Caring Medical - Where the world comes for ProlotherapyResearchers challenge the idea of ankle impingement surgery

Danielle Steilen-Matias, MMS, PA-CIn this article Danielle Steilen-Matias, PA-C of Caring Medical Regenerative Medicine Clinics discusses the various challenges with determining a correct diagnosis and treatment plan for Ankle Impingement Syndrome.

Researchers challenge the idea of ankle impingement surgery

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, and instability,

A French team writing in the December 2017 issue of Orthopaedics & traumatology, surgery & research, 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 anterior talo-fibular 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.”(1)

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.

Ankle ligaments

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.(2)

Prolotherapy is the Best Alternative Treatment for Anterior or Posterior Ankle Impingement Syndrome

Ankle Prolotherapy UltrasoundAt 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).

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 bone)
  3. High-grade anterior superficial deltoid layer chronic sprain of 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.(3)

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.

Other articles on ankle problems on our website

If you have questions about Ankle Impingement Syndrome treatment options, get help and information from our Caring Medical Staff

1 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]

2 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]

3 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]


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