Anterior ankle impingement
Anterior Ankle Impingement is a condition where an individual experiences discomfort and pain in the front part of their ankle. This is caused by compression of the bony or soft tissue structures during activities that involve maximal ankle dorsiflexion motion. It can also be referred to as Anterior Impingement Syndrome, Footballer’s Ankle, Anterior Impingement of the Ankle and Ankle Impingement.
There are two bones in the ankle joint – the tibia and talus. These two bones glide on one another and have articular cartilage that cushions the impact of the tibia of the tibia on the talus during activities the involve weight bearing.
When moving the ankle dorsiflexion, the shin and foot move towards each other, which means that the tibia approaches the front of the talus. The result is that this places pressure on the structures at the front of the ankle joint. Inflammation and damage can occur when this pressure is too intense, beyond what the ankle can withstand.
Repeated pressure at the front or anterior aspect of the ankle joint results in pinching of the joint capsule, which is responsible for causing pain in patients with anterior ankle impingement.
In some cases, this pressure on the anterior ankle joint can result in bone spurs, which is also known as an osteophyte. It is believed that these bone spurs develop to help protect the affected surface from repeatedly pulling on the front tip of the tibia. This process is not necessarily associated with arthritis of the ankle joint, although, it can be accelerated with repeated ankle sprains.
Causes of anterior ankle impingement
Ankle sprains, activities that require repeated Dorsiflexion of the ankle (for example deep squatting) and recurrent ankle sprains are the common causes of anterior ankle impingement.
There are various factors that can predispose you to developing anterior ankle impingement. A chiropractor or physiotherapist is able to identify these factors and correct them to reduce the risk of developing anterior ankle impingement.
Factor that contribute to the development of this include:
- Muscle tightness
- Bony anomalies
- Inadequate rehabilitation from an ankle injury
- Poor core stability
- Poor lower limb biomechanics
- Inadequate recovery from training
- Excessive training
- Joint stiffness or swelling
- Inadequate length of warm up
- Poor foot biomechanics (for example, high arches or “flat foot”)
- Poor proprioception or balance
- Unsuitable training technique and footwear
Symptoms of anterior ankle impingement
Those who suffer from anterior ankle impingement, can experience:
- Increased symptoms from partaking in particular activities, such as excessive: walking, running, squatting, lunging, jumping and landing, performing calf stretches, twisting activities or heavy lifting
- Tenderness, inflammation or swelling of the ankle joint
- Clicking sensation during particular ankle movements
- Ache at the front of the ankle with rest, which then becomes sharp pain at the front of the ankle
Your chiropractor or physiotherapist can diagnose anterior ankle impingement from a physical assessment and information about your history. You may be advised to obtain x-rays to assist in the assessment.
X-rays: X-rays can be helpful when assessing anterior ankle impingement as it can show the ankle on its side and can identify bone spurs. This is useful when the spurs are located on the inside of the ankle and therefore difficult to see on the standard lateral radiograph. Therefore, x-rays taken on an angle can be the most effective in seeing anteromedial bone spurs.
Magnetic Resonance Image (MRI): An MRI is useful for a few different reasons. It can provide certainty that there is no other foot or ankle pain that could be mimicking anterior ankle impingement. An MRI can also show signs of swelling and inflammation in the front of the ankle. This can help confirm the patient’s ankle history and physical examination and help plan any future surgery.
Treatment of anterior ankle impingement
Stage one: pain relief, minimise swelling and injury protection
Pain is the prime reason that treatment for anterior ankle impingement is sought.
Rest: Our first approach is to decrease pain caused from provoking postures and movements through active rest. The first step is to stop doing the movement or activity that provokes the particular ankle pain.
Ice: A simple and easily accessible way to reduce your pain and inflammation is by applying ice. Apply ice for 20-30 minutes every 2-4 hours when you first notice the injury becoming warm or hot.
Compression: To support and reduce excessive swelling of the injured soft tissue, use a compression bandage, compression stocking or kinesiology supportive tape.
Elevation: Elevating the injured ankle above your heart will reduce excessive swelling around your ankle.
There are various treatments that your chiropractor or physiotherapist will use to reduce your pain and inflammation, including: ice, acupuncture, electrotherapy, soft tissue massage, deloading taping techniques and temporary use of a mobility aid (ie brace) to off-load the injured structures.
In more severe cases, your chiropractor or physiotherapist will recommend rest from certain activity that causes aggravation and recommend alternative exercises. To help reduce pain and inflammation, medication and natural creams can be taken. Your chiropractor or physiotherapist will advise on what these should be.
Stage two: restore full range of motion
Throughout the treatment process, the aim is to begin rehabilitation and regain full active range of motion of the ankle. Your chiropractor or physiotherapist will monitor when you are ready and when it is comfortable to do so.
Stage three: restore muscle strength
To recover from the injury preventing any future ankle injuries occurring, strengthening is required on your calf, ankle and foot muscles. It’s important to regain normal muscle strength to provide normal dynamic ankle control and function. Strength and power will gradually progress from non-weight bearing to partial and eventually, full weight bearing exercises. Strengthening may also be required on your other leg and lower core muscles, depending on your assessment findings. You chiropractor or physiotherapist will advise you.
Stage four: restore high speed, power, proprioception and agility
Most cases of anterior ankle impingement occur during high-speed activities that place force on your ankle and adjacent structures. To ensure a full recovery and prevent re-injury, proprioception (the sense of the relative position of neighboring parts of the body) and balance are required.
Stage five: return to normal daily function and sport
Depending on your needs and progress of daily functions, such as squatting and walking, your chiropractor or physiotherapist will advise on your return back to sports. To successfully return to sport, you may require specific sport-related exercises and a tailored training routine to ensure a safe an injury-free return to sport. Your chiropractor or physiotherapist will discuss the objectives, goals and training of your schedule with you.
Ultimately, the perfect outcome will include you performing at full speed, agility and power with added knowledge on how to prevent future injuries.
Surgery is not a common outcome for anterior ankle impingement. Although, in rare, persistent cases operative treatment may be necessary and beneficial for high-level athletes. If a patient’s symptoms are the direct result of impingement, rather than ankle arthritis, removing the impinging bone spur or soft tissue structure can help symptoms.
Surgery involves opening up the ankle joint with an incision, or arthroscopically, to remove the offending bone or soft tissue. If the bone spurs are large it is more effective to make a larger incision to remove the bone spurs.
If the pain experienced is caused by ankle arthritis, then it’s important to note that surgery will not typically help. In fact, in some cases surgery to remove the bone spur can result in an increase in symptoms, if it allows the ankle joint to be able to move more and the ankle joint has significant arthritis.