sports podiatry - anterior ankle impingement

Anterior ankle impingement occurs when soft tissues around the ankle are pinched or nipped. Impingement mainly happens when the ankle is fully bent up or down, leading to pain in the front of the ankle

anterior ankle impingement -

anatomy

The ankle joint is formed where the bones of the lower leg, the tibia and the fibula, connect above the anklebone, called the talus. The tibia is the main bone of the lower leg. The fibula is the small, thin bone along the outer edge of the tibia.

The ankle joint is a hinge that allows the foot to move up (dorsiflexion) and down (plantarflexion). The ankle is a synovial joint, meaning it is enclosed in a joint capsule that contains a lubricant called synovial fluid.

Strong ligaments surround and support the ankle joint. The ligament that crosses just above the front of the ankle and connects the tibia to the fibula is called the anterior inferior tibiofibular ligament (AITFL). The anterior talofibular ligament (ATFL) supports the outer edge of the ankle. The ATFL goes from the tip of the fibula and angles forward to connect with the talus.

The talus rests on the the heel bone (the calcaneus). The joint formed between these two bones is called the subtalar joint. The calcaneus extends backward below the ankle, forming a shelf on which the talus rests.

Two small bony bumps, called tuberosities, project from the back of the talus, one on the inside (medial) edge and one on the outer (lateral) edge.

causes of anterior ankle impingement

Pinching of tissues in the front of the ankle is called anterior impingement. Athletes who have had several mild ankle sprains or one severe sprain are most likely to have anterior impingement. This is especially true for athletes who repeatedly bend the ankle upward (dorsiflexion). Irritation along the front edge of the ankle can lead to impingement.

Irritation in the lower edge of the AITFL and the front of the ATFL can thicken these ligaments. The irritated ligaments become vulnerable to getting pinched between the tibia and talus as the foot is dorsi flexed. These ligaments may also begin to rub on the joint capsule of the ankle. This can inflame the synovial lining of the capsule, a condition called synovitis.

A similar problem can happen after an ankle sprain. As the torn or ruptured ligament heals, the body responds by forming too much scar tissue along the front and side of the ankle joint. This creates a small mass of tissue called a meniscoid lesion. Dorsi flexing the ankle can trap the tissue between the edge of the ankle joint, causing pain, popping, and a feeling that the ankle will give out and not support your body weight.

Over time, damage from past ankle sprains may also lead to the formation of small projections of bone called bone spurs. Bone spurs can form along the bottom ledge of the tibia bone or on the upper surface of the talus. As the ankle hinges into dorsiflexion, the bone spurs may begin to jab into the soft tissues along the front edge of the ankle joint, causing symptoms of anterior impingement.

symptoms of anterior ankle impingement

Anterior ankle impingement may feel like ankle pain that continues long after an ankle sprain. The ankle may feel weak, like it can't be trusted to hold steady during routine activities. When anterior impingement comes from ligament irritation, pain and tissue thickening are usually felt in front and slightly to the side of the ankle. This is the area of the ATFL. The pain worsens as the foot is forced upward into dorsiflexion. If the ligaments have irritated the synovium of the ankle joint capsule, throbbing pain and swelling from inflammation (synovitis) may also be felt in this area.

anterior ankle impingement

treatment in the acute phase

P - R - I - C - E

Protection - Your ankle may be splinted, taped or braced to prevent further injury.
Rest - You should rest from all activities that cause pain or limping. Use crutches/cane until you can walk without pain or limping.
	Ice - Place a plastic bag with ice on the ankle for 15-20 minutes, 3-5 times a day for the first 24-72 hours. Leave the ice off at least 1 1/2 hours between applications.
	Compression - Wrap an elastic bandage from the toes to mid calf, using even pressure. Wear this until swelling decreases. Loosen the wrap if your toes start to turn blue or feel cold.
Elevate - Make sure to elevate the ankle above heart level (hip level is acceptable during class).

 

IF SYMPTOMS PERSISTS OR NUMBNESS/ DISCOLOURATION OF THE FOOT OCCURS CONSULT A MEDICAL PROFESSIONAL IMMEDIATELY.

 

to restore normal ankle function

WARNING! EXERCISES SHOULD NOT HURT. IF THEY DO, STOP!

 

Range of Motion Exercises
Help you regain normal ankle motion.

Technique:

Sit with your knee straight and hold the foot position as long as possible. Do as frequently as possible for the first 3-10 days.

Pullback Flex your foot back toward your body.

 

Flexibility (Stretching) Exercises
Loosen tight leg muscles. Tightness makes it hard to use stairs, walk, run and jump and it puts extra mechanical stress on the ankle..

Technique:	Hold each exercise 30 seconds at a gentle stretch. Do not bounce!
Frequency:	6-10 repetitions/exercise, 5-7 days per week

Calf Stretch   Basic:  Sit with your knee straight    and towel looped   around the ball of your foot. Slowly pull back until you feel your upper calf stretch.

Calf Stretch    Advanced: Once you can stand, try stretching with   your hands on a wall. Place the injured foot behind the other with your toes pointing forward. Keep your heels down and back leg straight. Slowly bend your front knee until you feel the calf stretch in the back leg.

Heel Stretch    Basic: Sit with your knee slightly bent. Loop a towel   around the ball of your foot. Slowly pull back until you feel a stretch in the lower calf and heel.

Heel Stretch    Advanced: Once you can stand, try placing your   injured foot behind the other with your toes pointing   forward. Keeping your heels down, slowly bend your back knee until you feel a heel stretch in the back leg.

 

strengthening exercises

Strong leg muscles help the ligaments hold the ankle together.

Frequency:

Three sets of 20 repetitions, 5-7 days per week

Front of Shin   Basic - Push Out With your foot flat on the floor, push it outward against a wall, file cabinet or bookcase. Hold for three seconds.

Front of Shin   Advanced - Band Tie the band to a desk or dresser. Sit with your foot and knee in line and loop the band over the outside of your foot. Push your foot out against the band.

Inner Shin   Basic - Push In With your foot flat on the floor, push it inward against your other foot. Hold for three seconds.

Inner Shin   Advanced - Band Tie the band to a desk or dresser. Sit with your foot and knee in line, and loop the band over the inside of your foot. Push your foot in against the band.

Front of Shin   Basic - Push Up Place the heel of your other foot on top of the injured one. Push down with the top heel while trying to push up with the injured foot. Hold for three seconds.

Front of Shin   Advanced - Band Tie the band to a desk or dresser. Sit with your leg straight and loop the band over the top of your foot. Slowly pull your foot back against the band.

 

balance exercises

An ankle sprain can decrease your ability to balance on that foot and makes it easier to roll the ankle again. As soon as you can stand without pain, try the balance tests below. If you can't balance for ten seconds without wobbling, practice that level every day until you can.

 

Technique:	Balance on your injured foot for ten seconds, do a least 6 repetitions per day.
Goal:	Stand 60 seconds without losing your balance, then move to the next level.

Level 1 - Arms out to your side, eyes open   Level 2 - Arms across your chest, eyes open   Level 3 - Arms out to your side, eyes closed   Level 4 - Arms across your chest, eyes closed

WARNING! Do the above exercise with someone in attendance who can help you if you lose your balance!

To further improve proprioception consider a wobble board

Wobble boards- Designed to improve proprioception these devices used as per the manufacturers instructions will improve the connection between the brain and the injured nerve fibres in the ankle. A must for quick rehabilitation of a sprained ankle especially if its a repeat injury.

 

 

 

Bracing Injured ligaments can take up to 16 weeks or more to heal. An ankle brace helps protect the ligaments not only during recovery but also when returning to sport or exercise activities.

 

to help prevent injury

Remember that unless trauma related virtually all ankle problems  occur at contact phase of gait (when the foot hits the ground) due to increased biomechanical stress at this point. No amount of exercising will influence what happens at the point of heel strike, mid-stance and toe off phases of gait. It is therefore vital to improve your biomechanics with orthotics designed for your chosen sport.

Golden rule- Don't ignore the problem, it won't go away!

The way we function biomechanically is predominantly controlled by genetics, its hereditary (runs in the family). The way you function is set and cannot be cured. What you can do however is control lower limb biomechanics by altering foot position during the contact phase of gait (when the foot is on the ground). This can only be done by wearing a good shoe and with orthotics  (foot beds).

This is the cheapest and most cost effective way for any athlete to reduce the risks of injury from occurring and from helping to prevent re-injury. Overall costs for the average athlete will run into pennies per mile/hour of sport. Orthotics are designed to alter the biomechanics during the time the foot is on the ground. They are also used to provide increased shock absorbency working in harmony with the sport shoe worn.

Bracing- Proprioception (where the brain knows where the foot is) is markedly decreased after an ankle injury. Also the affected ligaments are weakened and as a consequence will never regain their full strength (maximum 90%). Therefore it is a good idea to brace the affected ankle when starting back into your chosen sport. We have a range of braces that are sport specific allowing you maximum comfort when wearing the shoes designed for your sport.

Wobble boards- Designed to improve proprioception these devices used as per the manufacturers instructions will improve the connection between the brain and the injured nerve fibres in the ankle. A must for quick rehabilitation of a sprained ankle especially if its a repeat injury.

Check the online store for our ankle rehab package, including all of the above at a discounted package rate.

The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your ankle recovers, not by how many days or weeks it has been since your injury occurred.

You may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true:

You have full range of motion in the injured leg compared to the uninjured leg.

You have full strength of the injured leg compared to the uninjured leg.

You can jog straight ahead without pain or limping.

You can sprint straight ahead without pain or limping.

You can do 45-degree cuts, first at half-speed, then at full-speed.

You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.

You can do 90-degree cuts, first at half-speed, then at full-speed.

You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.

You can jump on both legs without pain and you can jump on the injured leg without pain.

Surgical intervention

If nonsurgical treatments do not work, surgery may be recommended. The type of surgery will vary depending on the location and cause of ankle impingement.

Surgical debridement

Debridement is the most common surgery for anterior ankle impingement. Many surgeons prefer to perform this procedure with an arthroscope. An arthroscope is a tiny TV camera that can be inserted into a very small incision. It allows the surgeon to see the area where he or she is working on a TV screen.

To begin, two small incisions are made through the skin on each side of the impingement area. The surgeon inserts the arthroscope to see which area of the tendons or joint capsule are irritated and thickened. The arthroscope lets the doctor see if a meniscoid lesion (mentioned earlier) is present. A small shaver is used to clear away (debride) irritated tissue from the affected ligaments. The surgeon also debrides the tissue forming a meniscoid lesion and any areas of the joint capsule that are inflamed. Small forceps may also be used to clear away irritated or inflamed tissue.

Small bone spurs on the tibia or talus are removed. If the spurs are large, the surgeon may decide to create a new incision over or next to the spur. This allows a special instrument, called an osteotome, to be inserted. The surgeon uses the osteotome to carefully remove these larger bone spurs.

Before concluding the procedure, a fluoroscope is used to check the debridement and to make sure no bony fragments remain. A fluoroscope is a special X-ray machine that allows the surgeon to see a live X-ray picture on a TV screen during surgery. When the surgeon is satisfied that debridement and removal of bone fragments is complete, the skin is stitched together.