Review
The management of posterior ankle impingement syndrome in sport: A review

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Highlights

  • There is a lack of prospective studies on the treatment of PAIS.

  • Long term outcomes from open and endoscopic surgery are satisfactory.

  • Complications rates are comparable between open medial and endoscopic surgery.

  • Return to sporting activities is quicker in artho-endoscopically treated patients.

  • No evidence supports superior long term results with any one technique.

Abstract

A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Forty-seven papers have reported on the surgical outcomes of 905 procedures involving both open and artho-endoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers.

Introduction

Posterior ankle impingement syndrome (PAIS) describes a collection of pathologies characterised by posterior ankle joint pain usually aggravated by plantarflexion and under repetitive load frequently leading to restriction of movement.

Many different causes of PAIS have been described and the range of pathologies are depicted in Fig. 1.

PAIS should be distinguished from other causes of hindfoot pain arising from the Achilles tendon and its insertion, Peroneal sheath contents, Tibialis Posterior tendon, primary ankle and subtalar joint pathology and damage to the Tibial and Sural nerves.

Although PAIS is a relatively unusual cause of pain in the non-sporting population, it can be a cause of significant disability in certain sports and dance disciplines.

The purpose of this paper is to review the evidence regarding both the natural history and efficacy and complications arising from different management strategies for PAIS. For a fuller description of the clinical features and investigation of PAIS, the reader is referred to excellent articles on the subject by the following authors [1], [2], [3], [4].

Section snippets

Materials and methods

The primary medical search engines used for the study were MEDLINE/OVID and EMBASE databases.

Keywords: and phrases such as “Posterior ankle impingement”; “Posterior ankle pain”; “Posterior ankle endoscopy”; “Flexor hallucis longus”; “Os trigonum”; “Posterior talar tubercle”; “treatment”; “conservative” and “surgical” were used in mixed combinations to ensure the greatest possible variation. This was supplemented by manual searches of the bibliography of key papers. Combination; truncation and

History of PAIS publications

The first paper on the surgical management of PAIS in our observed series was published in 1979 by Sammarco [21] although Hamilton highlighted the problem of Flexor Hallucis Longus (FHL) Tendon problems in a 1976 presentation [22]. Fig. 2 outlines the subsequent history of PAIS scientific publications.

From 905 surgical procedures for PAIS, 521 patients underwent endoscopic/arthroscopic procedures compared to 384 patients undergoing open procedures. The peak of reporting outcomes of open surgery

Pathology of PAIS

Many conditions attributed to causing PAIS were identified. Diagnostic exclusions are outlined in the Materials and Methods section. During 905 procedures 1105 pathologies were recorded.

Two broad, common groups of pathology were identified: Osseous (81% of surgeries) and soft-tissue (42%). The common causes of bony impingement and FHL pathology are shown in Fig. 3, Fig. 4. The breadth and frequency of the pathologies described in the 47 papers are shown in Table 1. It is recognised that rarer

Epidemiology and natural history of PAIS

There is a paucity of work upon the prevalence and natural history of the various conditions contributing to PAIS and the outcomes of conservative treatment.

Injury Audit Data from the English Cricket Board covering 18 1st Class County teams for the year 2001–2002 (unpublished data made available to one of the authors, WJR) revealed that PAIS was the most common cause for players deemed unfit to train or play secondary to foot and ankle problems. The condition represented 31% of all days lost

How effective are conservative treatment options for PAIS?

Conservative treatment options for the management of PAIS include:

  • Rest.

  • Cessation of activity.

  • Technique modification.

  • Physical therapy.

  • Orthotics/footwear modification.

  • NSAIDs.

  • Injections.

The prevalence of PAIS in the community, both sporting and non-sporting, is unknown. Many patients do not present to Orthopaedic Surgeons preferring to self-manage by activity modification, or are successfully treated by family and sports physicians, physical therapists or podiatrists.

In 1997, Marumoto and Ferkel

Open surgery – which incision?

The open approach to the posterior ankle region can be undertaken via a posteromedial or posterolateral approach. Review of 384 open procedures in 26 papers revealed that 65.6% were undertaken through the posteromedial approach, 27.3% via the posterolateral approach, and in 7.1% of cases the exact approach was not recorded [2], [3], [11], [12], [21], [26], [27], [28], [29], [30], [31], [35], [36], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50]. Four papers

Endoscopic surgery – which portals?

A number of different portal combinations have been described for PAIS surgery and 25 papers detailing 521 procedures were analysed for outcomes and complications [2], [7], [8], [9], [10], [15], [16], [17], [19], [20], [23], [24], [25], [26], [27], [32], [33], [34], [37], [50], [51], [52], [53], [54], [55].

Endoscopy requires a minimum of two portals – one for the camera and the other for instrumentation. Other portals can be utilised for irrigation and additional instrumentation.

Most techniques

Is the overall outcome following arthro-endoscopic surgery better than open surgery?

One of the problems in comparing surgical results is a lack of standardised outcomes, especially for open surgery. The AOFAS Ankle-Hindfoot scoring system was first published in 1994 and is a commonly used rating system in the assessment of surgical outcomes [57]. For the open series, only 2 of the 26 papers contained a post-operative AOFAS score [39], [50] and only one a VAS (Visual Analogue Pain scale) [50].

Most papers have their own non-validated rating system such as

Which sports are most commonly implicated in PAIS?

The establishment of true risk for the development of PAIS in individuals and specific sports would require exposure rates (training and competition/performance hours) along with participation numbers. However, an indication of the relative importance of different sports in terms of surgical load can be gauged from summating numbers from the reviewed papers.

From the 905 surgical patients reviewed, 445 (49.2%) had details of specific sports described and 382 (42.2%) did not have their sports

Do certain sports suffer from specific PAIS pathologies?

Table 1 illustrates the most frequent causes of PAIS. Our analysis of 905 surgeries revealed 1105 different pathologies. Not all potential causes were identified in our review (Fig. 1). The overwhelming majority of authors identify 1 pathology per procedure, however, others, such as Hamilton's ballet paper [12], revealed multiple pathologies contributing to PAIS–78 combined soft-tissue and osseous lesions in 41 patients. Kolettis [36] described 48 different pathologies in 13 FHL tendons of

Do certain sports recover more quickly than others from PAIS surgery?

A number of papers contain either a mixture of sports or sports and non-sports combined, for which the results of individual sports cannot be extracted. Table 8 contains the papers and sports where some degree of sport-specific analysis is possible. There is more information on outcomes on dance-related open surgery for PAIS than other sports. There is comparatively little information on outcomes of sports-specific endoscopic surgery.

Analysis of the results suggests that soccer players return

Do professional/elite sports people recover better that amateur sports people?

With the likely superior rehabilitation facilities, incentives and time available to devote to recovery, it might be expected that professional and/or elite sports people would have better outcomes than amateur, occasional sports men and women. Conversely the higher level of performance required of the elite sports person brooks no drop in levels of skill and mobility and even minor long-term disability may be recognised and affect future sports participation at that level.

Review of the papers

Do soft-tissue causes of PAIS recover more quickly that osseous causes?

Analysis of the literature to establish whether pure soft-tissue pathology, e.g. FHL tendonitis, recovers more quickly than various osseous pathologies is difficult based on the information available. Where authors have expressed an opinion, it was mixed. Van Dijk [7] reported that osseous pathology recovered more quickly whereas Calder [34] reported that soft-tissue pathologies returned to activity sooner. Hamilton [12] reported pure osseous impingements returned one month earlier than dancers

Do overuse causes of PAIS do better than post-traumatic?

Some authors have categorised the potential causes of PAIS into overuse and post-traumatic problems. Overuse injuries would include a symptomatic os trigonum and inflamed FHL. Post-traumatic causes include a Shepherd's fracture of the posterolateral talar process or impingement from a malunion or periosteal thickening of a posterior malleolar or syndesmotic injury.

Both Scholten's [10] endoscopic series and Stibbe's [48] open series reported better surgical outcomes from the treatment of more

Lateral ankle ligament instability in association with PAIS

Laxity of the anterior talofibular ligament allows increased forward glide of the talus beneath the tibia. Theoretically such a translation brings the posterior talar elements closer to the posterior tibial lip and increases the risk of producing posterior PAIS.

However, within the papers reviewed only 4 cases of patients (ballerina, cricketer, triathlete and basketball player) requiring simultaneous lateral ligament stabilisation and PAIS decompression were identified [12], [26], [33] Hamilton

PAIS surgery in adolescents

Review of the various recreations and sports pursued by those experiencing PAIS confirms that Dance is the most frequent sport/pastime identified. Since dance is undertaken by predominantly young females, guidance was sought from the literature on the outcome of surgery in the younger patient.

Spicer [47] concluded that better results following surgery occurred in skeletally immature patients, whereas Roche [2] reported that their younger patients were rehabilitated less aggressively and

Conclusions

Our review of the body of published literature on the management of PAIS, with particular emphasis on sport, reveals a predominance of retrospective Level IV and Level V evidence.

There is a paucity of work upon the natural history of the various conditions contributing to the syndrome and similarly the outcomes of conservative treatment.

The early surgical outcome papers (predominantly open techniques) are dominated by dance-related case series; whereas later papers (predominantly

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      Citation Excerpt :

      Finally, if plain film radiographs, MRI, and conservative therapy do not identify or manage symptoms consistent with posterior ankle joint impingement, diagnostic and therapeutic posterior ankle joint arthroscopy can be a definitive means of diagnosis and treatment of PAI. Treatment of PAI consists of conservative and surgical interventions, where conservative treatments focus on rest, activity modification, physical therapy, and antiinflammatory measures.12,16 If symptoms do not improve with this first-line therapy, ultrasound-guided injections have been found to be successful especially among high-level athletes.6

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