Posterior Ankle Pain Research Articles

Ganglion Cyst Contiguity of the Flexor Hallusis Longus Tendon in a National Swimmer

Objectives:Tendinopathy of the flexor hallusis longus tendon is common in the athletes. This case is intended to be reported diagnose and treatment ganglion cyst contiguity of the flexor hallucis longus tendon that located atypical region and adversely affect the athlete's training program.Methods:25-year-old male national swimmer was assessed with a left ankle pain. He had an intensive training program in the pool using pallets at the everyday. Pain in the left ankle was localized posterior and distal of the medial malleolus . Ankle range of motion and muscle strength was full. Neurovascular examination was normal. Radiography with anterior posterior, lateral and oblique analysis was not any unusual finding. In the evaluation with magnetic resonance imaging, thickening of the tendon sheath and effusion around the flexor hallucis longus was revealed and tendon integrity was exact.Results:Conservative treatment was planned. It was applied non-steroidal anti-inflammatory medicine, modification of the training (without or low weight pallet), platelet rich plasma (two weeks, two times peer weeks). During the six-month follow-up the patient's symptoms improved, but with the increased intensity of training at follow-up complaints started again. Professional athletes who did not respond adequately to conservative treatment surgical exposure were planned. Patient is approached the flexor hallucis longus musculotendinous junction from the posteromedial ankle at the level of the posterior talar tubercles. During the tendon exposure cyst was found at the level of talocalcaneal joint. Excision of the cyst was achieved; its size was 5x5 mm, looking transparent, well defined and soft consistency. Tenolysis is accomplished from superior to inferior to the level of the superior calcaneus. A histopathologic examination result of the cyst consistent with ganglion cyst was detected. Sport-specific training program started at the 6 weeks. There was no recurrence during the 6 months follow-up.Conclusion:Tendon associated ganglion cyst is not usual although flexor hallucis longus tendinopathy is common in athletes. External pressure causes in addition to the overuse injuries should be remembered in the differential diagnosis of posterior ankle and medial arch pain. Clinical suspicion and magnetic resonance imaging are valuable in establishing the diagnosis. Tenolysis and excision of the associated mass has proven to be a relatively safe and successful procedure especially in highly demanded elite athletes.

Dor no tornozelo – Um caso de Síndroma Os trigonum

Introduction: Diagnosing painful osteoarticular or musculoskeletal conditions in children and teenagers is often a challenge. Ankle pain is a frequent complaint but the Os trigonum syndrome is rarely considered. Case report: We report the case of an 18 year-old boy who complained of frequent ankle pain. Physical examination and x-ray examination were inconclusive, without remarkable changes. However, the persistence of complaints and the history of an injury led to CT scanning, which revealed an Os trigonum. Comment: This article presents the differential diagnosis of posterior ankle pain and focuses on the Os trigonum Syndrome

Os Trigonum Syndrome

Os trigonum syndrome is the result of an overuse injury of the posterior ankle caused by repetitive plantar flexion stress. It is predominantly seen in ballet dancers and soccer players and is primarily a clinical diagnosis of exacerbated posterior ankle pain while dancing on pointe or demi-pointe or while doing push-off maneuvers. Symptoms may improve with rest or activity modification. Imaging studies, including a lateral radiographic view of the ankle in maximal plantar flexion, will typically reveal the os trigonum between the posterior tibial lip and calcaneus. If an os trigonum is absent on radiography, an MRI may reveal scar tissue behind the posterior talus, a condition associated with similar symptoms. Os trigonum syndrome is often associated with pathology of the flexor hallucis longus tendon. Treatment begins with nonsurgical measures. In addition to physical therapy, symptomatic athletes may need surgical excision of os trigonum secondary to unavoidable plantar flexion associated with their sport. This surgery can be performed using open or arthroscopic approaches.

Hindfoot endoscopy for the treatment of posterior ankle impingement syndrome: a safe and reproducible technique.

Posterior ankle impingement is a clinical syndrome characterized by posterior ankle pain that is mainly presented on plantar flexion. The aim of this study is to compare and evaluate the results of posterior ankle impingement treated by endoscopic hindfoot posterior portals. Between 2004 and 2009, a total of 38 endoscopic hindfoot procedures were performed to treat posterior ankle impingement. The indication for procedure was posterior ankle impingement syndrome in all cases. There were 38 patients, 17 females and 21 males. Mean age was 27.6 years (16-59 years). Mean follow-up was 27.6 months (12.5-52 months). The results were evaluated following the AOFAS score. Data statistical analysis was performed using the Student's t-test. The main preoperative AOFAS score increased from 67.42 (range 41-91) to 97.13 (range 84-100) at follow-up. No complications were reported in any case. Hindfoot endoscopy is a reproducible and safe procedure which offers excellent outcomes in posterior ankle impingement syndrome.

Evaluation and Management of Posterior Ankle Pain in Dancers

Posterior ankle pain is a common complaint in dancers. There are multiple structures in the posterior ankle that have the potential to be the source of pain. The objective of this article is to review several of the most common causes of posterior ankle pain: peroneal tendon subluxation, posterior impingement syndrome secondary to a painful os trigonum, posterior talus osteochondritis dissecans, flexor hallucis longus tendinopathy, and posterior tibial tendinopathy. For dancers, we offer typical clinical presentations of these disorders to increase awareness and provide guidance regarding when to seek professional medical attention. For medical personnel who are responsible for optimizing dancers' health and training, we include a discussion of pertinent physical exam findings, diagnostic imaging options, non-operative and operative management, as well as surgical suggestions and postoperative rehabilitation guidelines.

Heterotopic ossification after total ankle arthroplasty

We evaluated the incidence of heterotopic ossification following total ankle replacement to determine whether the degree of ossification was associated with the clinical outcome. We evaluated 90 ankles in 81 consecutive patients who underwent total ankle replacement, and heterotopic ossification was assessed according to proportional involvement of the ankle joint. Correlation analysis was used to investigate the association between heterotopic ossification and outcome. No significant association was found between the formation of heterotopic ossification and the clinical outcome. The degree of heterotopic ossification in the posterior ankle joint was not significantly correlated with posterior ankle pain (p = 0.929), the American Orthopaedic Foot and Ankle Society score (p = 0.454) or range of movement (p = 0.283). This study indicates that caution should be observed in attributing symptoms and functional limitation to the presence of heterotopic ossification in the posterior ankle joint when considering excision of heterotopic bone after total ankle replacement.

Diagnostic Imaging of an Achilles Tendon Rupture

The patient was a 45-year-old man who was referred to a physical therapist with a chief complaint of posterior right ankle pain for the past 2 weeks. The physical therapist requested radiographs, which demonstrated obliteration of Kager's fat pad, a finding highly suspicious for an Achilles tendon rupture. Based upon history, physical examination, and radiographic findings, the physical therapist ordered magnetic resonance imaging which confirmed the diagnosis of Achilles tendon rupture.

The fibulocalcaneus (peroneocalcaneus) internus muscle of MacAlister: Clinical and surgical implications

A fibulocalcaneus (peroneocalcaneus) internus (PCI) muscle (of MacAlister) was identified and photographed in the left leg of a 78-year-old Caucasian female cadaver. This case study provides the first gross anatomical photo of this anomalous leg muscle and represents the first gross anatomical dissection of this muscle since 1914. The PCI muscle arose from the distal third of the fibula, posterior intermuscular septum of the leg, and flexor hallucis longus muscle. The PCI muscle inserted into the inferior surface of the medial calcaneus distal to the coronoid fossa, a small depression between the anterior tuberosity and the anterior apex of the sustentaculum tali. This insertion point differs from the historical literature, which commonly refers to the muscle inserting into the inferior surface of the sustentaculum tali of the calcaneus or simply distal to the sustentaculum tali into the medial aspect of the calcaneus. The PCI muscle is one of the least common muscular variants associated with the ankle joint, and it has been implicated in posterior ankle pain and impingement, as well as involvement in tarsal tunnel syndrome. This muscle is often confused with the flexor digitorum accessorius longus (FDAL) muscle. Additionally, this study describes ways to differentiate between the PCI and FDAL muscles in the lower leg. Radiologists and clinicians should be aware of this anomalous muscle when considering various diagnoses, interpreting radiographs, and pursuing surgical intervention to relieve posterior ankle symptoms.

Gout as a cause of posterior ankle pain

Introduction A case study is presented which illustrates how gout can be overlooked as a cause of posterior ankle pain in primary care settings. Case presentation A case of gout affecting the posterior ankle is presented. The case discussed was referred to a physiotherapy service as suspected bursitis and tendonitis, following consultant referral and subsequent magnetic resonance imaging, but after minimal improvements were seen, further assessment revealed the possibility of gout as the cause of symptoms. Conclusion This case study discusses an alternative diagnosis for posterior ankle pain that is not responding to physiotherapeutic management.

Síndrome do impacto posterior do tornozelo: um diagnóstico que deve ser lembrado pelo reumatologista. Relato de dois casos

The ankle is a common site of painful symptoms in athletes and nonathletes. Posterior ankle pain can be the end result of several pathologies, and a diagnostic challenge for rheumatologists. The posterior ankle impingement syndrome, also known as os trigonum syndrome and posterior tibiotalar compression syndrome, is a clinical disorder characterized by acute or chronic posterior ankle pain triggered by forced plantar flexion, which causes chronic repetitive microtrauma. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but there are other causes, such as tenosynovitis of the flexor hallucis longus, ankle osteochondritis, subtalar joint disease, and fracture. Diagnosis is based on clinical history and physical examination, and complemented by findings on plain radiography (RX), ultrasound (US), scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI). It is worth noting that RX has low cost and good sensitivity, US can provide guidance to therapeutic infiltrations, and MRI allows the assessment of surrounding soft tissues.

Hindfoot Endoscopic Findings of Posterior Ankle Impingement Syndrome in Ballet Dancers (SS-56)

Introduction Posterior ankle pain is a common but serious problem in ballet dancers. Certain kinds of pathological conditions have been reported, such as os trigonum (OT) syndrome, fracture of the Stieda process, flexor hallucis longus (FHL) tendinosis and/or tenosynovitis, soft tissue impingement, and so on. They are considered as a pathological unit of posterior ankle impingement syndrome (PAIS). The purpose of this study is to elucidate the pathologies of PAIS and to clarify how to approach and treat these conditions. Methods Between September 2007 and August 2010, 35 feet of 32 patients, including only one foot of a male patient, underwent hindfoot endoscopic surgery due to PAIS. Average age was 19.6 years (range, 12-40) at the time of surgery. The pathological conditions were retrospectively analyzed mainly with operative findings, also referring with X-ray, MRI, and histological findings. Surgical technique presented by van Dijk was applied to all feet. Results Synchondrosis injury (SCI) was detected in 14 feet, synovitis associated with one or more movable os trigonum (mOT) in 12, a fracture (or microfracture) in os trigonum or posterior process of the talus in four, DJD beneath the OT in two. Injury to the FHL tendon matrix was observed in 23 feet, distal insertion of FHL muscle fibers in 12, and anomalous muscle (FDAL) in two. Intermalleolar ligament (IML), which is also called a tibial slip, a part of transverse tibiofibular ligament, or a pseudomeniscoid were found in 21 feet (60%), ranging from 1 to 5 mm in width. Among them, five were adherent to the FHL tendon sheath, and three had behavior linked with the FHL motion, which seemed to undergo posterior ankle impingement. Osteochondral lesion of the medial talar trochlea were observed in two feet, nodular fibrosis in posterior talocalcaneal ligament and marked synovitis in ankle and posterior subtalar joint in one, respectively. A great majority of feet were affected with two or more pathologic conditions, except four feet. 22 feet (62.9%) had combined bony impingement (SCI, mOT, fracture) with FHL tendon injury. Conclusion Bony impingement was the major pathological process, related in more than 90 percent of the patients; special attention, however, should be paid to some other conditions that concomitantly existed. The hindfoot arthroscopic approach has great diagnostic potentials to posterior aspect of ankle and posterior subtalar joint. And also enables to treat bony impingement, IML lesions, and tenolysis of the FHL and/or FDAL tendon. But when repair of the severely injured FHL tendonor extirpation of ganglions on the tendon sheath is necessary, the other approach should be considered.

Current Concepts Review: Insertional Achilles Tendinopathy

Pathology of the Achilles tendon is a common source of posterior ankle and heel pain. A variety of terms have been used to describe similar but clinically distinct conditions involving this tendon including tendinosis, tendinitis, paratenonitis, and peritendinitis. The latter are misleading because their suffixes imply an inflammatory process. However, inflammatory cells are rarely present in biopsies from involved tendons.3 The most common histopathologic finding is a degenerative process characterized by disorganized collagen, abnormal neovascularization, necrosis and mucoid degeneration.34,58 Based on these findings, Maffulli and colleagues advocated for the term tendinopathy to describe the syndrome characterized by pain, swelling and impaired performance.39 While runners comprise the largest group of patients with chronic pain in the Achilles tendon, individuals of all activity levels and ages present with similar complaints. The location of the pain is an important discriminating factor, as insertional (tendon-bone junction) pain is often treated differently than noninsertional (2 to 6 cm proximal to the insertion) pain. This review will focus on insertional tendinopathy and will discuss related disorders including retrocalcaneal bursitis and Haglund’s deformity. Recently, much has been learned regarding the pathophysiology of Achilles tendinopathy and this knowledge has lead to the development of new treatment options. However, the evidence to support these innovative approaches has not been appraised. This current concepts review will present the etiology, pathophysiology, and evaluate the merits of

Clinical Evaluation and Treatment of Posterior Impingement in Dancers

Os trigonum impingement is a frequent cause of posterior ankle pain in ballet dancers because they need extreme plantar flexion during the execution of relevé in demipointe and en pointe positions. Clinical examination and standard and modified x-rays should be carried out to clearly identify the site and entity of the impingement. If a posterior impingement is clinically diagnosed, standard and modified magnetic resonance imaging should be also performed. From September 2005 to September 2006, we considered 186 young trainee ballet dancers. Twelve suffered from posterior ankle pain, and six of these had os trigona. We treated all the ballet dancers nonoperatively, and nine of them had good results. Conservative treatment failed in only three cases after 1-4 mos of physical and medical therapies, and, in these cases, good results were obtained through surgical excision of the accessory ossicle. Modified x-ray and magnetic resonance imaging help to determine the site and entity of the posterior impingement. If this is properly diagnosed, good results can be obtained through a nonoperative approach in a majority of cases.

Arthroscopic release of flexor hallucis longus tendon using modified posteromedial and posterolateral portals in the supine position

Background The flexor hallucis longus (FHL) is a known site of pathological conditions. FHL stenosing tenosynovitis presents as posterior medial ankle pain or great toe discomfort and is often associated with a catching sensation of the great toe. There are a wide variety of open procedures for the treatment of FHL stenosing tenosynovitis. Objective Arthroscopic treatment may circumvent some of the complications associated with open surgical treatment of the hindfoot. Methods Arthroscopic surgery was completed in the supine position using modified posteromedial and posterolateral portals. A 70° arthroscope allowed for circumferential evaluation of the ankle through the posterolateral portal including the subtalar areas and the entire FHL tendon for release using basket forceps and a 3.5 mm shaver. Results This method allows for decompression of the FHL from the entrance of the fibro-osseous tunnel to the knot of Henry. Active and passive range of motion of both the ankle and toes was encouraged postoperatively. The patient returned to sporting activity 6 weeks after surgery. Conclusions Endoscopic treatment of the FHL stenosing tenosynovitis is presented as an alternative to an open surgical procedure; it may reduce wound complications and may allow for an earlier return to sport.

An unusual complication after syndesmotic injury: retrotibial heterotopic ossification

A 27-year-old male patient sustained an isolated syndesmotic injury in the right ankle following a fall. His complaints subsided gradually within the first six weeks of conservative treatment. At the end of the third month, he returned to follow-up with posterior ankle pain. Radiological examinations revealed heterotopic ossification adjacent to the posterior inferior tibiofibular ligament and posterior capsule. His complaints disappeared only after local excision of the ossification. Heterotopic ossification may be a cause of persistent pain after ankle ligament injuries.

Arthroscopic Capsular Shrinkage for Chronic Ankle Instability with Thermal Radiofrequency: Prospective Multicenter Trial

The study was designed as a prospective multicenter longitudinal trial. Adult patients with symptomatic mechanical chronic ankle instability, not improving with conservative therapy, were included and underwent surgery. Primary outcome measures were radiological and manually tested mechanical laxity. Secondary outcome measures were number of complications, reoperations and symptoms, range of motion, and functional (ankle) scores (Karlsson and SF-36 score). The latest follow-up was 9 months for each patient. Thirty-nine patients underwent surgery (19 male patients; 16 right ankles; median age, 27 years). Mechanical stability showed no clinically relevant improvement whereas most secondary outcome measures showed a substantial and statistically significant improvement. One surgery-related complication occurred without functional consequences, and 3 patients underwent a secondary procedure. One was considered a treatment failure, requiring an open anatomic ligament reconstruction. The second patient sustained a severe supination trauma by starting intensive training too early, also requiring an open anatomic reconstruction. The third patient had posterior ankle pain, which was successfully treated by posterior ankle arthroscopy. Arthroscopic thermal capsular shrinkage of the ankle is a safe procedure, leading to resolution of symptoms in the majority of patients with chronic ankle instability.

Arthroscopic Capsular Shrinkage for Chronic Ankle Instability with Thermal Radiofrequency: Prospective Multicenter Trial

The study was designed as a prospective multicenter longitudinal trial. Adult patients with symptomatic mechanical chronic ankle instability, not improving with conservative therapy, were included and underwent surgery. Primary outcome measures were radiological and manually tested mechanical laxity. Secondary outcome measures were number of complications, reoperations and symptoms, range of motion, and functional (ankle) scores (Karlsson and SF-36 score). The latest follow-up was 9 months for each patient. Thirty-nine patients underwent surgery (19 male patients; 16 right ankles; median age, 27 years). Mechanical stability showed no clinically relevant improvement whereas most secondary outcome measures showed a substantial and statistically significant improvement. One surgery-related complication occurred without functional consequences, and 3 patients underwent a secondary procedure. One was considered a treatment failure, requiring an open anatomic ligament reconstruction. The second patient sustained a severe supination trauma by starting intensive training too early, also requiring an open anatomic reconstruction. The third patient had posterior ankle pain, which was successfully treated by posterior ankle arthroscopy. Arthroscopic thermal capsular shrinkage of the ankle is a safe procedure, leading to resolution of symptoms in the majority of patients with chronic ankle instability.

Posterior arthroscopic excision of bilateral posterior bony impingement syndrome of the ankle: a case report

The common cause of posterior ankle impingement syndrome (PAIS) is impingement of the os trigonum or talar posterior process. There were few reports of bilateral PAIS of the os trigonum, and bilateral PAIS of the talar posterior process has not been previously reported. The authors report the case of a 32-year-old man who was diagnosed with bilateral PAIS related to a prominent lateral tubercle of the talar posterior process, and who was treated by posterior arthroscopic excision through posterolateral and posteromedial portals in a prone position. His preoperative posterior ankle pain disappeared completely after surgery, and the patient returned to contact sports 3 months postoperatively.

Outcome of Posterior Ankle Arthroscopy for Hindfoot Impingement

To provide short-term clinical results of posterior ankle arthroscopy in the treatment of posterior ankle impingement. This was a retrospective evaluation of the clinical outcomes of posterior ankle arthroscopy in a series of patients with posterior ankle pain. Of 23 patients who underwent 24 posterior ankle arthroscopies between July 1998 and February 2004, 15 patients (mean age, 25 years) with 16 posterior ankle arthroscopies were evaluated at a mean follow-up time of 32 months (range, 6 to 74). Procedures carried out were: excision of os trigonum (11); decompression of prominent posterior talar process (5); tenolysis of flexor hallucis longus (5); removal of loose body (1); osteochondritis dissecans lesion debridement (1); and arthrotomy (1). The average time to return to work was 1 month (range, 0 to 3) and to sports, 5.8 months (range, 1 to 24). Fourteen patients returned to their preinjury level of athletics. Mean Health Survey Short Form (SF-12) scores were 51.80 for the mental component (range, 30.77 to 60.53) and 55.80 for the physical component (range, 44.26 to 63.33). Mean score on the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale was 91 (range, 77 to 100) and on the Lower Extremity Functional Scale was 75 (range, 65 to 80). Documented complications included temporary numbness in the region of the scar in 5 patients and temporary ankle stiffness in 1 patient. There were no permanent neurovascular injuries. All subjects reported significant improvement and indicated that they would undergo the surgery again if needed. Functional and clinical evaluations following posterior ankle arthroscopy revealed that all patients were very satisfied. They reported good to excellent health-related quality of life scores, satisfactory functional outcomes, and a high rate of return to sporting activities. Most importantly, no significant complications were encountered. This review suggests that posterior ankle arthroscopy is a safe and effective surgical procedure in the treatment of posterior ankle impingement. Level IV, therapeutic case series.

Posterior Ankle Pain Diagnosed by Positional MRI of the Ankle: A Unique Case of Posterior Ankle Impingement and Osteonecrosis of the Talus

Posterior Ankle Pain Diagnosed by Positional MRI of the Ankle: A Unique Case of Posterior Ankle Impingement and Osteonecrosis of the Talus