Ankle Impingement

iCSP has posted a discussion about ankle impingement:

Added by: juliephysio
Posted: 26 August 2009 04:17

Hi

I'm currently treating a patient who has presented to physio 6/52 post G2 strain of lateral ankle ligaments and has subsequently developed anterior ankle impingement due to synovitis. Was just curious if anyone had found any manual therapy or other treatment techniques to be effective with ankle impingement? She is a high level rower and is hoping to compete in a full marathon in a couple of months, so is extremly keen to return to training asap (currently she is unable to row/run due to pain++ with EOR DF)

Thanks

Ref: QQQ012

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If your patient is very keen to get back in the boat to continue rowing, you could put a heel raise in her rowing shoe to reduce the amount of dorsi flexion she'll go into at the start of her stroke so she doesn't continually irritate the impingement. Short term solution whilst working on all the other ideas??

As noted before MWMs are very useful. I find the ATFL frequently gets shortened and pulls the lateral malleolus forwards, thereby blocking DF and eversion. I would get the patient in 4-pt kneeling on the bed, (the bed is up high for you to lean on it) and the affected foot up on the bed. As they flex forwards at the ankle, simultaneously glide the malleolus backwards. If this technique is successful at improving range and decreasing pain, do it a few more times, then tape the malleolus back afterwards. I also find the exercise noted by nellmead above very useful. I.e. 4 pt kneeling and rock back onto the plantarflexed ankle. I would bias it into inversion, and instruct them to rock back until they feel it "give" but not to sit on their heels.

These techniques have worked well many times for me in the past but I had one patient last year with a planterflexion sprain of the inferior tib/fib syndesmosis jt who got a subsequent synovitis which had to be injected by a foot and ankle specialist.

Hi. I have found a few techniques useful in the past for ankle impingment. One is an MWM - AP glide of talus on tibia as patient moves to end range DF in weight bearing. Another is a distraction manip in DF. Neural stretching and masses of proprioceptive work are also helpful.

Julie

I agree with the above posts re: Mulligan type techniques. A-P glide of talus in standing (using belt) can be exceptionally effective for this. I would also get on with some soft tissue work along the anterior joint line.

Anterior joint pain after Inv sprain is often due to fwd positional fault of talus or fib or both (opinion not fact). Inv MWM is very useful to improve fib positional and can sometime clear DF. If not try a W/Bing DF MWM to slide talus back into the mortise+/- fibular AP, its worth noting that sometimes relief is only gained from firm end ROM MWM,so dont be shy. The page or two on "ATFL injury" in the Mulligan textbook is well worth a read.... ATFL damage a medical fallicy??

Anterior impingements are a pain! Along with mobilisations of which using MWM would give immediate response as to its effectiveness i have recently been very impressed with Functional fascial taping especially developed for anterior impingement in ballet dancers. Basically take the rower into pain position then on the site of pain direct the skin in differing directions until you find the direction that abolishes pain. Then tape strongly into this position with half width non elastic tape.

Not sure what you've done to date regarding the capsular restriction, but the vast majority of my patients in this situation respond well to joint mobilisations - distraction of the talocrural joint (i.e. patient supine and holding onto the bed, grip calcaneus and talus and pull, grade 3 oscillations, until you feel the joint "give") followed by AP/PA glides; then I'd also palpate for subtalar joint mobility and inferior and superior tibiofibular joint glide. If your patient is still feeling impingement at EOR DF once these feel clear to you, then localise the point of impingement and stretch the foot into plantarflexion with a bias away from the impingement, to stretch the capsule at that point.

For "homework" I tend to get the patients stretching into plantarflexion - kneel with feet plantarflexed, and sit back onto the heels until it becomes too uncomfortable, building up to about a minute over time. Again, they can bias the stretch with in/eversion depending on the location of the impingement.

Just wondering if you had considered the possibility of osteohcondral injury. The risk of this increases with the grade of ankle sprain and reported incidence is in 40% of ankle sprains.

Patients complain of an ache, intra-articularly, on loading the joint and with end range DF. This will be demonstrable on MRI and is an important differential diagnosis as this injury can require a protracted rest period and occassionally surgical management should there be significant articular surface damage. Where this is present then rest is necessary to prevent a chronic inflammatory state and reduce the risk of further damage to the articular surface. Modified activity is possible.

A synovitis can sometimes be managed successfully with steroid injection but I'm not aware of successful physiotherapy management and as time scales are tight this may be the best course of action.

Regards,

Damian

If you have several months to play with it may be beneficial to give the capsule a chance to settle down. We do this by imobilising the ankle in a boot for 7-10 days while on NSAIDS. The ankle can still be mobilised with conventional manual therapy techniques. If this doesn't completely irradicate symptoms steroidal injection could be considered witha similar time of imobilisation. I have found investing in that first week of immobilisation to address the synovitis beneficial to final outcome.