Ankle Impingement: Tips Tricks and Management

Ankle impingement is a common condition that affects individuals engaging in various physical activities, particularly athletes, and can significantly impede their performance. Understanding the mechanisms of injury leading to impingement, and effective early stage management strategies are critical for facilitating optimal rehabilitation. In this discussion, we will explore the intricacies of ankle impingement, how it comes about and some of the useful tips to manage it long term.

Anatomy and Function of the Ankle Joint Complex

The ankle joint complex comprises the articulation between the tibia, fibula, and talus bones. This joint is supported by several ligaments, tendons, and muscles crucial for stability and movement. The primary ankle joint, known as the talocrural joint, allows dorsiflexion and plantarflexion, while the subtalar joint, situated below, permits inversion and eversion movements. The ligaments and soft tissues structures, including the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL), stabilises the ankle against excessive inversion. Meanwhile, the deltoid ligament, positioned medially, guards against excessive eversion.

During walking or sports activities, the ankle is subjected to substantial forces. Dorsiflexion occurs when the foot moves upward, while plantarflexion involves pointing the foot downwards. Inversion and eversion motions describe the inward and outward rotation of the foot.

Mechanisms of Injury Leading to Ankle Impingement:

Ankle impingement occurs when soft tissues are compressed between joint surfaces, often resulting from repeated microtrauma or acute injury with the two main types of impingement being, anterior and posterior.

Anterior Impingement: This commonly affects the anterior talofibular ligament and surrounding structures including that make up the ankle capsule. It typically arises from repetitive dorsiflexion, as seen in activities like sprinting, jumping, or ballet. Overuse or traumatic events can lead to thickening of the ligamentous and connective tissue and/or osteophyte formation, resulting in a reduction of space around the articular surfaces causing impingement during dorsiflexion.

Posterior Impingement: In contrast, posterior impingement involves compression at the back of the ankle, often during forced plantarflexion. Ballet dancers frequently experience this due to the extreme plantarflexion demanded by their art going “en pointe”, as well as footballers given the repetitive nature of kicking a ball, thickening of the posterior capsule or growth of osteophytes.

Early Stage Management Strategies

1. Rest and Ice: Initially, it's crucial to reduce inflammation. Rest and applying ice can help alleviate pain and swelling.

2. Physiotherapy: A specialised exercise program, focusing on strength, flexibility, and proprioception, is fundamental. This aims to restore the normal range of motion and strengthen the ankle complex, including proprioceptive training to improve joint awareness.

3. Taping and Bracing: Using techniques for taping or providing ankle braces can offer temporary support and assist in stabilising the joint and reducing movement in the ranges that aggravate the symptoms.

4. Manual Therapy: Physiotherapists can employ hands-on techniques to mobilise the joint and soft tissues, aiming to reduce pain and restore optimal function. They can guide self help routines and ankle mobility drills that can be used regularly to help alleviate symptoms and facilitate range of movement.

5. Activity Modification: Modifying or avoiding activities that exacerbate symptoms is pivotal to prevent further injury or irritation to the impinged structures. This helps to reduce the persistent nature of the chronic inflammatory cycle, which encourages the thickening of the capsules or growth of osteophytes. 

Conclusion

Ankle impingement is a complex condition demanding a comprehensive understanding of ankle joint anatomy, injury mechanisms, and optimal management strategies. As physiotherapists, the integration of evidence-based practices and clinical expertise is paramount in providing effective care to individuals experiencing ankle impingement. However, Scientific evidence for managing ankle impingement is not prolific and still remains based mostly on clinical experience with an understanding of the biomechanics and anatomy, along with a good understanding of what aggravates the person's symptoms. By focusing on early stage management, including rest, specialised exercises, taping, manual therapy, and activity modification, we can effectively address this condition and facilitate a safe return to full function.

References:

Fong, D. T., et al. (2013). Ankle impingement mechanisms and management: a literature review. Open Access Journal of Sports Medicine, 4, 63–68.

Hubbard, T. J., et al. (2011). Mechanical instability after an acute lateral ankle sprain. Archives of Physical Medicine and Rehabilitation, 92(10), 1676–1681.

Hertel, J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training, 37(4), 364–375.