Podiatry Arena members do not see these ads

I have been managing a patient with chronic anterior ankle pain following an inversion sprain 6 months again. The trauma was diagnosed as a grade 2 ATF tear by her physio and appropriate management and rehabilitation was conducted.
Her anterior ankle pain developed approx 3 months after the incident. There is no swelling, joint ROM is normal and pain is very difficult to reproduce in a clinical setting. X rays and CTs are negative. No MRI studies have been conducted at this stage. I have initiated a 6 week period of below knee cam walker wear but am sceptical as to wether this will reduce her pain enough to allow her to return to triathlon training.I would be interested to hear thoughts regarding conservative and surgical management to simialar anterior impingement/ bassett impingement problems.
Luke Grainger

For anterior ankle impingement to exist, there must be some (albeit minor) deficit in ROM. Re-check the ankle dorsi-flexion lunge test. If it has identical ROM to the contra-lateral ankle (which I doubt), then surely, the patient should perceive anterior symptoms with the test (compared with the physiological achilles stretch on the 'good' ankle).

Once you have found the specific joint (obstruction) limitation, or the specific pain provocative test, then we can discuss the plethora of conservative options that the clinician has in dealing with anterior ankle impingement.

If you can't find the limitation or provocation test, then you must clear other DDx's that can contribute to 'anterior ankle pain' but are not necessarily impingement/compressive pathologies. Such as anterior ankle tendinopathy (foot/toe dorsi-flexors) that xray/CT may not highlight. You should be able to clear these with resistance testing etc.



My advice is to go back to the lunge test, and ask WHERE the patient feels the end-range restriction. If an impingement exists on the 'bad' ankle, the patient will point anterior; compared to the achilles stretch perceieved on the 'good' one.

BTW, you should be commended for bringing 'ankle impingement' into the arena. This is not well understood and often missed, and then we wonder why months of proprioception and strengthening exercises dont work with some/many.

IMO, the impingement is the cake, and the often over-prescribed over-used exercises are the icing.

Moreover, simple mechancal principles underpin impingement pathology. When it is understood by more foot/ankle clinicians, suddenly complex ankle conditions will not be so complex anymore.

The patient may have a high ankle sprain. They eventually heal, but they take a very long time.

BTW, it is possible to suffer anterior impingement subsequent to a signifiicant anterior ankle sprain without preexisting ROM deficit. The talus has to have displaced forward enough to prevent adequate posterior glide in the mortise on dorsiflexion. Does the ankle hurt on stair descent? Do you have a reliable method to check both accessory roms (distal tib-fib mobility, anterior, and posterior dispalcement of the talus), as well as a quantifiable way to check gastroc-obviated talar dorsiflexion? You need these technics to diagnose and treat anterior impingement.

__________________
A pain-free foot is a beautiful foot

Some interesting points. Just a quick update as to what is happening. MRI scans were ordered by her GP this week and results are pending. Lunge testing was conducted and was within normal limits. With regards to the talar displacement i question wether this would be visible in her CT investigations. From my observations her talar position in the CT scans appears normal when compared to her other ankle. I will keep you informed of her MRI results
Regards
Luke

Hi

If there is no obvious physical cause has anyone explored tissue memory or mind memory (not brain) as a store for the trauma of the incident.

I had a lady who broke her fibula. 12 months later there was still some residual pain but, significantly, a noticable limp on the affected side. All else seemed to be OK. Being a family friend I suggested letting me treat her, without explanation of the treatment until it was over. She was OK with this so we went ahead. The treatment only lasted 45 seconds. Her gait immediately after the treatment was normal with improved leg swing, base and angle of gait and arm swing.

Simply a suggestion.

Ian

Hi Luke

I have seen several cases such as these where the pain eventually turned out to be impingement at the distal end of the tibial/fibular ligament (post injury scarring). After failure of conservative treatment relatively simple surgery to excise the soft tissue impingement has worked well in each case. My preference is open ankle approach rather than arethrosopic in these circumstances. You can often see the anomalie on MRI.

Regards Mark

What about trying to bind/compress tib and fib distally in the transverse plane in order to see if pain decreases in use...get some expansion stress off structures posed by Mark?
Regards Phill

Anterior impingement syndrome in dancers
John William O’Kane and Nancy Kadel
Current Reviews in Musculoskeletal Medicine
Link

__________________
Who is NewsBot?
Buy Admin a Beer