed for eight athletes.
- Eighteen players returned to training for a mean time of 36.3 days (24-42 days) after conservative treatment.
- The patients who underwent arthroscopic surgery returned to training for a mean time of 49.8 days (42-56 days) after the surgery.
- All athletes returned to their previous level of competition after treatment without any complications or recurrence in a mean follow-up 36.5 months (19-77 months).
Non-surgical treatment modalities were effective in 2/3 of posterior ankle impingement syndrome in elite soccer players. On the other hand, posterior ankle arthroscopy is safe and effective treatment option for posterior ankle impingement syndrome if the conservative treatment fails.(8)
Surgeons challenge the idea of peroneal tendon subluxation in cases of ankle impingment
The suggestion that your ankle pain is not really coming from a problem with your Peroneal Tendon is demonstrated in the title of a June 2020 paper published in the Journal of clinical orthopaedics and trauma (9) from Texas Children’s Hospital and the University of California at San Francisco. Here three young patients were examined.
“Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantar flexion 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 (not causing) 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.”
Below we will discuss whether similar outcomes can be achieved without surgery.
Bone spurs in anterior ankle impingement
One of the challenges of treating patients with advanced ankle osteoarthritis is the formation of bone spurs. Many of these patients come into our clinics with an recommendation for fusion surgery. They do not want the fusion because it will limit their motion and for once and for all, lock up their ankle in an immovable position. When the patient gives us x-rays with large bone spurs present, we explain to them that their own body is busy doing its own fusion. The bone overgrowth or bone spurs are already locking up the ankle to help support the weight of the body. Advanced degeneration of this nature is challenging to treat.
In November 2018 in the journal Clinical Anatomy (10), doctors from Case Western Reserve University School of Medicine and the University Hospitals Cleveland Medical Center, examined the relationship between Anterior ankle impingement and bone spur formation. Here are the learning points of their research:
- Anterior ankle impingement results from repetitive microtrauma leading to pain and decreased dorsiflexion (your ability to point your toes upward) due to spur formation and synovial hypertrophy (Swelling).
- In a study on cadavers, (people who died between the ages of 20 – 40) bony impingement was observed in 21% of the ankles examined, with bilateral (both ankles) involvement in 8% (
- In the ankles with Anterior ankle impingement, spurs were seen:
- on the talus only in 61%,
- on the tibia only in 14%,
- and on both the tibia and talus in 26%.
- Spurs were significantly more prevalent in males and with increasing specimen age.
What does this study help us understand? Ankle impingement brings about the quick formation of bone spurs.
Prolotherapy is a non-surgical alternative treatment for anterior or posterior Ankle Impingement Syndrome
At Caring Medical we think surgery should only be utilized for pain after more conservative treatments have failed. So we typically wouldn’t recommend surgery for impingement syndromes in the ankle unless the person first had a trial of Prolotherapy. Why? Because Prolotherapy typically resolves it (there are exceptions of course).
What is Prolotherapy? In this video Danielle R. Steilen-Matias, MMS, PA-C demonstrates treatment to the lateral ankle
The treatment begins immediately in the video
This is comprehensive Prolotherapy, meaning there are a lot of injections. The patient getting the injections in this video is comfortable and tolerates the treatment well. The patient in this video is having the lateral or outer ankle treated.
- The injections are given at the ligament attachment to the bone. This helps stimulate healing and strengthening of the ankle ligaments.
- At 0:48 the importance of treating the lateral ligaments of the ankle, the anterior talo-fibular ligament (ATFL), the calcaneo-fibular ligament (CFL) and the posterior talo-fibular ligament.
- The patient is not sedated in anyway, once treatment begins patients are surprised that it is not as painful as it looks. We do offer various pre-treatment medications to help the patient including IV sedation. Especially those with a fear of needles.
- This patient came to see us for an old ankle sprain injury causing chronic ankle instability and pain with running and lower body activities.
- On his first physical exam he had some ligament laxity, a lot of tenderness and instability in his ankle. At that visit we treated the lateral side. This is a follow up treatment.
- Depending on the severity of the ankle sprain, it could take 3 to 8 treatments to affect a repair.
Patients who have ankle impingement syndrome give a history of ankle sprain or significant ankle injury. Therefore, it becomes clear that it is the injury that was ultimately the cause of the impingement. Associated with it may be some bony spurs or anatomical variants like os trigonum (an extra bone in the ankle). Bone spurs are the body’s response to stabilize an unstable structure. So bone spurs associated with impingement are telling the person and doctor that at some point ligaments around the ankle were injured and did not heal completely so the body developed a bone spur in an area to stabilize the area.
Recently, a patient came into the office with a long history of ankle problems and had multiple findings on his MRI report. Here is what his report included:
- Inframalleolar tendinopathy (tendon degeneration within the ankle)
- Os tibiale stress reaction (stress fracture in bone)
- High-grade anterior superficial deltoid layer chronic sprain of anterior medial ankle with impingement (this actually may be two or three diagnoses!)
- Mild anterior talofibular ligament sprain
- Mild calcaneofibular ligament sprain
- Low-grade posterolateral impingement
The major items that stand out in the above report are the various ligament sprains, stress reactions, and tendinopathy, which often mean a weakened or degenerative tendon.
Stress reactions are commonly reported on MRI. To give you an example, stress reactions were found in 43% of 21 asymptomatic college distance runners and were not predictors of future stress reactions or stress fractures.(11)
So what do stress reactions mean?
For college runners, stress reactions mean very little according to the above study. Stress reactions occur because of accelerated remodeling of the bone or periosteum (outside of the bone). They typically occur where tendons attach to bone and are typically a sign that the body is getting excessive pressure at the fibro-osseous junction or enthesis (the points where soft tissue attach to the bones). Prolotherapy strengthen theses fibro-osseous junctions.
Traditional Treatments vs. Comprehensive Prolotherapy for Ankle Impingement
The patient would be recommended to Prolotherapy to treat most of the ligament structures around the ankle to stimulate the repair of those tissues. This means that both the front and the back of the ankle need to be treated. Along with this, an exercise program that involves ankle motion, including cycling and swimming or kicking in the pool, would be needed. To help improve proprioception (balance) single leg standing and balance exercises would also be recommended. By strengthening the ligaments and structures involved with ankle stability over time, Prolotherapy will typically resolve the pain associated with ankle impingement syndrome. Typically four to seven visits for this condition are needed.
If you have questions about Ankle Impingement Syndrome treatment options, get help and information from our Caring Medical Staff
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