Posterior Ankle Impingement and Posterior Process

with Rehab

Impingement is a condition in which bones pinch surrounding soft tissues and cause pain and inflammation of the soft tissues. Posterior ankle impingement is an impingement of the soft tissues in the back (posterior) are of the ankle. The bones that cause posterior ankle impingement are most commonly the ankle bone (talus) and an extra anklebone, known as the os trigonum.

SYMPTOMS

  • Pain, tenderness, swelling, and bruising (contusion) in the posterior ankle.

  • Pain that worsens with pointing the toes downward (plantar flexion) as with ballet dancers and gymnasts.

  • Pain when running, jumping, or walking down stairs or hills or when squatting while standing on the toes.

CAUSES

Posterior ankle impingement is caused by the soft tissue being pinched between bony structures, and results in adverse symptoms. Common mechanisms of injury include:

  • Repetitive stress full plantar flexion.

  • Direct trauma to the heel.

RISK INCREASES WITH:

  • Activities that involve repetitive ankle plantar flexion (ballet, gymnastics, or ice skating).

  • Activities that involve trauma while the foot is plantar flexed (kicking).

  • Previous foot or ankle injury.

  • Improperly fitted or unsupportive shoes.

  • Poor strength and flexibility.

PREVENTION

  • Warm up and stretch properly before activity.

  • Maintain physical fitness:

  • Strength, flexibility, and endurance.

  • Cardiovascular fitness.

  • Learn and use proper technique and have a coach correct improper technique.

  • Protect the ankle from excessive plantar flexion with tape, braces, or compression bandages.

  • Wear properly fitted and supportive shoes.

PROGNOSIS

If treated properly, then the symptoms of posterior ankle impingement usually resolve within 4 to 6 weeks.

RELATED COMPLICATIONS

  • Prolonged healing time, if improperly treated or re-injured.

  • Recurrent symptoms that result in a chronic problem.

  • Inability to compete in athletics.

  • Risks of surgery: infection, bleeding, nerve damage, or damage to surrounding tissues.

TREATMENT

Treatment initially involves the use of ice and medication to help reduce pain and inflammation. The use of strengthening and stretching exercises may help reduce pain with activity. These exercises may be performed at home or with referral to a therapist. Your caregiver may also recommend that you immobilize the ankle for a period of time to allow for healing of damaged tissue. Corticosteroid injections may be given to reduce inflammation, but should be reserved for the most severe cases. If symptoms persist for greaten than 6 months despite non-surgical (conservative) treatment, then surgery may be recommended. Surgery involves the removal of a portion of the bone that is placing pressure on its surrounding soft tissue.

MEDICATION

  • If pain medication is necessary, then nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

  • Do not take pain medication for 7 days before surgery.

  • Prescription pain relievers may be given if deemed necessary by your caregiver. Use only as directed and only as much as you need.

  • Corticosteroid injections may be given by your caregiver. These injections should be reserved for the most serious cases, because they may only be given a certain number of times.

HEAT AND COLD

  • Cold treatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or massage the area with a piece of ice (ice massage).

  • Heat treatment may be used prior to performing the stretching and strengthening activities prescribed by your caregiver, physical therapist, or athletic trainer. Use a heat pack or soak the injury in warm water.

SEEK MEDICAL CARE IF:

  • Treatment seems to offer no benefit, or the condition worsens.

  • Any medications produce adverse side effects.

  • Any complications from surgery occur:

  • Pain, numbness, or coldness in the extremity operated upon.

  • Discoloration of the nail beds (they become blue or gray) of the extremity operated upon.

  • Signs of infections (fever, pain, inflammation, redness, or persistent bleeding).

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Posterior Ankle Impingement

These exercises may help you when beginning to rehabilitate your injury. Your symptoms may resolve with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

RANGE OF MOTION - Toe Extension, Flexion

  • Sit with your right / left leg crossed over your opposite knee.

  • Grasp your toes and gently pull them back toward the top of your foot. You should feel a stretch on the bottom of your toes and/or foot.

  • Hold this stretch for __________ seconds.

  • Now, gently pull your toes toward the bottom of your foot. You should feel a stretch on the top of your toes and or foot.

  • Hold this stretch for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

RANGE OF MOTION - Ankle Dorsiflexion, Active Assisted

  • Remove shoes and sit on a chair that is preferably not on a carpeted surface.

  • Place right / left foot under knee. Extend your opposite leg for support.

  • Keeping your heel down, slide your right / left foot back toward the chair until you feel a stretch at your ankle or calf. If you do not feel a stretch, slide your bottom forward to the edge of the chair, while still keeping your heel down.

  • Hold this stretch for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRETCH – Gastroc, Standing

  • Place hands on wall.

  • Extend right / left leg, keeping the front knee somewhat bent.

  • Slightly point your toes inward on your back foot.

  • Keeping your right / left heel on the floor and your knee straight, shift your weight toward the wall, not allowing your back to arch.

  • You should feel a gentle stretch in the right / left calf. Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRETCH – Soleus, Standing

  • Place hands on wall.

  • Extend right / left leg, keeping the other knee somewhat bent.

  • Slightly point your toes inward on your back foot.

  • Keep your right / left heel on the floor, bend your back knee, and slightly shift your weight over the back leg so that you feel a gentle stretch deep in your back calf.

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRETCH – Gastrocsoleus, Standing

Note: This exercise can place a lot of stress on your foot and ankle. Please complete this exercise only if specifically instructed by your caregiver.

  • Place the ball of your right / left foot on a step, keeping your other foot firmly on the same step.

  • Hold on to the wall or a rail for balance.

  • Slowly lift your other foot, allowing your body weight to press your heel down over the edge of the step.

  • You should feel a stretch in your right / left calf.

  • Hold this position for __________ seconds.

  • Repeat this exercise with a slight bend in your right / left knee.

Repeat __________ times. Complete this stretch __________ times per day.

STRENGTHENING EXERCISES - Posterior Ankle Impingement

These exercises may help you when beginning to rehabilitate your injury. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress the resistance and repetitions only as guided.

STRENGTH - Plantar-flexors

  • Sit with your right / left leg extended. Holding onto both ends of a rubber exercise band/tubing, loop it around the ball of your foot. Keep a slight tension in the band.

  • Slowly push your toes away from you, pointing them downward.

  • Hold this position for __________ seconds. Return slowly, controlling the tension in the band/tubing.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Plantar-flexors

  • Stand with your feet shoulder width apart. Steady yourself with a wall or table using as little support as needed.

  • Keeping your weight evenly spread over the width of your feet, rise up on your toes.*

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

*If this is too easy, shift your weight toward your right / left leg until you feel challenged. Ultimately, you may be asked to do this exercise with your right / left foot only.

STRENGTH - Towel Curls

  • Sit in a chair positioned on a non-carpeted surface.

  • Place your foot on a towel, keeping your heel on the floor.

  • Pull the towel toward your heel by only curling your toes. Keep your heel on the floor.

  • If instructed by your physician, physical therapist or athletic trainer, add ____________________ at the end of the towel.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Ankle Eversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Drawing the band/tubing across your opposite foot, slowly, pull your little toe out and up. Make sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Ankle Inversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Slowly, pull your big toe up and in, making sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercises __________ times per day.