1. Management of Ankle Impingement by dr
Management of Ankle Impingement by dr. mohamed akl assistant Lecturer of orthopedic surgery Faculty of Medicine – Al-Azhar University

2. Impingement is a painful mechanical limitation of full ankle movement secondary to osseous or soft tissue abnormality.
The prevalence and incidence rates are high. Impingement complicates 3% of all ankle sprains, and with incidence rate in athletes reaching 16%.

3. Ankle impingement was first described by Morris, (1943) as a common cause of ankle pain in athletic patients who undergo repetitive forced dorsiflexion or plantar flexion of the ankle.

4. Anatomy

5. The ankle joint is approximately a uniaxial hinge
The ankle joint is approximately a uniaxial hinge. The lower end of the tibia and its medial malleolus, the lateral malleolus and the transverse tibiofibular ligament, form a deep recess ('Mortise') for the body of the talus.
Dorsiflexion is to 10º with the knee straight, and to 30º with knee flexion and planter flexion is to 30º.

6. Bony anatomy of ankle joint formed by:
Tibial plafond.
Medial Malleolus.
Lateral malleolus.
Talus.

7. Ankle ligaments: A. Lateral collateral ligament (LCL):
Anterior talo-fibular ligament (ATFL)
Calcaneofibular ligament (CFL)
Posterior talo-fibular ligament (PTFL)

8. B. Medial collateral ligament (MCL) “Deltoid ligament”:
Superficial Layer:
Tibionavicular ligament
Tibiospring ligament
Superficial tibiotalar ligament
Tibiocalcaneal ligament
Deep Layer:
Deep posterior tibiotalar ligament
Deep anterior tibiotalar ligament

9. C. Syndesmosis: Anteroinferior tibio-fibular ligament.
Posteroinferior tibio-fibular ligament.
Interosseous tibio-fibular ligament.

10. Biomechanics

11. Bony stabilizers:
They contribute approximately 30% of the resistance to rotational forces around the ankle, with the remainder attributed to the soft tissues.
The trapezoidal shape of the talus, wide anteriorly and narrow posteriorly, provides strong bony constraint to the tibio-talar joint in neutral flexion and dorsiflexion.

12. Ligamentous stabilizers:
The lateral collateral ligament.
The Medial collateral ligament (Deltoid ligament).
Additional important stabilizers of the sub-talar joint are the interosseous ligament, cervical ligament and the lateral root of the inferior extensor retinaculum.

13. Anatomy of the major ligamentous stabilizers of the lateral ankle.
In the plantarflexed position the ATFL acts as the “sole” stabilizer, placing it at the most risk for inversion injury.
Anatomy of the major ligamentous stabilizers of the lateral ankle.

14. Classification

15. Ankle Impingement Anterior Ankle Impingement
Posterior Ankle Impingement
Bony
Soft tissue
Bony
Soft tissue

16. Etiology

17. Etiology of anterior ankle impingement:
Traction theory: traction to the anterior ankle capsule during plantarflexion movements results in the formation of anterior tibiotalar osteophytes.
Bone formation is considered to be a response of the skeletal system to intermittent stress and injury, as evidenced by Wolff's law of bone remodeling.

18. Anterolateral impingement is thought to develop subsequent to a relatively minor injury usually consisting of forced ankle plantar flexion and supination.
Bassett et al., (1990), were the first who reported a ligamentous etiology of anterior ankle impingement. The distal part of the AITFL fascicle rubs against the talus, and this causes pain at the ankle.

19. Anteromedial impingement lesions are associated with both eversion and inversion ankle injuries and also may occur following medial malleolar or talar fractures.
It results from injury to the deltoid ligament complex leading to scar formation and synovitis along the anteromedial joint line.

20. Etiology of posterior ankle impingement:
Posterior ankle impingement can be caused by trauma or overuse as in ballet dancers and runners.
An anatomic variation such as an os trigonum is often associated with this entity.
Between 8 and 11 years of age, a separate ossification center appears posterior to the posterior process of talus.

21. When the ossification center doesn't fuse to the lateral tubercle, the ossicle is named the “Os trigonum”.
When it is fused to the posterior process, it becomes an elongated posterior process. "Trigonal process" or "Stieda's process" .
The articular surface of the posterior tibia and the calcaneal tuberosity are also involved in the impingement mechanism.

22. Diagram demonstrating variations in posterior ankle anatomy that contribute to posterior ankle impingement syndrome. 1.Stieda's process; 2.Os trigonum; 3.Fractured lateral tubercle of talus; 4.Downward sloping posterior tibial plafond; 5.Calcified inflammatory tissue; 6.Prominent superior surface of calcaneal tuberosity.

23. Pathology

24. Pathology of anterior ankle impingement:
Bony anterior ankle impingement:
Osteophytosis is the process of formation of new bony spurs at the joint margin causing protrusions around the joint space.
Once the osteophytic prominence forms, impingement occurs more easily. So that, the impingement spur once formed often increase in size and eventually may break off forming a loose body.

25. Scranton and McDermott in 2000, advised a classification system that aide in both clinical and operative decision making:
Grade 1: Synovial impingement & inflammation. Tibial spurs > 3mm.
Grade 2: Grade 1 with tibial spurs <3 mm. No talus spurs.
Grade 3: Grade 2 with spurs on the talus.
Grade 4: Tibial and talar spurs with pantalocural arthritis.

26. Soft tissue anterior ankle impingement:
A localized soft tissue reaction can occur after an ankle sprain with a localized synovial or hyalinized fibrocartilaginous scar reaction.
Chronic impingement can results in further hypertrophic synovium or fibrocartilage formation.
Histological examination of the meniscoid lesion showed hyalinized and fibrous stroma partially covered by synovial membrane with blood vessels, but no ligamentous structures were found.

27. Pathology of posterior ankle impingement:
Soft tissue posteromedial impingement lesion is usually caused by entrapment of fibrotic scar tissue in the medial ankle gutter and posterior aspect of the medial malleolus.
Osteophytes of the posterior tibial rim, an os trigonum, and even part of the posterior talar process may break off during a hyper-plantarflexion trauma and act as a loose body.
After a severe inversion trauma, the posterior talofibular ligament may avulse a bony fragment from posterior talar process and may cause posterior ankle impingement.

28. Diagnosis

29. Diagnosis of anterior ankle impingement:
Clinical diagnosis:
Occurs more commonly in active people and athletes probably because recurrent sub- clinical injury.
Symptoms: Patients present with pain, stiffness, swelling and subjective feeling of blocking on dorsiflexion. Symptoms are exacerbated by activity and may radiate to the lateral or medial malleolus.

30. Signs: Molloy et al., (2003), described a physical sign for diagnosis synovial anterolateral impingement.
If the combined maneuver produces pain or intensifies the pain already felt with pressure alone in the plantar flexed position, this is considered to be a positive sign.
Photographs showing a) plantar flexion of the ankle with thumb pressure over the anterolateral aspect, b) dorsiflexion of the ankle with no thumb pressure over the anterolateral aspect and c) the combined maneuver by thumb pressure and dorsiflexion.

31. External rotation test.
Syndesmotic ankle impingement is diagnosed by positive squeeze test and external rotation test.
Squeeze test.
External rotation test.

32. Radilological diagnosis:
X-Ray:
Bony ridge may be seen extending forward from the surface of the tibia. Occasionally, a similar bony outgrowth is seen projecting upward and slightly backward form the neck of the talus.

33. CT :
CT is helpful in localizing the osteophyte and planning the operative approach. 3D CT is an excellent tool investigating the morphology, location, shape, size and number of the osteophytes preoperatively.

34. Ultrasound :
Ultrasound assessment show nodular, mixed echogenic synovial mass within the anterolateral recess.
Importantly, findings of U/S are not dependent on the presence of an ankle joint effusion, unlike MR imaging.

35. MRI :
MR imaging accurately detects and localizes anterior tibiotalar spurs, adjacent reactive synovitis and fibrosis, subchondral marrow edema , collateral ligament complex injury, osteochondral lesions and intra- articular bodies.
sagittal T1-weighted, demonstrating anterior tibial and talar osteophytes,
sagittal proton density T2 with fat suppression show bone marrow edema, besides anterior capsular thickening characterizing anterior ankle impingement.

36. Diagnosis of posterior ankle impingement:
Clinical diagnosis:
It occurs usually in ballet dancers as well as individuals who are active in sports as soccer, basketball, running, and volleyball players.
Symptoms: The patient complains pricking posterior ankle pain during push off while running. The pain is often absent during walking on level ground. Plantarflexion may be limited and painful.
Signs: Physical examination can reveals the presence of moderate swelling on the medial or on both sides of the Achilles tendon, with tenderness on palpation.

37. Posterior impingement test : repetitive quick passive hyper-plantarflexion movements in a patient sitting with the knee flexed at 90o, with slight external rotation or internal rotation of the foot on the tibia, which cause grinding the posterior talar process/os trigonum between tibia and calcaneus, which intensifies the pain.
Diagnostic infiltration test: the pain disappears on forced plantar flexion after local infiltration of xylocain is diagnostic for posterior ankle impingement.

38. Radilological diagnosis:
X-Ray:
Is the first step in the assessment of all cases of posterior ankle impingement.
Os trigonum is usually triangular.
Acute fracture of the posterior process or Stieda’s process will appear as an irregular and rough fracture line.

39. Bone scan:
Bone scan is positive in an acute fracture of the posterior process and in symptomatic os trigonum.

40. Also can identify capsular abnormality.
Ultrasound:
Hypoechoic nodular, soft tissue thickening deep to tibialis posterior, between the medial malleolus and talus involving the posterior tibiotalar ligament.
Also can identify capsular abnormality.
Nonsurgical injection treatment of soccer player with clinical posterior impingement. Axial ultrasound shows nodular hypoechoic synovitis (*), os trigonum (Os), talus, and needle placement (arrow).

41. CT :
CT scan is best suited to make the distinction between intraarticular abnormalities versus an extra-articular or intracapsular.
Sagittal (A) and axial (B) CT image of the ankle in long-standing os trigonum.

42. MRI :
Common soft tissue abnormalities include posterior capsular thickening, a fluid-distended posterior joint space and increased T2 weighted signal along the posterior margin of the ankle are indicative of synovitis and FHL tenosynovitis .

43. Sagittal T2 shows posterolateral capsular synovitis and thickening.
Sagittal T2 showing marked inflammation in the flexor hallucis longus (FHL) sheath (arrow) in a professional ballerina.

44. Treatment

45. Conservative treatment:
In the form of ankle braces, physical therapy, non-steroidal anti- inflammatory drugs and one or more injections of local anaesthetic and/or steroid into the posterior ankle to treat the impingement symptoms which may be successful.

46. Surgical treatment of anterior ankle impingement:
Open spur resection and debridement:
Severe tibio-talar spurs in grade IV lesions (Scranton’s grading) should be considered for arthrotomy.
the resection should be restricted mainly to the tibial spurs in order to prevent osteonecrosis of the talar neck.
skin incision just lateral to the anterior-most fibers of the deltoid ligament, proximal extent to the level of the tibio-talar articulation and the distal extent should reach the region of the talar neck.

47. Arthroscopic treatment:
Anterior ankle arthroscopy is both diagnostic and therapeutic for many ankle disorders.
Ankle arthroscopy can be performed with or without distraction device.
Standard anteromedial and anterolateral ankle arthroscopy portals are utilized.

48. Guhl technique: James F. Guhl et. al
Guhl technique: James F.Guhl et. al., prefer supine position with the thigh supported by a thigh holder and non-invasive distraction is applied.
Van Dijk technique : Patient is in supine position without distraction with the ankle in the fully dorsiflexed position.

49. Surgical treatment of posterior ankle impingement:
Open surgery:
Historically, it can be performed through a lateral or medial approach. But the complication rates reported were rather high.
The most commonly recommended approaches in open operative treatment are posterolateral, posteromedial, or combined approach.

50. Arthroscopic treatment:
Marumota and Ferkel technique: Place the patient supine with a thigh support and utilize standard anterolateral and posterolateral portals to access the subtalar joints.
Lombardi et al., technique: Place the patient in the lateral decubitus position and describe the use of two "stacked" posterolateral portals to access and excise the os trigonum.

51. Van Dijk technique: patient placed in a prone position with access via both posterolateral and posteromedial portals.

52. Rehabilitation of ankle arthroscopy:
Immobilization in a posterior splint and the patient is non–weight bearing immediately after surgery for 10 days then gradual weight bearing as tolerated in boot walker.
After 2 weeks postoperatively, patients are weaned from the boot and can start working with a physical therapist on progressive ankle strengthening, ROM and gait training.

53. Advantages of arthroscopic surgery over open surgery in treatment of ankle impingement:
Direct visualization of structures.
Improved assessment of articular cartilage.
Less post-operative morbidity.
Faster as well as functional rehabilitation, earlier resumption of sports.

54. Complications of ankle arthroscopy:
Ankle portals are in close proximity to neurovascular structures that can be easily damaged.
The anterolateral portal should avoid the terminal branches of the superficial peroneal nerve and FHL.
The anteromedial portal should avoid the saphenous vein and nerve.

55. The infection rate after arthroscopic surgery of the ankle is approximately 0.1%, which is similar to most of other joints.
Damage to the articular cartilage, loose bodies and debris created during the resection, sinus tract formation, and fluid extravasation are other possible complications.

57. Summary

58. Ankle impingement is a frequent ankle morbidity that has higher incidence and prevalence rates among a highly demanding group (athletes and dancers).
Once the diagnosis of impingement is confirmed by clinical and radiological evaluation, usually there is a little improvement with nonsurgical treatment.
Arthroscopy has proved to provide better functional and overall results compared with open techniques.
Most of the existing literature promotes the use of ankle arthroscopy to surgically treat ankle impingement.

59. Thank you