Posterior Ankle Impingement: Don t Get Pinched

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Clyde Parrish
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1 Posterior Ankle Impingement: Don t Get Pinched 11 th Annual Sports Medicine Continuing Education Conference Gregory P Witkowski, MD Orthopaedic Trauma and Foot/Ankle Surgery

2 Disclosures I have nothing to disclose relative to this talk 2

3 Objectives Discuss the etiology of posterior ankle impingement Explain the relative anatomy associated with posterior ankle impingement Explore non-surgical treatment Explore surgical treatment options Look at outcomes and return to sport after non-surgical and surgical treatment 3

4 What is it? Numerous names Posterior ankle impingement syndrome (PAIS) Os trigonum syndrome Hindfoot impingement Talar compression syndrome Clinical disorder characterized by posterior ankle pain associated with ankle plantar flexion 4

5 Anatomy 2 posterior tubercles (processes) Lateral larger (Steida process) Medial FHL runs between Posterior talo-fibular ligament attaches to lateral tubercle Secondary ossification center arises between 8 and 13 years 5

$(synchondrosis) From 7 to 14% of people Stress fracture of lateral$

6 Anatomy Os tirgonum Failure of fusion of the ossification center (synchondrosis) From 7 to 14% of people Stress fracture of lateral tubercle 6

7 Etiology of Posterior Ankle Pain Most commonly associated with an os trigonum (bony impingement) Fracture Osteochondritis Flexor hallicus longus tendinitis Scar tissue (soft tissue impingement) Tibiotalar pathology Osteochondral lesion Arthritis Subtalar joint disease 7

Steidia process Disruption of the synchondrosis

8 Mechanism Overuse injury resulting from ankle plantar flexion Acute trauma Fracture of the Steidia process Disruption of the synchondrosis Avulsion of the posterior talofibular ligament Os trigonum fracture 8

of ankle sprain Posterior ankle pain worse with plantar

9 Clinical Presentation Associated with numerous sports Ballet Soccer Any kicking sport Running downhill History of ankle sprain Posterior ankle pain worse with plantar flexion Worse with aggravating activities Better with rest 9

Worse with maximal passive plantar flexion Pain

10 Clinical Presentation Exam Posterolateral ankle tenderness Between Achilles and peroneal tendons Worse with maximal passive plantar flexion Pain with dorsiflexion of great toe may suggest FHL tenosynovitis 10

11 Imaging Standard ankle X-rays AP, lateral and mortise Typically sufficient to diagnose with history Maximal plantar flexion stress radiograph May show the ankle impingement 11

12 Imaging MRI Can show marrow edema of os trigonum/stieda process Can allow you to differentiate causes of PAIS Not always associated with an os trigonum 12

13 Nonsurgical Treatment Nonsurgical Rest Ice NSAID s Boot immobilization Activity modification 13

14 Nonsurgical Treatment Corticosteroid injections Under flouro or US guided Can lead to complete symptom resolution Mouhsine et al 2004, Knee Surg Sports Traumatol Arthrosc 19 patients received injection under flouro 10 complete resolution, 6 had resolution after 2 injections 14

Nonsurgical Treatment Albisetti et al 2009 Nonsurgical protocol in ballet dancers Activity restriction (demi-pointe, pointe work) NSAID s PT with proprioception training Goal is to minimize the role

15 Nonsurgical Treatment Albisetti et al 2009 Nonsurgical protocol in ballet dancers Activity restriction (demi-pointe, pointe work) NSAID s PT with proprioception training Goal is to minimize the role of the gastrocnemius when relevé position performed 9 out of 12 had success, 3 went on to surgical management Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20(5):

16 Surgical Treatment Open Excision Excision of the Os trigonum or Stieda process FHL tenosynovectomy Posteromedial Labs et al ballet dancers 54% very good, 21% good 72 days average to return to dance Tibial neuropraxia (1), hematoma (1) Labs K, Leutloff D, Perka C: Posterior ankle impingement syndrome in dancers: A shortterm follow-up after operative treatment. Foot Ankle Surg 2002;8(1):

17 Surgical Treatment Open Excision Posterolateral Marotta and Micheli dancers (15 ankles) Average time to full recovery 3 months All returned to pre injury function Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20(5):

Surgical Treatment Posterior Ankle Endoscopy Posterior ankle endoscopy Van Dijk CN et al 2000 Prone patient Posterolateral and posteromedial portal van Dijk CN, Scholten PE, Krips R: A

18 Surgical Treatment Posterior Ankle Endoscopy Posterior ankle endoscopy Van Dijk CN et al 2000 Prone patient Posterolateral and posteromedial portal van Dijk CN, Scholten PE, Krips R: A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy 2000;16(8): Standard of care for surgical management Earlier return to play/training 18

19 Surgical Treatment Posterior Ankle Endoscopy Guo et al 2010 Open vs. posterior endoscopic excision of os trigonum 41 patients 16 open excision, 25 posterior endoscopy No difference at mean 38 months follow up RTS open group 11.9 weeks RTS endoscopy group 6 weeks Guo QW, Hu YL, Jiao C, Ao YF, Tian X: Open versus endoscopic excision of a symptomatic os trigonum: A comparative study of 41 cases. Arthroscopy 2010;26(3):

20 Post Op Protocol Open Splint for 2 weeks for wound healing Transition to boot WBAT PT for ROM, proprioception Endoscopy Immediate boot WBAT Start early ROM PT at 2 weeks 20

21 Case 20 y/o college football player Initially injured ankle in March 2016 Treated conservatively and responded August 2016 planted foot and had a forced plantar flexion injury Felt pop and had similar pain to what he had in March Exam TTP posteromedial and lateral ankle Worse with plantar flexion 21

22 22

23 Fracture of Stieda process 23

24 Treatment Options Nonsurgical Boot RICE NSAID s PT Likely out for season Surgical treatment Open vs. Endoscopic excision 24

25 Treatment FHL Posterior ankle endoscopy Boot post op Weight bearing as tolerated PT at 2 weeks Returned to training at week 6 Excised Stieda process Calcaneus 25

26 Summary Most likely cause of PAIS is an injury to an Os Trigonum or Stieda process Diagnosis is usually made by history and physical exam MRI is beneficial to rule out other causes Nonsurgical management helpful about 50% of time Posterior endoscopy is very successful surgical management with good outcomes and early return to play 26

27 Thank You

Case Report Combined Posterior and Anterior Ankle Arthroscopy

Case Reports in Orthopedics Volume 2012, Article ID 693124, 4 pages doi:10.1155/2012/693124 Case Report Combined Posterior and Anterior Ankle Arthroscopy Peter E. Scholten 1, 2 andc.niekvandijk 2 1 Department