Ankle Impingement Overview

Do you suffer from pain in the front or back of your ankle? Do you notice that symptoms get worse when you squat, kick a ball, stand on your toes, or walk uphill? You may be suffering from ankle impingement—an umbrella term characterized by pain and inflammation that affects the range of motion in your ankle due to pinching of local soft tissues. Keep reading to find out more about ankle impingement: causes, symptoms, and the treatments available.

What is Ankle Impingement?

Ankle impingement is described as painful pinching of the tissue in the front or back of the ankle. This onset can be insidious or secondary to an injury and is most common in athletes. There are two primary categories of ankle impingement: anterior impingement and posterior impingement. 

Anterior Ankle Impingement Syndrome

Also known as footballer’s ankle, anterior ankle impingement is the most common cause of pain in the front (anterior) of the ankle joint. The condition results from increased pressure or irritation of the anterior bones, such as the talus or tibia, or soft tissues with ankle dorsiflexion (toes up toward the shin). In some cases, this pressure can lead to the formation of bone spurs, or osteophytes—bony projections which can then "impinge" on each other, or pinch the surrounding joint capsule and tissue even further.

These spurs most often develop in response to the repeated stress or bony contact caused by repetitive motions, so it’s no surprise that the people most at risk of anterior ankle impingement are soccer players, runners, and other athletes that spend a lot of time squatting, kicking, and running. However, acute trauma like an ankle sprain, or conditions like arthritis, can also lead to ankle impingement.

Posterior Ankle Impingement Syndrome

Also known as ballet dancer’s ankle, posterior ankle impingement is a less common condition characterized by compression of the structures in the back of the heel and ankle. The pain, swelling, and stiffness are caused by tissue irritation with plantar flexion, or pointing the toes. Bone spurs can also grow in the posterior ankle. However, it is less common. Any sport or activity that requires extensive time in the toes, such as dancing, can lead to this issue.

The Causes and Risk Factors

There are several causes and risk factors associated with ankle impingement, ranging from acute trauma to inadequate warmup. Common reasons you may be suffering from ankle impingement include:

• Activities that repeatedly put stress and microtrauma (high impact) on the ankle, including football, soccer, volleyball, running, ballet, basketball, jumping, deep squats, etc.
• Acute trauma, such as an inversion ankle sprain or ankle fracture, that lead to soft tissue impingement
• Age—this condition slowly progresses over time, so it’s generally seen in people who are at least 25 years old
• Arthritis of the ankle
• Excessive training
• Failure to warm up properly before workouts
• Inadequate rehabilitation from a prior ankle injury
• Inappropriate footwear
• Lack of recovery time between training sessions
• Poor athletic technique or form
• Structural issues with the feet, such as flat feet or high arches
• Swollen or stiff joints
• Tight muscles

The Main Symptoms

If you’re suffering from any of the following symptoms, you may have ankle impingement. Consult your doctor immediately to prevent unnecessary aggravation and reduce necessary down time for recovery.

• Acute or chronic ankle pain in the anteromedial (front/middle) ankle with ankle dorsiflexion (bend) or inversion (inward)- most common with anterior impingement
• Pain in the back of the ankle when pointing the toes- most common with posterior impingement
• Dull ache in the front or back of the ankle when resting
• Increased front ankle pain when walking or running, especially uphill or on uneven terrain
• Increased back ankle pain with the push off phase of running, walking, or jumping
• Tenderness when touching the front, back, or even medial ankle
• Feeling the ankle "click" or catch during certain movements
• Swelling of the ankle joint
• Ankle weakness or ankle instability, particularly of the peroneals
• Limited and/or painful range of motion of the ankle
• A bony bump or lesion on the front or back of the ankle

How Ankle Impingement is Diagnosed

Although you may suspect you have ankle impingement based on symptoms like pain in the front of the ankle when flexing or the back of the ankle with pointing the toes, you should see your doctor or physiotherapist for a formal diagnosis. Your doctor will diagnose based on a physical exam and the results of imaging techniques (if needed).

Physical Exam

Your orthopedic doctor or physiotherapist will take your medical history and will inquire about your participation in sports and other activities. They will make a record of your symptoms and prior injuries and then perform a physical examination to check for range of motion, strength, joint mobility, pain, swelling, or lumps around the ankle.

They may also perform this simple ankle impingement test to gauge your pain response. There are also a handful of special tests they can perform to rule out and determine what is causing your ankle pain.

Imaging Techniques

X-rays or MRI scans can be ordered by your sports medicine doctor to diagnose anterior and posterior ankle impingement and to rule out other conditions. X-rays can highlight bone spurs, while magnetic resonance imaging (MRI) scans may uncover things an X-ray cannot, such as inflammation, fluid build-up, or injury to the cartilage, ligaments, and muscle.

Ankle Impingement Recovery Time

The prognosis and recovery time for ankle impingement varies from person to person and depends on a number of factors, including the type, severity, general health, and treatments employed.

• If you have a straightforward case of ankle impingement, you may be able to return to activities within four to six weeks.
• Severe symptoms requiring surgery, most often secondary to bone spurs, may need up to six months to completely recover before returning to strenuous activities and competitive sports.

Common invasive interventions include corticosteroid injections, arthroscopy and debridement to allow more space for normal ankle movement without pinching.

Regardless of the severity of the condition, early intervention is key to a speedy recovery. People who use the RICE protocol and other pain relieving modalities along with physical therapy tend to recover faster than those who delay treatment or employ inadequate recovery techniques.

Treatment for Ankle Impingement

What to Do About it

Ankle impingement is a common condition, but one which is easily preventable with the right tools and awareness.

Our feet and ankles do so much for us—literally supporting us in all we do. They deserve our support, too. If you're experiencing any of the symptoms we talked about, be sure to get a proper evaluation done by your doctor or even a physical therapist. 

Sources:

https://www.physio-pedia.com/Ankle_Impingement#:~:text=Ankle%20impingement%20is%20defined%20as,the%20tibiotalar%20(talocrural)%20joint.

https://josr-online.biomedcentral.com/articles/10.1186/s13018-016-0430-x