Anterior ankle impingement

If you're experiencing persistent pain at the front of your ankle, then you may have anterior ankle impingement. Keep reading below to find out more about this condition and how we can help.

What is it?

Anterior ankle impingement is pain that is felt at the anterior (front) portion of your ankle due to compression of bony or soft tissue structures during activities that involve maximally bending your foot up (dorsiflexion).

During dorsiflexion the shin bone (tibia) glides towards the front portion of the talus, narrowing the space between the two bones and potentially causing compression and pinching of the structures at the front of your ankle such as the joint capsule or synovium. If these compressive forces are unable to be withstood by the ankle joint than inflammation of these structures can occur which may result in pain, swelling, restricted movement, a locking sensation and even weakness around the foot and ankle.

In some cases, repeated compression of the ankle can result in the formation of bony spurs on the front edge of the tibia or talus.

What does it feel like?

Anterior ankle impingement presents as a dull ache at the front of your ankle at rest, which then becomes a sharp pain with excessive weight bearing activities or when bending your foot up. You may also notice that it is very painful to touch the front of your ankle and occasionally you may even experience clicking or swelling at the front of your ankle joint (anterior talocrural joint).

It is common for the following activities to be aggravating:

- excessive walking or running, in particular hills or uneven surfaces

- deep squatting or lunging

- landing from a jump (particularly on an incline or uneven surface)

- calf stretching with a bent knee

- heavy lifting or twisting activities

How does anterior ankle impingement occur?

Anterior ankle impingement commonly occurs following recurrent ankle sprains or repeated weight bearing and dorsiflexion in loaded positions (i.e. Landing, deep squats and lunges). However, it may also occur following a trip or a fall with your foot still firmly planted in the ground (forced dorsiflexion).

Along with these mechanisms, there are a number of risk factors that may predispose you to Anterior ankle impingement:

- inadequate rehabilitation following a previous ankle injury, resulting in calcification

- joint stiffness or swelling which causes narrowing of the joint space

- cyst or other growth at the front of the ankle

- muscle tightness

- irregular bone shape at the anterior talus

- poor foot biomechanics (e.g. “flat feet” or high arches)

- poor lower limb biomechanics

- inappropriate training (including technique, footwear or training surfaces)

- excessive training

- inadequate recovery periods from practice and games

- inadequate warm-up

- poor core stability

- poor proprioception or balance

How is anterior ankle impingement diagnosed?

It is usually diagnosed following a consultation with your physiotherapist, where they will conduct a comprehensive physical assessment as well as ask you series of questions about your history.

In some cases, your physiotherapist may refer you for some imaging to ensure the diagnosis is correct. An X-ray (lateral and oblique radiograph) can be used to identify bony spurs. An MRI can also be useful to identify swelling and irritation of the anterior capsule and synovium (soft tissues) as well as rule out other potential causes

How can physiotherapy help?

Physiotherapy treatment of anterior ankle impingement comprises of several phases.

During the initial phase, we focus on pain relief, minimise swelling and injury protection. This may involve:

• Active rest from pain provocative movements or activities (ie. short term rest from squatting, jumping and landing, running hills etc)

• Ice during initial phase for pain relief

• Compression

• Elevation to facilitate lymphatic drainage for excess swelling

• Electrotherapy, unloading taping techniques, STM, heel raises and bracing may all be used to de-load the irritated ankle structure and reduce pain and inflammation.

The second phase is designed to restore your full range of motion.

In the third phase, we aim to restore muscle strength.

• Progress calf, ankle and foot strengthening.

• Address proximal kinetic chain and strengthen as appropriate.

• Restoring strength in ankle, calf and foot muscles as well as proximal chain is pivotal to provide dynamic ankle control required for function and to prevent future episodes.

We then help you restore function (speed, power, proprioception and agility)

• This is important for full recovery and prevention of re-injury.

• Most anterior ankle impingement occurs with high loading and high speeds – we can help to ensure that the ankle is given time to adapt to these loads and are reintroduced before return to sport.

• Train sport specific demands (part practice).

Lastly, the treatment aims to help you to return to sport (RTS) and daily activities

• Gradual return to sport program (starting with lighter training sessions before progressing all the way towards full training load and game play with full speed, power, agility and function).

• If rehab has been effective RTS should be pain free and safe.

If you have any further questions or would like an individualised assessment and treatment on your ankle injury, please give us a call on 3061 7128.

Blog and videos by Physiotherapy Student undertaking clinical placement from the University of Queensland, Australia, supervised by Principal Physiotherapist, Winnie Lu.

References:

Vaseenon, T., & Amendola, A. (2012). Update on anterior ankle impingement. Current reviews in musculoskeletal medicine, 5(2), 145–150. https://doi.org/10.1007/s12178-012-9117-z

Kerkhoffs, G., Golanó, P., & de Leeuw, P. (2014). Anterior Ankle Impingement. Sports Injuries, 1-15. doi: 10.1007/978-3-642-36801-1_139-1