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PosteriorAnkleImpingementbony
Posteriorimpingementrelatestoposteriorpainonendrangeplantarflexion(PF)duetocompressionof
posteriorbonyandsofttissuestructures(Sofka2010Giannini,Budaetal.2013).Itcanbecausedby
overuse,suchasballetdancingorfootballwithrepetitiveendrangePF,oracutetrauma(vanDijk2006).
Althoughtherearemanycausesforposteriorankleimpingement,thesymptomsandsubsequenttreatment
arequitesimilar(Roche,Calderetal.2013).
BonyImpingement
ThetwomostcommonformsofbonyimpingementareaStiedaprocess,anenlargedposterolateraltalar
process,andanostrigonum,asecondaryossificationsiteofthetaluswhichdoesnotfuseinteenage
yearsremainingasanaccessorybone,presentin714%ofadults(Giannini,Budaetal.2013).An
enlargedcalcanealtuberositycancreatethesameissues(Hess2011)butislessdescribedinthe
literature.
TheStiedaprocessisoftenasymptomaticbut,withrepetitivePFloading,canbecomecompacted
betweenthecalcaneusandtibia,compressingtheposteriorsofttissueandcausingmicrotraumatothebony
structures(NiekvanDijk2006Hess2011).Withcontinualcompression,chronicinflammationandreduced
PFcanoccur(Hess2011).Alternatively,anacuteimpactinjury,inthepresenceofaStiedaprocess,can
causeafracturewhichthenpresentssimilarlytoanostrigonumimpingement(Hess2011).

ApatientwithafractureoftheStiedaprocess
OstrigonumimpingementoccurswhenrepetitivePFcompressionirritateslocalsofttissuelaunchinga
chronicinflammatoryresponse(Hess2011).Scartissuehypertrophy,jointcapsulethickening
andexcessiveinversionoreversiononendrangePFcanfurthercompresstheostrigonum(NiekvanDijk
2006).Giannini(2013)alsodescribesanavulsionoftheostrigonumonforceddorsiflexion,then
becomingcompressedonPF,placingexcessivestressontheposteriortalofibularligament.
Thepresenceofanostrigonumdoesnotautomaticallyindicatepain,theremustalsobeahistoryof
repetitiveplantarflexionorforceddorsiflexion,withvanDijk(1995)finding18of38retiredballetdancers
hadostrigonumsorStiedaprocessesbutexperiencednoposteriorimpingement.

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Ostrigonum(left),Stiedaprocess(right)
Diagnosis
Diagnosisisthroughsubjectivequestioningandphysicalexamination,withconfirmationthrough
investigationsanddiagnosticinjections(Hamilton2008).Theindividualgenerallyreportschronicposterior
anklepainonendrangeplantarflexionorpushingoffactivities,forexamplekickingorwearinghighheel
shoes(Giannini,Budaetal.2013),followingahistoryofrepetitiveoveruseoranacuteankletrauma,with
tendernessonposteriortalarpalpation(NiekvanDijk2006).Giannini(2013)claimsindividuals
compensatingforareductioninplantarflexionmaymaintainfootinversiononweightbearing,possibly
reportingrecurrentanklesprains,calfinjury,plantarfasciitisandcurlingofthetoes.Apassiveforced
plantarflexiontest(NiekvanDijk2006)isthemostsensitivetesttoimplicateposteriorimpingement,
involvingquick,repetitivepassiveendrangeplantarflexionoscillationsonapatientsittingin90knee
flexion.Internalandexternalrotationcanbeaddedatendrangeplantarflexion,grindingthebonyandsoft
tissuestructures,withanegativetestclearingposteriorimpingement(NiekvanDijk2006).Apositive
testshouldthenbeconfirmedthroughimaginganddiagnosticinfiltration,withanaestheticor
corticosteroidbeinginjectedintothesiteofbonyimpingement.IfthepainonPFisresolvedfollowing
injection,adiagnosisofposteriorbonyankleimpingementcanbegiven(NiekvanDijk2006).
Fortreatment,refertopreviousblogpostregardingsofttissueankleimpingement.Differential
DiagnosisFlexorHallucisLongusTendinopathy
Theflexorhallucislongus(FHL)tendontraversesafibroosseoustunnelpriortoinsertingonthedistal
hallux,wheninflamedwithinthistunnelposteromedialpaincanbeproduced(Hamilton2008).Chronic
overusecaninitiatemusclebellyhypertrophyinsidethetunnel,causingmuscleentrapmentanda
chronicinflammatoryresponse,ultimatelycausingFHLstenosingtenosynovitis(SchulhoferandOloff
2002).TheFHLtendonissusceptibletoinflammatorysymptomsfollowingasingularorrepetitiveankle
inversioninjury,causingmedialcompressionandirritationofthetendon,withpoormanagementincreasing
thelikelihoodofdevelopingatenosynovitis(Hess2011).Inachroniccondition,crepitus,nodule
developmentandcalcificationofthetendoncanoccur.SchulhoferandOloff(2002)statethisiscommonly
seeninballetdancerswhoperformcontinuouslyinaplantarflexedandtoeextendedposition,while
Hess(2011)describesthepresenceinathletesrequiringaquickpushoffaction,suchassprintersor
hockeyplayers.Oncethetendinopathyhasinitiated,repetitiveplantarflexionandinversionfurtherentraps
andirritatesthetendon(Giannini,Budaetal.2013).
Onassessment,thereispainonpalpationoftheFHLtendonattheposteromedialankle,worsenedby
ankleandhalluxdorsiflexion(SchulhoferandOloff2002).MichelsonandDunn(2005)proposetheFHL
stretchtestaseffectiveindeterminingthelengthandirritabilityoftheFHLtendontherangeofhallux
dorsiflexionisassessedinbothankleplantarflexionanddorsiflexion.Thereshouldbemovementatthe
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halluxmetatarsophalangealjointinbothpositions,ifnohalluxdorsiflexionoccurswhentheankleis
dorsiflexed,atightFHLispresent(MichelsonandDunn2005).MRIisnecessarytodiagnose
tenosynovitisortendinopathy,aswellasexcludingbonypathology,othersofttissuestructuresandjoint
disruption(SchulhoferandOloff2002).
TreatmentFHLTendinopathy
TreatmentofFHLtendinopathy,intheliterature,consistsofrest,immobilisation,deeptissue
mobilisation,corticosteroids,nonsteroidalantiinflammatoriesandphysiotherapy,withlimited
successreported(SchulhoferandOloff2002).Hamilton(2008)proposesinitialimmobilisationtooffload
thetendonandbreakthechronicinflammatorycycle,withnonsteroidalantiinflammatoriesand
corticosteroidinjectionsintothetendonsheathifindicated.Howeverrecentevidenceregardingtendon
injuriescontradictsthisproposedmethod.Currentlytheliteraturedoesnotprovideavalidtreatment
regimespecificallyforFHL,howeveradoptingtheprinciplesfromJillCookstendinopathyresearchwhich
focusesmostlyontheAchillestendon(AlfredsonandCook2007),andaddressingtheinflammatory,
strength,enduranceandreturntofunctionaspectsoftendonhealing,appearsamoreevidence
basedstrategytoresolvethiscondition.

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