What is posterior ankle impingement?
Posterior ankle impingement is characterized by a pain in the back of your ankle when you point your foot, or relevé. This problem is very common for dancers and is therefore also known as “dancer’s heel”. It is a chronic condition involving soft tissue and bony changes in the back of the ankle joint, where the shinbone (tibia) articulates with the anklebone (talus). Side-view X-rays of the foot will reveal these bony abnormalities. They include an elongation of the posterior process of the talus, or a little bone on the back of the talus called os trigonum.
How can it occur?
Posterior ankle impingement is a result of jamming the heelbone (calcaneus) into the back of the tibia over years, when pointing the foot. It is particularly common in dancers who are compensating for reduced turnout of the hip with an inward rolling of the foot. The bony changes that occur over time may lead to a soft tissue impingement in the back of the ankle that can cause inflammation and pain. Muscle dysfunction can seriously affect ankle alignment and stabilization and is an important contributing factor to pain with posterior ankle impingement.
Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
The psoas muscle is probably the most important muscle involved with dance injuries. Psoas dysfunction leads to tightness of the rectus femoris (a part of the quadriceps) and deactivation of the piriformis (one of the smaller pelvic muscles inserting on the sacrum) and 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 posterior ankle impingement?
The typical symptom of posterior ankle impingement is pain in the back of your ankle when pointing your foot or relevé. You may as well feel a block or that there is “something in the way”. The pain in the back of your ankle is rather felt to the outside than to the inside. Pain in the back of your ankle that is localized to the inside is more probable to arise from an inflammation of the flexor hallucis longus (FHL) tendon – the muscle that points your big toe. Inflammation of the FHL tendon is an overuse issue that may arise from posterior ankle impingement itself due to the effort to compensate for a blocked ankle by forced pointing of the big toe. These two problems therefore frequently can be found at the same time.
Probably you will notice that your pain varies and that you have good days and bad days, sometimes depending on how active you’ve been but sometimes for no clear reason.
If pain in the back of your ankle gets very acute after a jump and you notice some swelling behind your Achilles tendon, a fracture of either the posterior process of the talus or the os trigonum may have occurred. You should instantly see a doctor in this situation.
How can posterior ankle impingement be diagnosed?
Your doctor will examine your foot and ankle and may find tenderness and swelling in the back of your ankle. The typical pain of a posterior ankle impingement can be provoked by pressing the heelbone (calcaneus) against the back of the shinbone (tibia) in clinical examination. 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 an elongation of the posterior process of the talus or a little bone on the back of the talus called os trigonum have occurred.
This MRI scan shows the typical aspect of an acute posterior ankle impingement. All liquid appears white in this picture. Inflamed soft tissue contains a high amount of liquid. You can easily spot the inflammation in the back of the ankle as well as an os trigonum with a stress reaction.
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. This may especially be the case with a big or traumatized os trigonum. Your doctor and orthopedic surgeon should help you to choose the best treatment option for you.
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:
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.