■ ■ ■ Description

Posterior ankle impingement is characterized by pinching and inflammation of the tissues in the back of the ankle. This may be associated with a fracture in the back of the ankle bone (talus) or an extra bone behind the ankle (os trigonum). This occurs in people who are their toes often, such as ballet dancers, ice skaters, and gymnasts.

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■ ■ ■ Common Signs and Symptoms

• Pain with forced plantar flexion (forcing the toes downward), when standing on tiptoes, and when wearing shoes with high heels; pain with flexing (bending) of the great (big) toe

• Tenderness in the back of the ankle (occasionally on the outside of the ankle)

• Pain when running, jumping, or walking down stairs or hills or when squatting while standing on the toes

• Mild swelling and occasionally bruising in the back of the ankle or heel (with fracture)

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■ ■ ■ Causes

• Repeated or single forced plantar flexion (toes pointing down) injury to the foot and ankle, such as from heels catching while going down stairs, from sliding and catching the heel of the shoe or cleats, when kicking a football, or when standing on the tips of the toes repeatedly

• Less commonly, due to excessive dorsiflexion (extension of the ankle, toes going up); often associated with twisting of the ankle

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■ ■ ■ Risk Increases With

• Sports that require repeated standing on the tips of the toes (ballet dancing, gymnastics, ice skating); sports that involve sliding in shoes with cleats, where the heel may catch the ground, causing a forced flexion of the ankle (soccer, baseball); or with repeated kicking with the foot plantarflexed (such as when kicking a football)

• Previous foot or ankle sprains or dislocations

• Shoes with inadequate support to prevent forced flexion of the ankle or shoes with excessively long cleats

• Poor physical conditioning (strength and flexibility)

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■ ■ ■ Preventive Measures

• Appropriately warm up and stretch before practice or competition.

• Maintain appropriate conditioning:

  • Ankle and leg flexibility

  • Muscle strength and endurance

• Use proper technique and have a coach correct improper technique.

• Taping, protective strapping, bracing, or high-top shoes may help prevent injury. Initially, tape is best; however, it loses most of its support function within 10 to 15 minutes.

• Wear proper protective shoes (high-top shoes with taping or bracing are more effective than either alone) and the correct length of cleats for the surface.

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■ ■ ■ Expected Outcome

This condition is usually curable within 4 to 6 weeks with appropriate treatment. The recovery is quicker if not associated with fracture.

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■ ■ ■ Possible Complications

• Prolonged healing time if not appropriately treated or if not given enough time to heal

• Prolonged disability

• Frequent recurrence of symptoms; appropriately addressing the problem with rehabilitation decreases frequency of recurrence and optimizes healing time

• Complications of surgery, including infection, bleeding, injury to nerves, pain, ankle stiffness, and weakness

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■ ■ ■ General Treatment Considerations

Initial treatment consists of medications and ice to relieve pain, stretching and strengthening exercises, and modification of the activity that initially caused the problem. These can all be carried out at home for acute cases. Occasionally, immobilizing the ankle with bracing, casting, or a walking boot may be attempted to allow the inflammation to settle down. Chronic cases often require referral to a physical therapist or athletic trainer for further evaluation and treatment. If symptoms persist, an injection of cortisone and anesthetics or surgical intervention may be required. Uncommonly, surgery may be necessary to remove the small piece of bone that may be causing the pinching and pain with flexion of the foot and ankle.

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■ ■ ■ Medication

• Nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen (do not take within 7 days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician. Contact your physician immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.

• Pain relievers may be prescribed as necessary by your physician. Use only as directed.

• Injections of corticosteroids may be given to reduce inflammation, although not usually for acute injuries.

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■ ■ ■ Heat and Cold Therapy

• Cold is used to relieve pain and reduce inflammation for acute and chronic cases. Cold should be applied for 20 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or ice massage.

• Heat may be used before performing stretching and strengthening activities prescribed by your physician, physical therapist, or athletic trainer. Use a heat pack or a warm soak.

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■ ■ ■ Notify Our Office If

• Symptoms get worse or do not improve in 2 weeks despite treatment

• Cast discomfort develops

• Any of the following occur after surgery:

• You experience pain, numbness, or coldness in the foot and ankle

• Blue, gray, or dusky color appears in the toenails

• Signs of infections develop, including fever, increased pain, swelling, redness, drainage, or bleeding in the surgical area

• New, unexplained symptoms develop (drugs used in treatment may produce side effects, including bleeding, stomach upset, or an allergic reaction)