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•There is a lack of prospective studies on the treatment of PAIS.
•Long term outcomes from open and endoscopic surgery are satisfactory.
•Complications rates are comparable between open medial and endoscopic surgery.
•Return to sporting activities is quicker in artho-endoscopically treated patients.
•No evidence supports superior long term results with any one technique.
A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Forty-seven papers have reported on the surgical outcomes of 905 procedures involving both open and artho-endoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers.
Background: An os trigonum may cause posterior ankle impingement syndrome (PAIS), which may lead to poor sports performance, especially in soccer players. The aim of the present study was to analyze the outcomes of endoscopic repaired posterior ankle impingement (PAI) secondary to os trigonum syndrome within a group of soccer players as well as their return to play time.
Methods: A retrospective review of 20 soccer players with Tegner activity level 9 was performed. All players were diagnosed of PAIS due to os trigonum. Chief complaint was pain produced with forced plantarflexion when kicking the ball. Conservative treatment was first performed during a 6-week rehabilitation program. When conservative treatment failed, arthroscopic surgical resection of the os trigonum was proposed. Visual analogue scale (VAS) was used to measure pain before and after surgery as well as time until their return to previous sports level.
Results: VAS showed a mean preoperative pain score of 7.5 (SD = 0.9), whereas postoperative VAS at 1 month after surgery decreased to 0.8 (SD = 1.36). Mean symptomatic period was 8.5 months (SD = 4.3), from the beginning of symptoms up to the surgery day. Once patients had undergone surgery, mean time until their return to previous level of sports was 46.9 days (SD = 25.96), reaching the same pre-lesion Tegner level.
Conclusions: Endoscopic treatment of posterior ankle impingement syndrome due to os trigonum showed excellent results. Hindfoot endoscopy with a posterior approach was an effective treatment and allowed for a prompt return to play in soccer players with a high activity level.
Pain posteriorly in the ankle can be caused by bony impingement of the posterolateral process of the talus. This process impinges between the tibia and calcaneus during deep forced plantar flexion. If this occurs it is called posterior ankle impingement syndrome. We report the case of 2 athletic monozygotic twin brothers with bony impingement posteriorly in the left ankle. Treatment consisted of ankle arthroscopy in both patients during which the symptomatic process was easily removed. At 3 months after surgery, both patients were completely free of pain, and 1 of the brothers had already returned to sports. The posterior ankle impingement syndrome is not a rare syndrome, but it has not been described in siblings thus far. That these 2 patients are monozygotic twin brothers suggests that genetics could play a role in the development of skeletal deformities that can result in posterior ankle impingement syndrome.
Objectives: Open and arthroscopic techniques have been utilized in the treatment of posterior impingement of the ankle and hindfoot. Because posterior impingement occurs more frequently in patients who repetitively plantarflex the ankle, this population may especially benefit from a procedure that reduces pain and results in maximal range of motion (ROM). The purpose of this study was to assess the outcome of hindfoot endoscopy in patients with posterior ankle impingement through higher level of function outcome measures and physical examination parameters, focused on analysis of ROM.
Methods: 20 ankles (19 patients) were followed prospectively at a minimum 1 year follow-up (mean 38.2 months). 19 of 20 patients were competitive athletes. Patients completed a minimum of 3 months of nonoperative treatment. Diagnoses included os trigonum, tibial exostosis, talar exostosis, loose body or fracture nonunion, and ganglion cyst removal. Patients underwent arthroscopic treatment utilizing a posterior approach; all relevant pathology was addressed. Post-surgery, patients were placed in a splint for 3 to 7 days then placed in a CAM boot for 2 to 3 weeks, weight bearing as tolerated. Physical therapy was initiated within 7-10 days; strengthening exercises were initiated postoperatively at 1 month.
Results: At most recent follow-up, VAS Pain and AOFAS Hindfoot scores showed significant improvement (p<0.01) pre to post-operatively; Tegner score remained unchanged (p=0.888). 3 patients were professional athletes; all returned to their previous level of professional activity. ROM variables between affected and unaffected sides reached statistical similarity at most recent follow-up. 15% of patients reported post-operative neuritis. No other complications were reported.
Conclusion: Posterior ankle arthroscopy allows for maintenance or restoration of anatomic ROM of the ankle and hindfoot, ability to return to at least previous level of activity, and improvement in objective assessment of pain relief and higher level of function parameters. Complications associated with this procedure are minimal.
The safety of the posterior ankle arthroscopy in management of posterior ankle impingement: a cadaveric study
T.H. Lui, L.K. Chan The Foot; Article in Press
?Arthroscopic management of the posterior ankle impingement with the patient in supine position has the advantage of dealing with anterior ankle pathology at the same time without the need to change position of the patient.
?Posteromedial portal is just anterior to the posterior tibial tendon and posterolateral portal is just posterior to the peroneal tendons.
?The coaxial portals are not suitable for treating the Achilles tendon pathology especially the insertional problem.
Arthroscopic management of the posterior ankle impingement with the patient in supine position has the advantage of dealing with anterior ankle pathology at the same time without the need to change position of the patient. This study aims at evaluation of the safety of portal establishment and instrumentation of this technique.
Sixteen fresh-frozen cadaver specimens were used. The relationships of the posteromedial and posterolateral portals to the adjacent tendons and nerves and the relationship of the coaxial portal tract with the posterior ankle capsule and the flexor hallucis longus tendon were studied.
Angle θ1 between the intermalleolar line and the posterior ankle coaxial portal tract averaged 1? (10? to 22?). Angle θ2 between the intermalleolar line and the metal rod where the neurovascular bundle started to move averaged 19? (10? to 30?). Angle θ3 between the intermalleolar line and the metal rod where it reached the lateral border of the Achilles tendon was larger than angle θ2 in all specimens. The angle of safety (θs) averaged 18? (-1? to 26?).
Injury to the tendon, nerves or vessels is possible during establishment of the portals and resection of the os trigonum.
Os Trigonum - Sheer Incidental or Quite Significant? Single Photon Emission Computed Tomography/Computed Tomography's Role in a Case of Ankle Impingement.
Chokkappan K et al World J Nucl Med. 2015 Sep-Dec;14(3):205-8
Accessory ossicles are widely prevalent in the ankle and foot. Although they are often asymptomatic, they can present clinically with symptoms at times. When they occur bilaterally in a patient who presents with unilateral complaints, it is clinically difficult to attribute the symptoms to the presence of these common anatomic variants. One needs specific imaging to assess the clinical relevance of the accessory ossicles, in order to tailor the treatment plan. The case presented in this article is one such example, where the patient presented with chronic unilateral ankle pain and initial radiographs revealed bilateral os trigonum and os subtibiale. He underwent a technetium-99m methyl diphosphonate (Tc-99m MDP) bone scan and single photon emission computed tomography/computed tomography (SPECT/CT). The Tc-99m MDP scan showed a focal uptake in the ankle of concern. SPECT/CT complemented the finding by exactly localizing the uptake to the posterior subtalar joint and around the os trigonum, thereby pointing to the diagnosis of os trigonum syndrome.
Background: Open and arthroscopic techniques have been utilized in the treatment of posterior impingement of the ankle and hindfoot. Because posterior impingement occurs more frequently in patients who repetitively plantarflex the ankle, this population may especially benefit from a procedure that reduces pain and results in maximal range of motion (ROM). The purpose of this study was to assess the outcome of hindfoot endoscopy in patients with posterior ankle impingement through a higher level of function outcome measures and physical examination parameters, focused on analysis of ROM.
Methods: Twenty patients were followed prospectively at a minimum 1-year follow-up (mean 38.2 months). Nineteen of 20 patients were competitive athletes. Patients completed a minimum of 3 months of nonoperative treatment. Diagnoses included os trigonum, tibial exostosis, talar exostosis, loose body or fracture nonunion, and ganglion cyst removal. Patients underwent arthroscopic treatment utilizing a posterior approach; all relevant pathology was addressed.
Results: At the most recent follow-up, visual analog scale pain and American Orthopaedic Foot & Ankle Society hindfoot scores showed significant improvement (P < .01) pre- to postoperatively; Tegner score remained unchanged (P = .888). Three patients were professional athletes; all returned to their previous level of professional activity. ROM variables between affected and unaffected sides reached statistical similarity at the most recent follow-up. Only ankle plantarflexion reached statistical significance when compared pre- to postoperatively. Fifteen percent of patients reported postoperative neuritis.
Conclusions: Posterior ankle arthroscopy allowed for maintenance or restoration of anatomic ROM of the ankle and hindfoot, ability to return to at least previous level of activity, and improvement in objective assessment of pain relief and higher level of function parameters. Complications associated with this procedure were minimal.
Posterior ankle impingement is a clinical diagnosis which can be seen following a traumatic hyper-plantar flexion event and may lead to painful symptoms in athletes such as female dancers ('en pointe'), football players, javelin throwers and gymnasts. Symptoms of posterior ankle impingement are due to failure to accommodate the reduced interval between the posterosuperior aspect of the talus and tibial plafond during plantar flexion, and can be due to osseous or soft tissue lesions. There are multiple causes of posterior ankle impingement. Most commonly, the structural correlates of impingement relate to post-traumatic synovitis and intra-articular fibrous bands-scar tissue, capsular scarring, or bony prominences. The aims of this pictorial review article is to describe different types of posterior ankle impingement due to traumatic and non-traumatic osseous and soft tissue pathology in athletes, to describe diagnostic imaging strategies of these pathologies, and illustrate their imaging features, including relevant differential diagnoses.
An os subtibiale is a rare accessory bone located below or behind the medial malleolus. Herein we present a rare case of a painful os subtibiale in a young triathlete who presented with pain, redness and swelling below his left medial malleolus. Plain radiographs and three-dimensional computed tomography revealed a well-defined oval bone distal to the left medial malleolus. After conservative treatment failed, the ossicle was excised in an open surgery with complete resolution of symptoms. This case report emphasizes the need for clinical awareness of different anatomical variations of the bones of the foot.