Anterior Ankle Impingement

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What is anterior ankle impingement?

Anterior impingement is a common problem for dancers and is characterized by pain in the front of the ankle when performing a deep plié. It is a chronic condition involving soft tissue and bony changes at the ankle joint, where the shinbone (tibia) articulates with the anklebone (talus).
Progressive bony deformation may eventually make deep plié impossible, and may put increased stress on the midfoot and the forefoot as the heel is lifted to compensate for the restricted range of motion. Over time, this compensation can lead to stress fractures of the metatarsals and to local osteoarthritis in the talonavicular joint (in front of the ankle joint).

How can it occur?

Anterior ankle impingement is a result of forcing into deep plié over years. It is particularly common in dancers who are compensating for reduced turnout of the hip with an inward rolling of the foot.
In some dancers, the anklebone adapts to the necessity of maximum dorsiflexion (flexing the foot upwards) by forming a deep groove in the neck of the talus. Other dancers, especially late starters, experience the formation of bony spurs (osteophytes) on the neck of the talus that further restrict the movement of the ankle joint and may cause soft tissue impingement and inflammation.
Muscle dysfunction can seriously affect leg alignment and stabilization and is an important contributing factor to pain with anterior ankle impingement.Muscle dysfunction often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very frequent and naturally occur as an adaptation to the specific needs of any training over time. As long as compensation is effective – or in other words, as long as the dysbalance is well managed by the body – they may not cause any problems. However, with high training loads or after a minor injury, the compensation may fail and muscle dysfunction will subsequently arise in all different muscle groups involved in the compensation. This is why symptoms may occur in different parts of the body at the same time in an overuse situation. The psoas muscle is probably the most important muscle involved with overuse of the foot and ankle. Psoas dysfunction leads to tightness of the rectus femoris muscle (a part of the quadriceps) and deactivation of the piriformis (one of the smaller pelvic muscles inserting on the sacrum). This causes pelvic torsion and functional leg length discrepancy.

The increased amount of stabilization work needed to compensate for leg length discrepancy will overcharge different groups of muscles. The peroneals – a group of two active foot stabilizers on the lower leg – are often affected. With impaired function of the peroneals, both active leg and foot stabilization will get worse and overuse symptoms can arise in an affected ankle.

What are the typical symptoms of anterior ankle impingement?

The typical symptom of anterior ankle impingement is pain in front of the ankle at the bottom of demi-plié. You may also feel a block or that there is “something in the way” when you flex your foot with full weight bearing. In situations of very acute anterior ankle impingent there might be significant soft tissue swelling in front of the ankle. Chronic anterior ankle impingement may lead to posterior ankle pain in the backside of your foot in plié over time. This is due to the ligaments at the backside of the ankle (talotibial and calcaneofibular ligament) getting loose. An effect related to the changes in joint kinetics (movement) of the ankle that goes with the condition.

How can anterior ankle impingement be diagnosed?

Your doctor will examine your foot and ankle and may find tenderness and swelling in front of the ankle. Ankle movement will be assessed in a weight bearing parallel position of the feet and may show decreased dorsiflexion of the affected ankle. Correct diagnosis of this issue demands a thorough functional clinical examination, including specific tests to identify joint and muscle dysfunction. Finding out the exact causes of acute pain with anterior ankle impingement is often challenging and your doctor may ask a specialist in manual medicine for his opinion.
To fully evaluate the condition, your doctor may order X-rays to determine if typical signs like a roughening on the edge of the frontal tibia or a bony spur (osteophyte) on the anklebone have occured. Weight-bared X-rays in demi-plié may show a “gapping” of the joint space on the backside of the joint.

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This MRI scan shows a typical anterior ankle impingement. You can easily spot the deep groove that has formed in the neck of the talus bone in due course.

What are the treatment options?

If you have severe or constant ankle pain, you should take a break from your ballet training immediately. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries. Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers.
In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine.
Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Surgery may be recommended if you have severe pain or mobility problems and non-operative treatment has failed to improve the situation. There are different surgical methods to address anterior ankle impingement. Your doctor and orthopedic surgeon will help you to choose the best option for you.

Next steps

Do you think that you might have an ankle impingement problem and want to have it sorted out? These are the next steps:

  • See a doctor

Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.

  • Find a specialist in manual medicine

Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.

  • Start working on your problem

There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:

Flexibility training: Foot release, Professional calf and foot release, Deep back release, Rectus femoris release, Psoas release, Piriformis release, Compex “DECONTRACTURE” program (peroneal muscles)

Strength training: Compex “DISUSE ATROPHY” program (peroneal muscles), “The clamshell” – Piriformis training,“The monster walk” – Piriformis training

Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.

  • Talk to your ballet master or dance teacher

Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.


 

 


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