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PosteriorAnkleImpingementsofttissue

PosteriorAnkleImpingementsofttissue
Posteriorimpingementoftheanklerelatestoposteriorpainonendrangeplantarflexiondueto
compressionofposteriorbonyandsofttissuestructures.Althoughtherearemanycausesforposterior
ankleimpingement,onlysofttissuecauseswillbeaddressedhere,withbonystructuresexpandedon
later.

PosteromedialImpingement
Firstnotedashypertrophyofscartissuefollowingaposteriordeltoidligamentsprain(Liu&Mirzayan,
1993).Giannini(2013)describesaplantarflexion/inversionsprainasthemostcommonmechanism,with
repeatedcompressionofthetibiotalarligamentresultinginsecondaryhyperplasiaandhypertrophic
fibrosis(Hess,2011Paterson&Brown,2001).Thisthickenedligamentcouldpotentiallyirritatetheflexor
tendonsandcompress/encloseposteriortibialis,flexorhallucislongusorflexordigitorumlongustendons
(Gianninietal.,2013).
Clinically,thepatientwilldisplaylocalisedswellingandTOPattheposteromedialjointlineoftheankle.
TheposteriortibiotalarligamentlosesitsnormalstriationsanddisplayssomehypertrophyonMRI(Roche
etal.,2013),withultrasoundalsoshowingligamentousabnormalities(Gianninietal.,2013).

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PosterolateralImpingement
Similarlyfollowsligamenttearingandhypertrophy,involvingPTFLandtheposteriorinferiortibiofibular
ligament(PITFL)(Hess,2011).Thiscausesaccessorymassestoformwhichbecomeimpingedatend
rangeplantarflexioncombiningwitheversioncausesfurtherimpingementbetweenthedistalfibulaandthe
posterolateralborderofthetalus(Hess,2011).
Additionally,impingementcanoccurattheposteriorintermalleolarligament(PIML)withthedamaged
ligamentcausingsecondaryhypertrophyandformationofameniscoid(Gianninietal.,2013).Repetitive
plantarflexioncancausethismeniscoidtoprojectintothejointcausinglockingandpainsimilartoaknee
meniscalinjury(Gianninietal.,2013),withforcedpassiveplantarflexion/eversionlikelytoreproduce
pain.MRIisthegoldstandard,showingathickenedmeniscoidposteriorly,withpossiblebruisingofthe
opposingchondralsurface(Rocheetal.,2013).
Treatment
Involvesbothconservativeandsurgicalintervention,withthecombinationofactivitymodificationand
physiotherapyinterventionprovidinggoodsymptomaticrelief(Rocheetal.,2013).NSAIDs,rest,softtissue
stretches,electrophysicalagents,bracingandimmobilisationaredescribedintheliteraturewithanecdotal
support,showinga60%successrateinresolvingposteriorimpingement(Gianninietal.,2013Hess,
2011).Whilethesetechniquesareoffered,thereisminimalreferencetomanualtherapytechniques,with
onlytherapeuticexercisesandmodalities(Hess,2011,p.296)describedwithnofurtherelaboration
provided.
Maitland(1991)describestwotechniquestoincreaseplantarflexion,involvingmobilisationofthetalocrural
joint.Ifthesetechniqueswereperformedjustbeforetheendrange,increasedplantarflexionrange,reduced
painandinflammationcouldbeachieved.Givenindividualscanhaveasymptomaticbonystructures
posteriorly(C.N.vanDijk,Lim,Poortman,Strubbe,&Marti,1995),manualtherapytargetingthesoft
tissueinflammationandincreasingtheavailablerangeofplantarflexionshouldbesufficienttoalleviate
symptoms,howeverfurtherresearchneedstobeconductedtoverifythis.Corticosteroidandlocal
anaestheticinjectionshaveshownaclinicalbenefitinreducingpainandimprovingfunctionin84%of
occurrences(Gianninietal.,2013).Theliteraturealsosupportsafunctionalrehabilitationprogram
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includinganklerangeandstrengthexercises,proprioceptionretraining,sportsspecificrehabilitationand
taping,inreturninganathletetosport,onceallsymptomshavesettled(Hess,2011).
Ifathreetosixmonthconservativeprogramdoesntresolvesymptoms,surgeryisindicated,witha
posterioranklearthroscopythemostfavouredtechniquetodebridethebonyorsofttissueimpingement
andregainfullplantarflexion(C.NiekvanDijk,2006).Followingsurgery,arehabilitationprogramis
initiatedattwoweekspostsurgerywithestimatedreturntosportatthreemonths,followingasimilar
programasprovidedinconservativecases(Hess,2011).
Alicia
References**Giannini,S.,Buda,R.,Mosca,M.,Parma,A.,&DiCaprio,F.(2013).Posteriorankle
impingement.Foot&ankleinternational./AmericanOrthopaedicFootandAnkleSociety[and]SwissFoot
andAnkleSociety,34(3),459465.**Hess,G.W.(2011).Ankleimpingementsyndromes:areviewof
etiologyandrelatedimplications.Foot&anklespecialist,4(5),290297.Liu,S.H.,&Mirzayan,R.(1993).
Posteromedialankleimpingement.Arthroscopy:thejournalofarthroscopic&relatedsurgery:official
publicationoftheArthroscopyAssociationofNorthAmericaandtheInternationalArthroscopyAssociation,
9(6),709711.Maitland,G.D.(1991).Peripheralmanipulation(3rded.).LondonBoston:Butterworth
Heinemann.Paterson,R.S.,&Brown,J.N.(2001).Theposteromedialimpingementlesionoftheankle.A
seriesofsixcases.TheAmericanjournalofsportsmedicine,29(5),550557.**Roche,A.J.,Calder,J.D.
F.,&LloydWilliams,R.(2013).Posteriorankleimpingementindancersandathletes.Footandankleclinics,
18(2),301318.Sofka,C.M.(2010).Posteriorankleimpingement:clarificationandconfirmationofthe
pathoanatomy.HSSjournal:themusculoskeletaljournalofHospitalforSpecialSurgery,6(1),99101.van
Dijk,C.N.(2006).Hindfootendoscopy.Footandankleclinics,11(2),391414,vii.vanDijk,C.N.,Lim,L.S.,
Poortman,A.,Strubbe,E.H.,&Marti,R.K.(1995).Degenerativejointdiseaseinfemaleballetdancers.The
Americanjournalofsportsmedicine,23(3),295300.**keyreferences

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