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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Anterior Impingement Syndrome of the Ankle   



- Bony Impingement:
    - pts who have persistent pain in anterior aspect of ankle & who have anterior tibiotalar spur evident on a lateral roentgenogram need additional diagnostic evaluation and management;
    - extreme dorsiflexion required by the demiplie position in ballet can lead to impingement of anterior lip of tibia on talar neck;
    - natural sulcus is present on superior aspect of talar neck & accomodates anterior tibial ridge in most ordinary circumstances of dorsiflexion;
            - however, w/ hyperdorsiflexion in ballet dancing can produce direct contact between the tibia and the talus;
    - w/ repeated impingement, exostoses form, providing basis for anterior impingement syndrome;


- Soft Tissue Impingement:
    - may arise from ankle sprains, but physical exam may fail to show instability;
    - may occur along the anterolateral portion of the ankle just above the ATFL;
    - radiographs may be unremarkable;
    - diff dx:
             - equinus contracture


- Exam:
    - tenderness is present between anterior tibial tendon & medial malleolus;
    - tenderness accentuated with dorsiflexion and relieved w/ plantar flex;
    - w/ ankle in plantar flexion, exostoses can be palpated on superior surface of the talar neck;
    - tenderness is present on the anterolateral aspect of the ankle joint;


- Radiographs:
    - lateral x-ray demonstrates hyperdorsiflexion contact of the anterior lip on talar neck;
    - lateral dorsiflexion-stress roentgenogram may also show abutment between anterior tibial spur and the talus;
    - consider radiographs of the opposite foot to determine the angle between the talus and calcaneus;


- Non Operative Treatment:
    - as both a diagnostic and therapeutic measure, single intra-articular injection of long-acting anesthetic, w/ or w/o use of cortisone, combined with a felt one-centimeter heel-lift can sometimes eliminate all painful symptoms;


- Treatment:
    - arthroscopic or open resection of spur may be considered (see: ankle arthroscopy);
    - w/ large spurs consider open arthrotomy over arthroscopic excision;
    - w/ arthroscopic technique, do not use distraction of the joint because it results in tightening of the anterior capsule, which makes it more difficult to identify the osteophytes;
    - spurs are identified when the ankle is in a fully dorsiflexed position (dorsiflexion also helps avoid iatrogenic injury to the talus);
    - operative radiographs should be compared to preopeartive radiographs;


- Outcomes:
    - in the report by van Dijk CN, et al (1997)
          - 62 consecutive patients with painful limited dorsiflexion of the ankle not responding to nonoperative treatment participated in a prospective study;
          - all underwent arthroscopic surgery;
          - preoperative radiographs were graded according to an osteoarthritic and an impingement classification;
          - results showed that the degree of osteoarthritic changes is a better prognostic factor for the outcome of arthroscopic surgery for anterior ankle impingement than size and location of the spurs;
          - hypothesis is that osteophytes without joint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma;
          - after 2 years, 73% of the patients experienced overall excellent or good results; 90% of those without joint space narrowing had good or excellent results;
          - 50% of those with joint space narrowing had good or excellent results.
          - at the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports;
          - history of anterior ankle pain of less than 2 years and an anteromedial impingement (as opposed to an anterolateral) resulted in superior patient satisfaction;
    - in the report by Tol JL, et al, the authors performed a prospective study to assess the long-term outcome of 57 arthroscopic debridement procedures carried out to treat anterior impingement in the ankle;
          - using preoperative radiographs, we grouped patients according to the extent of their osteoarthritis (OA);
          - symptoms of those with grade-0 changes could be attributed to anterior soft-tissue impingement alone;
          - patients with grade-I disease had both anterior soft-tissue and osteophytic impingement, but no narrowing of the joint space;
          - in those with grade-II OA, narrowing of the joint space was accompanied by osteophytic impingement;
          - radiographs taken before and after operation and at follow-up were compared to assess the recurrence of osteophytes and the progression of narrowing of the joint space;
          - at a mean follow-up of 6.5 years (5 to 8) all patients without OA had excellent or good results;
          - there were excellent or good results in 77% of patients with grade-I OA, despite partial or complete recurrence of osteophytes in two-thirds;
          - in most patients with grade-II OA, narrowing of the joint space had not progressed at follow-up;
                  - there was a notable improvement in pain in these patients, 53% of whom had excellent or good results;
          - although some osteophytes recurred, at long-term follow-up arthroscopic excision of soft-tissue overgrowths and osteophytes proved to be an effective way of treating anterior impingement of the ankle in patients who had no narrowing of the joint space;
          - refs: A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement.
                    Arthroscopic treatment of anterior impingement in the ankle.



Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain.

Arthroscopic treatment of synovial impingement of the ankle.

Arthroscopic treatment of anterolateral ankle impingement.

Meniscoid lesions of the ankle.
 
A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement.

Open treatment of anterior impingement of the ankle.

The anterior ankle impingement syndrome: diagnostic value of oblique radiographs.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, October 29, 2012 7:22 pm