Does ankle impingement require surgery? Improving range of motion without surgery

Ross A. Hauser, MD. , Danielle R. Steilen-Matias, MMS, PA-C.

Ankle impingement non-surgical treatment options

Over the years we have seen many people with ankle impingement syndrome. Some of these patients come into our center waiting on a surgical date. 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.”

Before someone becomes a patient, they will tell a story, unique to them, typical for others about their hit and miss treatment programs. They are talking to us because these treatments have been mostly “miss.” Here is an example where surgery was a “miss.”

I suffered a pretty bad sprain over 10 years ago. The injury never healed correctly and I still have pain from it. I have been from doctor to doctor and the general opinion is that I have an anterior ankle impingement. My doctors were all in agreement that we should try the conservative care options first and see if this could help me avoid surgery.

I was prescribed physical therapy to see if I could improve my range of motion. Maybe break down some scar tissue that formed over the ten years. I was also given a couple of “heavy-duty,” anti-inflammatories to try to calm things down as after the physical therapy my ankle kind of blew up. In fact, my ankle blew up so much that I had to be given cortisone on more than one occasion. Before having any more cortisone I decided on an arthroscopic surgery to “clean” things out and cut away the tissue and bone that may have been causing the impingement.

After the surgery, I felt pretty good for a little bit but the stiffness, limited range of motion, and pain returned. I was told the surgery helped, “but it all came back.” Now I am being told to consider a more extensive surgery. This has been going on for more than ten years and I already had a surgery that did not help. I am looking for other options.

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.

Let’s point out that some people have very successful surgeries and very successful physical therapy. Their ankle problems are fixed for them. These are the people we typically do not see. We see the people for whom treatments, up until now, have not alleviated their problem.

When extra strength anti-inflammatories, painkillers, heel lifts, and other shoe inserts and 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 include 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 clinic. 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 clinic. 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 clinic 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?

What are we seeing in this image?

This illustration discusses the various symptoms of ankle instability. Popping, decreased range of motion, ankle pain, arch cramping, foot pain, toe pain, cracking and crunching noises with movement. loss of foot and ankle strength among them.

This illustration discusses the various symptoms of ankle instability. Popping, decreased range of motion, ankle pain, arch cramping, foot pain, toe pain, cracking and crunching noises with movement. loss of foot and ankle strength among them.

This illustration discusses the various symptoms of ankle instability. Popping, decreased range of motion, ankle pain, arch cramping, foot pain, toe pain, cracking and crunching noises with movement. loss of foot and ankle strength among them.

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 with 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.

Doctors are not sure what your imaging studies say: Treat MRI interpretations with caution

Imaging studies are a science of rapidly developing technology. Every day new wonders are discovered. So when commenting on MRI or imaging accuracy in understanding interpretation and misinterpretation of what an MRI says and the path to surgery following this interpretation, one needs to make sure that the latest research is cited to give accurate updates. This helps us answer patient’s questions on MRI accuracy.

An April 2021 study in the medical journal Acta Radiologica (1) offers these cautions:

“Posterior ankle impingement syndrome is a common and debilitating condition, commonly affecting people who participate in activities that involve repetitive ankle plantar flexion. The relationship between clinical and imaging findings in Posterior ankle impingement syndrome has not been established.”

Therefore the researchers noted that the purpose of their study was “to investigate the relationship between clinical and imaging features in Posterior ankle impingement syndrome by reviewing the literature (the medical research) comparing symptomatic patients to asymptomatic (people).”

What the researchers found, or more appropriately did not find, was medical research that compared one group of people with no pain and one group of people with pain similar and ankle problems. This was out of 8394 articles on the subject of ankle impingement syndrome. Not one. The researchers concluded: “Until this information is available, imaging features in people with posterior ankle impingement should be interpreted with caution.”

In other words, people with no pain can have a bad MRI, as well as people with pain, can have a bad MRI. What separates the two groups? No one has speculated on this. What does this mean? If you have ankle pain, the MRI may or may not show what is causing it. You may have surgery that is not repairing what is happening in your ankle.

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, (2) of the different types of ankle impingements and suggested treatments.

There are three types of ankle impingement:

Anterior ankle impingement and ankle instability treatment

Here is a typical patient medical history we see with 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.

Bone spurs

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.

An introduction to surgical concerns

Some people have very successful ankle surgeries. These are typically not the people we see at our center. The people we see have had less than the desired results of their surgery and a good amount of residual pain. An April 2021 study published in the journal Orthopedic Research and Reviews (3) discusses the negative impact of ankle surgery for restoring ankle stability:

“A high frequency of associated injuries is seen in patients with chronic lateral ankle instability. Comorbidities include intraarticular pathologies (osteochondral lesion, soft tissue or bony impingement syndrome, loose body, synovitis, etc.), peroneal tendon pathologies, neural injuries, and other extraarticular pathologies. Surgeons should have a high index of suspicion for these associated pathologies before the operative intervention, correlate with clinical findings, and plan the treatment. Despite the restoration of ankle stability following ligament repair or reconstruction surgery, postoperative residual pain, which can negatively affect clinical outcomes and patient satisfaction, is highly prevalent (13-35%).”

What are we seeing in this image? The ligaments of the ankle provide stability and structural support.

What are we seeing in this image? The ligaments of the ankle that provide stability and structural support. 

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,(4) the following: 

“New inversion injuries after the arthroscopic procedure”

In 2010, writing in The Journal of Foot and Ankle Surgery (5) 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 with 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, (6) 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 these 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 (7), surgeons wrote:

“The typical presentation of anteromedial impingement is the 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 toes 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 in 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, (8give strong opinions on the use of surgery to correct ankle impingement syndrome. Here is what they said:

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, (9) 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 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 single 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.

The abnormal thickness of a ligament is a ligament response to injury from instability.

Surgeons challenge the idea of posterior ankle impingement syndrome for all – 2/3rds of athletes in one study returned to pre-injury level without surgery

Doctors at university hospitals in Turkey have published their research (10) on posterior ankle impingement syndrome in soccer players. Posterior ankle impingement syndrome is a 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:

Results:

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 a safe and effective treatment option for posterior ankle impingement syndrome if the conservative treatment fails.

Posterior ankle impingement syndrome and the flexor Hallucis Longus

The flexor hallucis longus muscle is one of the three deep muscles that runs in the back of the leg. If you have been treated for ankle impingement, you most probably have had a discussion of this muscle, specifically in cases where you have not responded to treatment. It may have been explained to you that this muscle attaches all the way to your big toe. It is a big powerful muscle that is important in our ability to walk and flex our ankles, extremely important to athletes and dancers. This brings us to this study.

A March 2018 study in the Journal of Dance Medicine and Science🙁11)

In this study, we have a group of patients who should respond well to surgery. In this study, it was 90%. At our center, we see some of the 10% type people who did not respond well to surgery or the people who had successful surgery but over time, the same problems of ankle instability and weakness developed after the surgery. The people in this study were followed for 6 months post-surgery. Long-term outcomes are unknown.

For more on this subject please see: Treating turf toe and sesamoiditis that does not go away without the need for surgery for problems related to flexor hallucis longus tendinopathy.

Surgeons challenge the idea of peroneal tendon subluxation in cases of ankle impingement

For more information on this topic please see our companion article: A missed peroneal tendon injury: Is this the cause of inappropriate surgery and continued foot and ankle pain?

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 (12)  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, a 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 a 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 clinic with a 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 (13), 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:

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.

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:

  1. Inframalleolar tendinopathy (tendon degeneration within the ankle)
  2. Os tibiale stress reaction (stress fracture in the bone)
  3. High-grade anterior superficial deltoid layer chronic sprain of the anterior medial ankle with impingement (this actually may be two or three diagnoses!)
  4. Mild anterior talofibular ligament sprain
  5. Mild calcaneofibular ligament sprain
  6. 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. (14)

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 attaches to the bones). Prolotherapy strengthens these fibro-osseous junctions.

Traditional Treatments vs. Comprehensive Prolotherapy for Ankle Impingement

The patient would be recommended 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.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your ankle problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

1 Baillie P, Mayes S, Lam J, Ferrar K, Cook J. Associations between clinical and imaging findings in posterior ankle impingement syndrome: a systematic review. Acta Radiologica. 2021 Apr 19:02841851211008389. [Google Scholar]
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4 Jacobson KE, Liu SH. Anterolateral impingement of the ankle. Journal of the Medical Association of Georgia. 1992 Jun;81(6):297-9. [Google Scholar]
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7 Zwiers R, Wiegerinck JI, Murawski CD, Fraser EJ, Kennedy JG, van Dijk CN. Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature. Arthroscopy. 2015;31(8):1585‐1596. doi:10.1016/j.arthro.2015.01.023 [Google Scholar]
8 Molinier F, Benoist J, Colin F, Padiolleau J, Guillo S, Stone J, Bauer T. Does Antero-Lateral Ankle Impingement Exist?. Orthopaedics & Traumatology: Surgery & Research. 2017 Sep 8. [Google Scholar]
9 Chen L, Wang X, Huang J, Zhang C, Wang C, Geng X, Ma X. Outcome Comparison Between Functional Ankle Instability Cases With and Without Anterior Ankle Impingement: A Retrospective Cohort Study. The Journal of Foot and Ankle Surgery. 2019 Jan 1;58(1):52-6. [Google Scholar]
10 Kudaş S, Dönmez G, Işık Ç, Çelebi M, Çay N, Bozkurt M. Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes Acta Orthop Traumatol Turc. 2016 Dec;50(6):649-654. doi: 10.1016/j.aott.2016.03.008. Epub 2016 Dec 3. [Google Scholar]
11 Rietveld AB, Haitjema S. Posterior Ankle Impingement Syndrome and M. Flexor Hallucis Longus Tendinopathy in Dancers Results of Open Surgery. Journal of Dance Medicine & Science. 2018 Mar 15;22(1):3-10. [Google Scholar]
12 Kushare IV, Allahabadi S, McKay S. Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes–a case report. Journal of Clinical Orthopaedics and Trauma. 2020 Mar 18. [Google Scholar]
13 Talbot CE, Knapik DM, Miskovsky SN. Prevalence and location of bone spurs in anterior ankle impingement: A cadaveric investigation. Clinical Anatomy. 2018 Nov;31(8):1144-50. [Google Scholar]
14 Bergman AG, Fredericson M. Asymptomatic tibial stress reactions: MRI detection and clinical follow-up in distance runners. American Journal of Radiology. 2004;183:635-638. [Google Scholar]

This article was updated May 6, 2021

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