Review
Current concepts review: Arthroscopic treatment of anterior ankle impingement

https://doi.org/10.1016/j.fas.2016.01.005Get rights and content

Highlights

  • Anterior ankle impingement is a common cause of chronic ankle pain, particularly in athletic populations.

  • Advancements in ankle arthroscopy have decreased the risk of complications.

  • A comprehensive understanding of diagnosis and surgical technique can influence patient outcomes.

  • The purpose of this review is to review the evidence-based outcomes of arthroscopic management for anterior ankle impingement.

Abstract

Anterior ankle impingement is a common cause of chronic ankle pain, particularly in athletic populations. Morris and McMurray provided the earliest descriptions of anterior impingement, coining the condition as “athlete's ankle” or “footballer's ankle”. The pathology has since been a topic of considerable investigation and has been re-termed “anterior ankle impingement syndrome”. Treatment with open surgery has provided good results historically, but at the price of significant complications. Advancements in ankle arthroscopy have decreased the risk of complication drastically and evidence in the literature indicates that anterior arthroscopy is an effective approach to treating osseous and soft tissue impingement. Effective clinical diagnosis and diagnostic imaging are critical for pre-surgical planning. Preoperative detection of anterior osteophytes has been correlated with outcomes. Factors such as joint space narrowing and large osteophytes may also influence outcomes. Therefore, a comprehensive understanding of diagnosis and surgical technique can influence patient outcomes, and patient expectations can be managed around prognostic indicators such as the presence of osteoarthritis. The purpose of this review is to discuss the etiology, clinical presentation, diagnosis, surgical technique, and postoperative rehabilitation of anteromedial and anterolateral anterior ankle impingement syndrome and to evaluate the evidence-based outcomes of arthroscopic management.

Introduction

Anterior ankle impingement is most often described as anterior ankle pain with restricted dorsiflexion as a result of either tibiotalar osteophytes and/or soft tissue impingement [1], [2], [3]. It is a common cause of chronic ankle pain and is particularly common in athletes that sustain repetitive dorsiflexion movements [4]. Morris and McMurray provided early descriptions of anterior impingement, coining the condition as “athlete's ankle” and “footballer's ankle”, respectively [4], [5]. Since then, substantial investigation into the pathology has occurred and the terminology was replaced with “anterior ankle impingement syndrome”.

Non-operative treatment options include rest, bracing, shoe modification, physical therapy, and intra-articular injection. Conservative treatment is unlikely to be successful and in such cases, surgical intervention is often indicated [1], [6]. A number of authors have reported good results with traditional open arthrotomy [7], [8], [9], [10], but the procedure is associated with complications, including cutaneous nerve entrapment, iatrogenic damage to the long extensor tendons, wound dehiscence, and formation of hypertrophic scar tissue [10], [11]. The growing popularity and efficacy of ankle arthroscopy has furthered the understanding of ankle impingement and chronic ankle pain; it is now accepted as a safe and effective procedure [1], [6], [12].

Bony impingement and soft tissue impingement have been distinguished and the prognostic factors, including presence of anteromedial versus anterolateral osteophytes, that influence outcomes of ankle arthroscopy have also been reported [1], [2], [13]. There are a wide range of indications, relative contraindications, and absolute contraindications for arthroscopic intervention (Table 1) [6]. Initially, arthroscopic surgery of the ankle was considered technically demanding and had complication rates as high as 26.4% [14]. However, as arthroscopic techniques and equipment have become more sophisticated, published complication rates after arthroscopic surgery in the ankle are reported as low as 3.5% [15]. Of these, the most commonly reported complication is neurological injury [15]. Other reported complications include vascular injury, false aneurism [16], [17], infection, and synovial fistula [15], [18]. Complications such as stress fracture, pin track infection, and ligament injury have occurred with use of invasive distraction [19]

The purpose of this article is to describe current knowledge of etiology, clinical presentation, diagnosis, surgical technique, and postoperative rehabilitation of anterior ankle impingement, as well as to provide an evidence-based review of arthroscopic treatment outcomes. The current review distinctly describes both anterolateral and anteromedial impingement in this manner.

Section snippets

Etiology

Anterior ankle impingement is thought to be the result of mechanical factors, traction, trauma, recurrent microtrauma, and chronic ankle instability [1], [20]. In the case of anterolateral ankle impingement (ALI), symptoms are believed to result from the entrapment of hypertrophic soft tissues or torn and inflamed ligaments in the lateral gutter and anterolateral ankle joint [21]. Several types of soft tissue impingement have been reported, including a “meniscoid” lesion, impinging fascicle of

Etiology

Different theories regarding the etiology of anteromedial impingement exist [36]. These theories are mainly based on mechanical factors, including traction, trauma, recurrent microtrauma, and chronic ankle instability [1], [4], [11], [20].

Traction to the anterior ankle capsule during forced plantar flexion in athletes (e.g. soccer players) was thought to be one of the most important etiologic factors in the formation of anterior tibiotalar osthophytes [1], [4], [11]. However, this hypothesis

Postoperative rehabilitation

The postoperative treatment course consists of non-weightbearing for two days to allow healing and decreased inflammation in the soft tissues as well as to prevent fistula formation through the soft tissue portals. The patient is instructed to perform ankle pumps the day after surgery for 20 min daily to prevent further scar tissue formation. Two days after surgery, weight-bearing is increased as tolerated. In cases of AMI, an AMI view radiograph can be obtained postoperatively at the time of

Conclusion

Open treatment of anterior ankle impingement has been demonstrated as effective, but has also been associated with a number of complications. Ankle arthroscopy, in contrast, has been growing in popularity and complication rates have dropped to as low as 3.5% [15]. According to current evidence, arthroscopic resection for both anterolateral and anteromedial impingement provides high rates of good to excellent outcomes with few complications. Although results of AMI resection may be superior to

Conflict of interest statement

The authors declare that they have no conflict of interest.

Disclosures

No financial disclosures directly related to this article.

The following relationships exist:

Kennedy: Consultant, Arteriocyte, Inc.

Van Dijk: Consultant, Smith & Nephew

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