In ankle impingement there is a limitation in the joint mobility of the ankle due to pain from a soft tissue or bony pathology. A common finding to precipitate this pain syndrome is an irritation of the synovial membrane or the joint capsule, typically after an ankle sprain or a repetitive series of such injuries. Chronic pain in the ankle and impingement can result from the ankle being sprained and this can give a persistent pain problem with limitations on involvement in sports. Numbers are unclear but some level of impingement could occur in about ten percent of people who undergo ankle sprains.

Acute ankle impingent is most commonly caused by the foot being moved into a pointed down and turned in position with the body weight on it, often from stepping on an uneven object or dip in the surface. Impingent can be at the front (anterior) or the back (posterior) or relate to the connecting joint between the tibia and the fibula just above the ankle joint. In anterior impingement the patient feels like the movement of the foot upward is blocked by the front of the ankle. Dorsiflexion of the ankle, especially if forced such as by lunging forward on the affected foot, is part of the diagnosis of this type of problem.

If I there is involvement of the connecting joint between the shin bone and the fibula then it will be very sensitive to firm palpation and respond with pain to malleolar compression. Impingement at the back of the ankle is much harder to establish as a diagnosis with its less clear presentation, with a strong toe-pointing movement of the foot bringing on symptoms potentially. In ballet and fencing people may perform repetitive lunge type movements which can give many small instances of damage to the joint lip which can result in the formation of bony outgrowths in that area.

The investigation of ankle impingement is difficult as the typical methods of imaging lesions may show up little. CT scanning, bone scans and normal x-rays are often reported as normal although there can be bony spur formation on the front lips of the tibia and talus in the case of anterior impingements. Magnetic resonance imaging scanning is used in these cases to attempt to clarify the soft tissue or bony changes responsible.

Conservative management is the mainstay of treatment for this condition and patients can reduce their symptoms if they modify the activity levels they are performing or alter their techniques and methods. Non-steroidal anti-inflammatory drugs can be prescribed to counter the pain and inflammatory changes. Referral to physiotherapy is common to attempt joint mobilisation methods on the foot and ankle, apply ultrasound, give deep friction massage and work on muscle power and joint motion. An ankle brace can be fitted to support the joint laterally or to restrict the range of motion and physiotherapists can also assess and fit orthotics in the shoes.

If ankle impingement is not managed successfully by conservative methods then the surgeon may consider operative intervention. Usual operating technique is via an arthroscope to tidy up the joint surfaces and edges and remove any bony spurs or soft tissue obstructions. Early mobilisation after surgery is common and if there has not been major internal work patients can typically walk soon after surgery. Four to six weeks is likely to elapse before patients can resume their typical activities, sometimes with physiotherapy guidance. Scientific results from studies on operated patients show over 80 percent are in the excellent or good outcome categories.

If the surgery is more extensive then patients may be given elbow crutches to protect the ankle joint from full weight bearing for up to two weeks, and they may also wear an ankle brace to reduce joint movement. Once settled to some degree the brace is removed and physiotherapy commenced with encouraging of the ranges of movement of the ankle joint and the foot. Ice and ultrasound may be used to help control pain and inflammation. As the ankle improves the physio will progress to more active exercises without great weight involved, such as cycling on the static bike. Further progression involves weight bearing work to improve joint position sense, coordination, balance and strength.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiothrapists in Southampton. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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