Physical Therapist's Guide to Ankle Impingement
Ankle impingement occurs when either soft or bony tissues are compressed within the ankle joint at the extreme end of a motion, such as pointing the foot sharply downward. It typically affects people who experience forces through their ankle at these "end-range" positions, such as dancers, gymnasts, or people performing kicking activities. Additionally, people who perform repetitive tasks that involve squatting or stair-climbing are susceptible to this condition. Physical therapists help people with ankle impingement reduce their pain, heal and strengthen the affected area, and improve their overall balance.
Ankle impingement can be categorized into 2 types:
- Anterior ankle impingement
- Posterior ankle impingement
Anterior ankle impingement involves pain on the front side of your ankle. Inflammation and swelling occur due to repetitive stresses at end-range positions of the ankle, such as when one jumps, squats, or descends stairs. These may eventually lead to development of bone spurs (a bony overgrowth) in the ankle joint space. An additional cause of anterior ankle impingement is ankle instability. Ankle instability is a looseness of the ankle joint that develops after repeated ankle sprains, causing damage to ligaments in the ankle. This damage can cause the ligaments to become scarred and take up more joint space. Tissue in the joint space is then compressed, causing pain during activities that require ankle dorsiflexion (stretching your toes up toward your shin). Examples of these activities include squatting, jumping, and stair-climbing.
Posterior ankle impingement involves pain on the back side of your ankle, especially during activities that involve pointing your toes. The pain is caused by compression of soft or bony tissue between the shin bone (tibia) and the heel bone (calcaneus). Some people have a small extra bone in the back of their ankle called the Os Trigonum. This little bone can lead to posterior impingement because of compression between the shin bone and the heel bone, when the foot is pointed. Additionally, large amounts of force on the ankle occasionally may cause small pieces to break off the ankle bone, which can also become compressed when the ankle moves into "end-range plantar flexion" (moving the foot or toes downward toward the sole of the foot). Compression of tissue causes inflammation and swelling that leads to pain.
With anterior ankle impingement, you may experience:
- Pain on the front and/or outside of the ankle joint
- A feeling of ankle instability
- Decreased ankle range of motion when stretching your toes up toward your shin
- Pain at the end-range of stretching your toes toward your shin
- Tenderness at the front of the ankle when touched
With posterior ankle impingement, you may experience:
- Pain on the back of your ankle, especially during activities that involve pointing your toes
- Decreased range of motion when pointing your toes
- Tenderness on the back of the ankle when touched
Your examination will begin with your personal health history and current symptoms. Your physical therapist will ask you when your symptoms began, where the location of your pain is, and what activities cause you pain. Your physical therapist will perform a physical examination to evaluate your ankle strength, range of motion, sensation, and structural stability as well as your balance. Your physical therapist also will perform special tests, such as gently moving your ankle to see if it causes symptoms.
To diagnose posterior ankle impingement in dancers, the exam may be specialized to that activity. For example, a physical therapist may ask a ballet dancer to demonstrate the “en pointe” position, which involves standing on the tips of the toes.
To provide a definitive diagnosis, your therapist may collaborate with an orthopedist or other health care provider. The most accurate method to diagnose ankle impingement is by X-ray or magnetic resonance imaging (MRI), which can be ordered by the orthopedist.
Once you have been diagnosed with ankle impingement, your physical therapist will work with you to achieve your functional goals, and help you return to activities you previously performed without pain. Your treatment may include:
Pain Management. Your physical therapist may use ice massage or electrical stimulation, if you have inflammation causing pain. Your physical therapist may ask you to reduce your activity level for a while, so the inflammation in your ankle can decrease.
Range-of-Motion Exercises. Your physical therapist may gently move your ankle through its available range of motion, or teach you the proper motions to move through in order to increase its mobility and decrease stiffness. If necessary, your physical therapist may perform joint mobilizations—skillfully moving the joint in a particular direction to improve its motion.
Muscle-Strengthening Exercises. It is important to strengthen the muscles acting on the foot, ankle, and lower leg to promote proper joint mechanics. When the muscles are strong and working properly, the joint space in the ankle is maintained, which decreases the risk of compression of soft or bony tissues.
Balance Exercises. Your physical therapist may give you balance exercises to challenge the way your body reacts to outside forces. These exercises make you more aware of where your body is in space. Improving your balance will lead to a more stable ankle, because your body can more easily respond to challenges.
Functional Training. Once your physical therapist has helped decrease your ankle pain and inflammation, you will progress to more activity-specific tasks. Your physical therapist will help ensure that your ankle can withstand challenges during occupational, sport, or artistic activities.
No injury is ever completely preventable. However, there are some actions that active and at-risk people can take to reduce the risk of ankle impingement, including:
- Using correct techniques when performing physical activities.
- Wearing proper footwear; eg, basketball players can wear high-top shoes to improve their ankle stability.
- Avoiding overtraining; conditions like ankle impingement tend to be brought on by repetitive stresses.
Mary is a 35-year-old mother and ballet instructor. Due to popular demand, she recently added 2 new ballet classes to her teaching schedule. A few weeks into her new schedule, she began to feel pain in the front of her ankle when performing pliés in class. At home, she noticed the pain recurred when she squatted down to pick up her infant daughter. The pain increased over the next week, and Mary worried that it would keep her from performing her daily tasks. She called her physical therapist.
Mary's physical therapist performed a thorough evaluation of her ankle, and asked her to describe which motions were causing her ankle pain. She tested Mary’s ankle range of motion, strength, and endurance, and her balance. Based on the findings of her evaluation, Mary’s physical therapist diagnosed anterior ankle impingement.
Mary and her physical therapist worked together to establish goals for a return to her previously pain-free activities. She advised Mary to temporarily decrease the number of demonstrations she performed during ballet class to reduce stress on the ankle joint, and to allow time for healing. Mary’s physical therapist performed gentle manipulations on her ankle to decrease her pain and improve her range of motion. Additionally, she used a skilled taping method on Mary’s foot to provide support and promote correct positioning of her ankle joint. She also taught Mary proper techniques for performing ice massages at home. She designed a specific home-exercise program for Mary, including range-of-motion, strengthening, and balance exercises.
After a few weeks, Mary reported her pain was greatly diminished, and that she was regaining more pain-free motion in her ankle. Mary’s physical therapist added dance-specific exercises to her plan of care, including higher-level balance exercises to improve her ankle stability, and dynamic strengthening exercises to target the muscles used in ballet.
Two months later, Mary is now teaching her full-class schedule pain free, and playing with her daughter after work—all with a new feeling of strength, improved balance, and overall well-being.
All physical therapists are prepared through education and experience to treat ankle impingement. However, you may want to consider:
- A physical therapist who is experienced in treating people with ankle impingement. Some physical therapists have a practice with an orthopedic or sports focus.
- A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have ankle impingement.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of ankle impingement. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Kadel N. Foot and ankle problems in dancers. Phys Med Rehabil Clin N Am. 2014;25(4):829–844. Article Summary in PubMed.
Albisetti W, Ometti M, Pascale V, De Bartolomeo O. Clinical evaluation and treatment of posterior impingement in dancers. Am J Phys Med Rehabil. 2009;88(5):349–354. Article Summary in PubMed.
van Giffen N, Seil R, Pape D, Nührenbörger C. The athlete's foot: the grey zone behind the ankle. Bull Soc Sci Med Grand Duche Luxemb. 2009(1):57–65. Article Summary in PubMed.
Umans H. Ankle impingement syndromes. Semin Musculoskelet Radiol. 2002;6(2):133–139. Article Summary in PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Kathleen Lillevik, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.
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