Impingement syndromes of the ankle

Eur Radiol (2007) 17: 3056–3065DOI 10.1007/s00330-007-0675-1 MUSCULOSKELETAL

Philip Robinson

Received: 12 December 2006Revised: 9 March 2007Accepted: 20 April 2007Published online: 15 May 2007# Springer-Verlag 2007

Impingement syndromes of the ankle

Abstract Ankle impingement syn-dromes are categorised accordingto their anatomical site around thetibiotalar joint. Anterolateral, anteri-or and posterior ankle impingementhas been extensively described inthe orthopaedic and radiology lit-erature with more recent studiesdescribing posteromedial and an-teromedial impingement. This articleaims to demonstrate the potential

spectrum of imaging findings foreach ankle impingement syndromeas well as the relative contributionsof ultrasound and MR imagingfor diagnosis and image-guidedtreatment.

Keywords Ankle . Injuries .Ankle impingement . Ankle . MRI .Ankle . Ultrasound . Athletic injuries

Introduction

Supination (inversion) injury of the ankle is one of the mostcommon injuries in the general population and athletes.Although the majority respond to rehabilitation, 15–20% ofsports injuries can result in persisting symptoms [1].Because of the large volume of acute ankle injuries chronicpain is a frequent clinical problem with the differentialdiagnosis including osteochondral injury, mechanicalinstability and impingement syndromes [1]. Originallydescribed in the 1950s, impingement syndromes are nowrecognised as a significant cause of chronic ankle pain [2–5]. Impingement used to be considered a clinical diagnosisof exclusion, but the literature now shows it can coexistwith other causes of chronic ankle dysfunction [5, 6].

Ankle impingement is defined as painful mechanicallimitation of full ankle movement secondary to osseousand/or soft tissue abnormality. These conditions occurmore commonly in active people and athletes probablybecause recurrent subclinical injury is an important factorin development [7]. Onset of symptoms is variable and caneither be insidious or secondary to a precipitating injury ina different anatomical area of the ankle [4, 7, 8].

Ankle impingement syndromes are categorised accord-ing to their anatomical site around the tibiotalar joint.Anterolateral, anterior and posterior ankle impingement

has been extensively described in the orthopaedic andradiology literature with more recent studies describingposteromedial and anteromedial impingement [2–5, 9].

This article aims to demonstrate the potential spectrumof imaging findings for each ankle impingement syndromeemphasising the contributions of ultrasound and MRimaging for diagnosis and image guided treatment.

Anterolateral impingement

Aetiology and clinical features

The boundaries of the anterolateral recess of the ankleconsist of the tibia and fibula posteromedially and laterallywith the capsule of the tibiotalar joint forming the anteriorand lateral margins (Fig. 1). The capsule is reinforced bythe anterior tibiofibular, anterior talofibular and calcaneo-fibular ligaments [2].

Anterolateral impingement is thought to develop sub-sequent to a relatively minor injury usually consisting offorced ankle plantar flexion and supination [2, 6, 10]. Thisinjury mechanism generates tensile forces which tear theanterolateral capsular tissues without clinically significantmechanical instability. However, subsequent functionalinstability and associated repeated microtrauma can lead

P. Robinson (*)Musculoskeletal Centre X-RayDepartment, Chapel Allerton Hospital,Leeds, LS7 4SA, UKe-mail: [email protected].: +44-113-3924514Fax: +44-113-3924550

to further soft tissue haemorrhage, synovial scarring andhypertrophy. Although some studies have described addi-tional hypertrophy of the inferior portion of the anteriortibiofibular ligament and occasionally osseous spurs, theseare rarely a predominant feature at imaging or surgery(Fig. 2) [2, 6, 11, 12].

Initially anterolateral impingement was described as aclinical diagnosis of exclusion only made in the absence ofmechanical instability and tendon abnormality [11]. How-ever it now is recognised that all the ankle impingementsyndromes can exist on their own or in combination withinjuries such as chondromalacia and tendinopathy. It isimportant to recognise this clinically and radiologically sothat coexistent pathologies are not missed resulting inpotential treatment failure [1].

Patients typically complain of anterolateral ankle painwhich is exacerbated on supination or pronation of the foot.Surgical series have found anterolateral tenderness, swell-ing, pain on single leg squat and pain on ankle dorsiflexionand eversion seem to correlate most strongly withsubsequent abnormality at surgery [11].

Imaging features

This condition remains a predominantly clinical diagnosisand the role of cross-sectional imaging in detecting capsularabnormalities is more controversial [2, 3, 6, 10]. Ultrasoundhas not been fully evaluated in this condition with one seriesreporting capsular nodularity in patients with clinicalimpingement, but no significant data regarding asymptom-atic or symptomatic controls are available (Fig. 2e) [13].

Studies investigating the use of conventional MR imaginghave produced conflicting results in the pre-operative patient[10, 14–17]. Sensitivity and specificity for the detectionof abnormality vary widely with an increase of accuracyoccurring when a significant joint effusion is present[10]. However most prior surgical and radiology serieshave retrospectively selected positive surgical cases withno evaluation in controls [10, 14, 16, 17]. MR and CTarthrography studies have found a strong associationbetween capsular irregularity of the anterolateral recessand subsequent surgical abnormality [6, 18]. Arthrographymay be most effective in anterolateral impingement as thiscondition predominantly consists of internal capsularirregularity rather than soft tissue oedema and has nosignificant osseous component which can be evaluated onconventional MR imaging and radiographs respectively.This capsular irregularity can be easily missed on conven-tional MR imaging and indirect MR arthrography unlessa native effusion is present. One prospective study ofpatients with clinical anterolateral impingement and controlswith chronic ankle pain found a smooth contour on MRarthrography correlated with normal capsular findings atarthroscopy. An irregular or nodular deep contour of theanterolateral capsule on MR arthrography correlated withscarring and synovitis of the ankle recess at arthroscopy(Fig. 2). The most common abnormality was best seen onaxial sequences and involved the capsule just above the levelof the anterior talofibular ligament, but could extendsuperiorly to the tibiofibular ligament. The ligamentsthemselves are usually not abnormal and unlike posteriorimpingement syndromes soft tissue oedema is not commonlyseen. A more specific sign was adherence of the capsular

Fig. 1 Normal anatomy. (a) Normal axial PD-weighted MRarthrogram image shows anterior talofibular (black arrowheads)and posterior talofibular (*) ligaments. The anterolateral recess isseen with its smooth capsular margin (arrows) extending betweenthe talus and fibula. (b) Sagittal T1-weighted fat-suppressed MR

arthrogram image shows normal triangular configuration of theposterior inter-malleolar ligament (arrow) adjacent to the tibia. Noteanterior synovitis (*). (c) Axial PD weighted MR arthrogram imageat the level of the talar dome shows the inter-malleolar ligament(arrowheads) extending from the fibula

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tissues to the anterolateral talus despite good arthrographicdistension elsewhere in the joint (Fig. 2). This featurecorrelated with marked, adherent, scarring at surgery andwas only found in a subset of patients with clinicalimpingement. However this study also highlighted anumber of patients without clinical anterolateral impinge-ment that had surgically confirmed capsular thickening onMR arthrography. All previous clinical series havedescribed concomitant intra-articular abnormalities includ-ing chondral damage, ligament abnormality and osseousspurs. These additional findings are usually relativelyminor, but not surprising given the original mechanism ofinjury and subsequent functional problems.

Management and role of imaging

The majority of patients with anterolateral impingementrespond to rehabilitative physiotherapy; however if this isunsuccessful, debridement of synovitis and scarring resultsin considerable improvement in symptoms and anklefunction [2, 11, 12].

If MR imaging is to play a role it should be reserved forpatients where there is some clinical uncertainty regardingthe diagnosis or if surgery is planned. A normal MRarthrogram seems to exclude anterolateral synovial scar-ring; however in patients with definite clinical impinge-ment conventional MR imaging may be all that isnecessary to detect coexisting pathology prior to surgery[6, 19, 20].

Anterior impingement


Anterior ankle impingement has been extensively de-scribed as a cause of chronic ankle dysfunction and issometimes termed “footballer’s ankle”. The underlyingmechanism of injury implicated is repeated supinationinjury which causes damage at the anteromedial margins ofthe articular cartilage [21, 22]. Other aetiological factorsinclude repeated forced dorsiflexion (common in ballet andfootball) and direct microtrauma (particularly seen infootball players during ball striking) [23, 24]. Unlike otherimpingement syndromes osseous abnormality (anteriortibiotalar spurs) forms a significant component of theimpinging mass (Fig. 3) [1, 22, 25–27]. Chronic damage tothe chondral margins leads to repair with fibrous tissue,hyaline and fibro-cartilage undergoing subsequent enchon-dral ossification producing bone spurs. Studies of asymp-tomatic professional athletes have found a significantportion (45–59%) to have anterior tibiotalar spurs on X-ray[28]. It is thought that although these osseous abnormalitiesare an important part of this condition the development ofadditional capsular abnormality is critical for producing theclinical syndrome (Fig. 3b & c) [23, 24, 27].

The clinical features of this condition are anterior anklepain with a subjective feeling of blocking on dorsiflexion.Examination reveals restrictive and painful dorsiflexionwith occasionally palpable soft tissue swelling over theanterior joint [27].

Fig. 2 Patients with clinicalanterolateral impingement. (a)Axial T1-weighted fat-sup-pressed MR arthrogram imageshows thickening of the anteriortibiofibular ligament (arrows)(Ti = tibia, F = fibula). (b) AxialT1-weighted fat-suppressed MRarthrogram image shows nodu-larity (white arrows) andstranding (black arrowheads) inthe anterolateral recess (Ta =talus, F = fibula). (c) Axial T1-weighted fat-suppressed MRarthrogram image shows an ir-regular and thickened anterolat-eral recess (arrowheads) with anodular contour that does notdistend away from the fibulaand talus. (d) Correspondingarthroscopic image (to c) showsthe talar dome with anterolateralsynovitis and nodularity (ar-rowheads). (e) Transverse axialultrasound shows a predomi-nantly hypoechoic nodule (ar-rows) in the anterolateral recessbetween the talus and fibula

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Imaging features

After clinical assessment conventional radiographs areusually performed to confirm the extent and presence ofosseous spurs on the lateral view [1, 21, 29]. The tibiotalarspurs occur in typical positions at the anterior and medialarticular cartilage margins and some authors advocate aspecial anteromedial view to highlight their extent [30].Radiographs also allow assessment of the remainder of thetibiotalar joint for secondary signs of degenerationincluding joint space reduction (Fig. 3b). Often this willbe the only imaging required, because if the patient doesproceed to arthroscopy, the remainder of the joint can bevisualised at that time. There have been no significantradiology series evaluating cross-sectional imaging orultrasound in this condition. MR imaging can demonstrateosseous spurs and synovial thickening extending over theanterior aspect of the joint (Fig. 3c). Like anterolateralimpingement and unlike posterior impingement (see later)these abnormalities rarely show striking soft tissue orosseous oedema.

Management and the role of imaging

In athletes with anterior ankle impingement resistant torehabilitative physiotherapy, arthroscopic resection of theosseous spurs and soft tissue abnormality with jointwashout has been shown to yield excellent functional andsymptomatic results [27]. As already stated radiographs areusually the only imaging required. Occasionally conven-tional MR imaging can be a useful tool for aidingmanagement decisions allowing evaluation of the entirejoint for other pathologies when symptoms are not severeenough to proceed directly to surgery. CT scanning can

have a role in surgical planning if the extent of the tibiotalarspurs is not clearly evident on radiographs.

The surgical literature shows that despite the presentingclinical severity overall outcome is more dependant on thedegree of degenerative change (chondral and sub-chondraldamage) present in the remainder of the tibiotalar joint atthe onset of treatment [27]. A large surgical series ofanterior ankle impingement described 57 patients witheither a normal joint space or minimal degeneration onconventional radiograph who had excellent function at6.5 years post operatively (100% and 77% respectively)[27].

Posterior impingement


Posterior impingement develops secondary to repeated orforced ankle plantarflexion with subsequent compressionof the soft tissues between the posterior process of the cal-caneus and the tibia (Figs. 4 and 5) [4, 31–33]. The lateraltalar process or an os trigonum can also increase the degreeof soft tissue compression with or without stress reaction inthe bone itself. The lateral process of the talus initially formsas a secondary ossification centre between the ages of 7 to13 years and usually fuses with the main body of the taluswithin 1 year of appearance [31]. If there is a failure offusion, the ossicle is known as an os trigonum andarticulates with the talus via a synchondrosis (incidence 7to 14%) [31]. If the lateral talar process is unusually large orprominent it is sometimes termed a Steida process.

The soft tissues compressed include the tibiotalarcapsule, posterior talofibular, intermalleolar and tibiofibu-lar ligaments (Fig. 1). The flexor hallucis longus (FHL)

Fig. 3 Footballers with clinicalanterior impingement. (a) Lat-eral ankle radiograph showsanterior tibial and the talar spurs(arrows) at the anterior articularcartilage margin. (b) Lateralankle radiograph shows anteriortibial and the talar spurs (ar-rows) with degeneration at theanterior articular cartilage mar-gin and soft tissue thickening(*). (c) Sagittal T2-weighted fatsuppressed MR image showsanterior tibial and talar spurs(arrows) but within the anteriorrecess of the joint there is aneffusion with capsular thicken-ing and stranding (arrowheads)

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tendon runs in the groove between the lateral and medialprocesses of the talus and can also be secondarily involvedalthough a primary tenosynovitis can clinically mimicposterior impingement [4].

Posterior impingement is typically a chronic problem ofinsidious onset affecting athletes who regularly undergoforced plantarflexion especially ballet dancers, jumpingathletes, squash and football players. Football players areparticularly affected because plantarflexion occurs not onlyon push off during sprinting and changing direction butalso occurs during kicking [4, 34]. As has been described inother impingement conditions the syndrome usuallymanifests clinically when a significant soft tissue compo-nent forms [4].

Symptoms can also develop subacutely after an acuteinjury either posteriorly or elsewhere in the ankle and is notuncommon in football and ballet athletes who developsymptoms 4–6 weeks after a precipitating injury (Fig. 4) [4,7]. This presentation would suggest that there is constantstress on the posterior tibiotalar capsular structures causing

subclinical posterior capsular damage and repair. Presum-ably the acute injury leads to haemarthrosis and furthersynovial thickening which added to the backgrounddamage is enough to precipitate the syndrome. In footballplayers as the initial anterolateral symptoms, bruising andswelling settle, posterolateral ankle pain develops as theplayer starts to try and sprint, push off, change direction orstrike through the ball [7].

Patients complain of posterior ankle pain exacerbated bydorsiflexion or plantarflexion, which results in stretching orcompression of the abnormal tissues respectively [4, 34].On examination there is posterior tibiotalar joint tendernessnot involving the achilles tendon exacerbated by plantarflexion and dorsiflexion.

Imaging features

Conventional radiographs can demonstrate an os trigonumor a Steida process; however these findings are commonlyseen in asymptomatic individuals and minor stressfractures can be easily missed [4]. CT scanning candemonstrate more detailed bony anatomy including stressfractures; however soft tissue resolution is poor [4, 31].Isotope bone scans have been previously advocated [4, 31];

Fig. 4 Footballer with clinical posterior impingement. (a) SagittalT1 fat-suppressed post intravenous gadolinium MR image showsmarked posterolateral soft tissue oedema and thickening (arrow-heads) and oedema of the posterior tibia (*). (b) Axial T2-weightedfat-suppressed MR image shows posterior capsular oedema (*) andbulging (arrowheads) posterior to the talus. (c) Correspondinglongitudinal ultrasound image shows cortical irregularity (arrow-heads) of the posterior tibia and associated nodular soft tissuethickening (arrows). Palliative injection to this area was made underultrasound guidance

Fig. 5 Footballer with clinical posterior impingement. Sagittal T1fat-suppressed post intravenous gadolinium MR image showsenhancing posterolateral capsular synovitis and thickening (arrows).There was relatively little soft tissue oedema seen on T2-weightedimages

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however if positive, precise resolution of the bonyabnormality is difficult and this technique is relativelyinsensitive for soft tissue problems.

Conventional MR imaging is the optimal imagingmodality as it can define bone marrow oedema, fracturelines or disruption of the synchondrosis indicating activebony impingement (Figs. 4, 5, 6 and 7) [31, 32, 35]. Thistechnique is also accurate in assessing the integrity of theposterior capsular ligaments, capsular abnormality andoedema [7, 20, 32, 36]. The ligaments are usually intact,but surrounding posterior (particularly posterolateral) cap-sular oedema is commonly best seen on axial and sagittalT2-weighted sequences extending into Kager’s fat pad.These features mean that direct and indirect MR arthro-graphy are not necessary, but intravenous gadolinium canhighlight small focal areas of enhancing synovitis aroundthe posterior ligaments if oedema is not a predominatingfeature (Fig. 5). MR imaging also allows accurateassessment of the remainder of the tibiotalar joint andsurrounding tendons, which can aid treatment and surgicalplanning.

Ultrasound is a very useful technique in this condition,as the symptomatic area is usually quite focal and amenableto visualisation despite diffuse oedema on MR imaging(Fig. 4) [7]. If the abnormality is confirmed as focal with noother significant internal derangement on MR imaging,athletes can get good symptomatic relief after targetedultrasound-guided injection of local anaesthetic and steroidinto the nodular area (see below).


The majority of cases of posterior impingement of theankle respond to conservative treatment (physiotherapy)[4]. Conventional MR imaging can define the degree ofoedematous change and exclude concomitant abnormal-

Fig. 6 Patient with clinical posterior impingement. Sagittal T2-weighted fat-suppressed MR image shows bone marrow oedemawithin the os trigonum (*) and fluid (large arrow) in thesynchondrosis. Marked nodular thickening (small arrows) in theposterior capsular recess

Fig. 7 Footballer with clinical posterior impingement. (a) SagittalT2-weighted fat-suppressed MR image shows a joint effusion (*)and nodular posterolateral synovitis (arrowheads). There is oedemaat the margins of the os trigonum synchondrosis (arrows). (b) Axialsonography image of the os trigonum (Os) and adjacent talusobtained during injection shows nodular synovitis (*) with needle(arrow) placed during infiltration and injection

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ities. It is our institutional practice to perform MR imagingprior to capsular injection so osteochondral injuries are notpotentially masked and allowed to progress. Image-guidedsteroid and local anaesthetic injection into focal capsularthickening or the Os trigonum synchondrosis provideslong-lasting symptomatic relief in the majority of patients,which can mean surgery is not required (Fig. 7) [7, 37].Even if this effect is temporary the treatment can allowprofessional athletes to delay surgery.

A number of surgical studies have shown that arthro-scopic resection of soft tissue thickening and any associatedbony abnormality with joint wash out produces good symp-tomatic and functional results in resistant cases [4, 34].

Posteromedial impingement


The exact aetiology and characteristic imaging features ofposteromedial impingement have not been as completelydefined as other impingement syndromes [5, 38, 39]. Thecondition develops after compression of the posteromedialtibiotalar capsule and posterior fibres of the tibiotalarligament (PTTL) between the talus and medial malleolusduring a supination injury [5]. It is thought that subsequentfibrosis and thickening of the contused PTTL and postero-medial capsule lead to painful impingement between themedial wall of the talus and posterior margin of the medialmalleolus [5]. Posteromedial tenderness on inversion withthe ankle in plantar flexion is an important clinical findingwhich differentiates pain originating from primary tibialisposterior abnormality [5]. In a similar manner to posteriorimpingement symptoms can be insidious or developsubacutely after another injury [5, 8, 38].

Imaging

Isotope bone scan, ultrasound and MR imaging featureshave previously been presented for three groups of patientswith clinical posteromedial impingement [5, 8, 38].Paterson et al. described increased posteromedial activityon isotope bone scanning in six patients (including fiveathletes) who presented a mean of 52 weeks after theoriginal injury. However further abnormalities not detectedon bone scan were treated at arthroscopy [5]. The other twoseries have concentrated on MR imaging and ultrasoundfeatures. Axial PD- and T2-weighted sequences show lossof striation of the posterior tibiotalar ligament (PTTL),capsular thickening with oedema abutting and occasionallyencasing the posteromedial tendons (especially tibialisposterior) (Figs. 8 and 9). Ultrasound can identify hypo-echoic posteromedial capsular thickening deep to andsometimes displacing tibialis posterior, obscuring detail ofthe underlying PTTL (Fig. 9). The main difference between

these two studies was the relatively low incidence of tendonencasement in the most recent series which evaluatedathletes presenting subacutely (within 4–6 weeks) while inthe earlier series patients had symptoms in excess of 1 year[8, 38]. This time difference may have resulted in differingproportions of encasing scar tissue present in the groupsstudied [8].

Arthrographic techniques and CT have not beenevaluated in this condition, but conventional MR imagingis probably the optimal imaging technique. The use ofintravenous gadolinium may be helpful in highlighting lowgrade synovitis in more subtle cases.


After failed rehabilitation MR imaging can be performed toconfirm posteromedial abnormality and exclude concom-itant abnormality. Ultrasound can then identify the capsularabnormality and guide effective injection treatment (Fig. 9)[8]. Injection of steroid and long-acting anaesthetic along

Fig. 8 Footballer with clinical posteromedial impingement. AxialPD-weighted MR image shows loss of striation of the tibiotalarligament (arrows) with soft tissue thickening displacing tibialisposterior (*)

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with dry needling of the capsular abnormality allows themajority of patients to rapidly return to activity withoutsurgical intervention. Surgical resection of capsular thick-ening is successful in resistant cases and no formalligamentous repair is usually necessary [5, 38].

Anteromedial impingement


The underlying mechanism of injury for this particularimpingement syndrome is not completely understood, butthe majority of cases described have initially suffered asupination injury [9, 40]. It seems likely that this conditionis a rare complication of supination injury and not secondaryto an eversion injury. There is probably a superimposedrotational component that leads to subsequent anterome-dial capsular tearing, and in a similar process to antero-lateral impingement, repeated micro trauma leads tosynovitis and capsular thickening (Fig. 10a). However,unlike anterolateral impingement, a proportion of thecases described have also had significant osseous spurs(Fig. 10b) [9, 40].

Clinically the majority of the patients described havechronic anteromedial pain exacerbated by dorsiflexion. Onclinical examination, there is usually focal anteromedialtenderness, with possible superimposed soft tissue swellingand limitation of full dorsiflexion and supination [9, 40].

Fig. 9 Footballer with clinical posteromedial impingement present-ing 3 weeks after a supination injury. (a) Axial T2-weighted fastspin echo fat-suppressed MR image shows posteromedial capsularoedema (arrow) displacing tibialis posterior (*). Note asymptomaticanterolateral talar oedema (arrowhead). (b) Axial ultrasound imageof the posteromedial talus and tibia (Ti) during injection (arrow)shows hypoechoic capsular thickening (white*) displacing tibialisposterior (black*)

Fig. 10 (a) Male patient with clinical anteromedial impingementfollowing a rotational injury. Axial T1-weighted fat-suppressed MRarthrogram image shows nodular capsular thickening (arrows) fillingthe anteromedial recess anterior to the deltoid ligament (De) andtalus (Ta). (b) Female patient with clinical anteromedial impinge-ment with no known precipitating injury. Axial PD-weighted MRarthrogram image shows anteromedial synovitis (arrows) and medialtalar spur (*)

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Imaging features

There are no large studies describing typical imagingappearances and previous surgical studies did not formerlyevaluate imaging. The few reports of imaging featuresdescribe focal anteromedial capsular thickening and syno-vitis with or without additional anteromedial tibiotalarspurs on MR arthrography (Fig. 10) [9]. Arthrographictechniques are probably more accurate than conventionalimaging as both CT and MR arthrography will detect thecapsular abnormality as well as any ossesous spurs.


All surgical studies have described good symptomatic andfunctional results after arthroscopic resection of the syno-vitis and any associated bony abnormality [9, 40]. It isdifficult to definitively describe a positive role of imaginggiven the limited series presented. Conventional MRimaging may have a role in detecting concomitant chon-dromalacia and other injuries allowing for the fact it may bemiss subtle capsular changes in clinical definite cases.

Conclusions

In recent years impingement syndromes of the ankle havebeen increasingly recognised as a cause of chronic ankle

pain especially in younger and athletic age groups. Theprecipitating mechanism of injury involved implies anassociated risk of additional concomitant ankle abnormal-ities (e.g., cartilage defects, ligament disruption). Imagingevaluation should be performed remembering impinge-ment can coexist with other abnormalities and is no longera diagnosis of exclusion.

The imaging features associated with these conditionsshould be cautiously interpreted, especially in athleteswhere some capsular and osseous changes can be asymp-tomatic. MR imaging is valuable in assessing the possiblesoft tissue and osseous abnormalities implicated in aparticular clinical setting of ankle impingement. Howeverthe other advantage of performing MR imaging rather thanCTor ultrasound is its ability to provide a global assessmentof the joint and soft tissues prior to treatment. Especially forposterior and posteromedial impingement this allows ultra-sound-guided injection to provide effective treatmentavoiding surgery. Direct arthrographic techniques areprobably more accurate for defining the capsular abnormal-ity associated with anterolateral and anteromedial impinge-ment, but are rarely performed in clinical practice. In thissituation conventionalMR imaging canmiss subtle capsularchanges, but is used to assess the rest of the joint whenclinical features of anterolateral impingement are definite.

References

1. Ogilvie-Harris DJ, Gilbart MK, ChorneyK (1997) Chronic pain following anklesprains in athletes: the role of arthro-scopic surgery. Arthroscopy 13:564–574

2. Ferkel RD, Karzel RP, Del Pizzo W,Friedman MJ, Fischer SP (1991) Ar-throscopic treatment of anterolateralimpingement of the ankle. Am J SportsMed 19:440–446

3. Bassett FH 3rd, Gates HS 3rd, BillysJB, Morris HB, Nikolaou PK (1990)Talar impingement by the anteroinferiortibiofibular ligament. A cause ofchronic pain in the ankle after inversionsprain. J Bone Joint Surg Am 72:55–59

4. Hamilton WG, Geppert MJ, ThompsonFM (1996) Pain in the posterior aspectof the ankle in dancers. Differentialdiagnosis and operative treatment. JBone Joint Surg Am 78:1491–1500

5. Paterson RS, Brown JN (2001) Theposteromedial impingement lesion ofthe ankle. A series of six cases. Am JSports Med 29:550–557

6. Robinson P, White LM, Salonen DC,Daniels TR, Ogilvie-Harris D (2001)Anterolateral ankle impingement: mrarthrographic assessment of the an-terolateral recess. Radiology 221:186–190

7. Robinson P, Bollen SR (2006) Posteriorankle impingement in professionalsoccer players: effectiveness of sono-graphically guided therapy. AJR Am JRoentgenol 187:W53–W58

8. Messiou C, Robinson P, O’Connor PJ,Grainger A (2006) Subacute postero-medial impingement of the ankle inathletes: MR imaging evaluation andultrasound guided therapy. SkeletalRadiol 35:88–94

9. Robinson P, White LM, Salonen D,Ogilvie-Harris D (2002) Anteromedialimpingement of the ankle: using MRarthrography to assess the anteromedialrecess. AJR Am J Roentgenol178:601–604

10. Rubin DA, Tishkoff NW, Britton CA,Conti SF, Towers JD (1997) Antero-lateral soft-tissue impingement in theankle: diagnosis using MR imaging.AJR Am J Roentgenol 169:829–835

11. Liu SH, Raskin A, Osti L et al (1994)Arthroscopic treatment of anterolateralankle impingement. Arthroscopy10:215–218

12. Ferkel RD, Fasulo GJ (1994) Arthro-scopic treatment of ankle injuries.Orthop Clin North Am 25:17–32

13. Bagnolesi P, Zampa V, Carafoli D,Cilotti A, Bartolozzi C (1998) Antero-lateral fibrous impingement of theankle. Report of 14 cases. Radiol Med(Torino) 95:293–297

14. Liu SH, Nuccion SL, Finerman G(1997) Diagnosis of anterolateral ankleimpingement. Comparison betweenmagnetic resonance imaging and clini-cal examination. Am J Sports Med25:389–393

15. Duncan D, Mologne T, Hildebrand H,Stanley M, Schreckengaust R, Sitler D(2006) The usefulness of magneticresonance imaging in the diagnosis ofanterolateral impingement of the ankle.J Foot Ankle Surg 45:304–307

3064

16. Farooki S, Yao L, Seeger LL (1998)Anterolateral impingement of theankle: effectiveness of MR imaging.Radiology 207:357–360

17. Jordan LK 3rd, Helms CA, CoopermanAE, Speer KP (2000) Magnetic reso-nance imaging findings in anterolateralimpingement of the ankle. SkeletalRadiol 29:34–39

18. Hauger O, Moinard M, Lasalarie JC,Chauveaux D, Diard F (1999) Antero-lateral compartment of the ankle in thelateral impingement syndrome: appear-ance on CT arthrography. AJR Am JRoentgenol 173:685–690

19. Chandnani VP, Harper MT, Ficke JRet al (1994) Chronic ankle instability:evaluation with MR arthrography, MRimaging, and stress radiography.Radiology 192:189–194

20. Helgason JW, Chandnani VP (1998)MR arthrography of the ankle. RadiolClin North Am 36:729–738

21. van Dijk CN, Tol JL, Verheyen CC(1997) A prospective study of prog-nostic factors concerning the outcomeof arthroscopic surgery for anteriorankle impingement. Am J Sports Med25:737–745

22. van Dijk CN, Bossuyt PM, Marti RK(1996) Medial ankle pain after lateralligament rupture. J Bone Joint Surg Br78:562–567

23. Tol JL, Slim E, van Soest AJ, van DijkCN (2002) The relationship of thekicking action in soccer and anteriorankle impingement syndrome. A bio-mechanical analysis. Am J Sports Med30:45–50

24. Tol JL, van Dijk CN (2004) Etiology ofthe anterior ankle impingement syn-drome: a descriptive anatomical study.Foot Ankle Int 25:382–386

25. van Dijk CN, Lim LS, Poortman A,Strubbe EH, Marti RK (1995) Degen-erative joint disease in female balletdancers. Am J Sports Med 23:295–300

26. Martin DF, Baker CL, Curl WW,Andrews JR, Robie DB, Haas AF(1989) Operative ankle arthroscopy.Long-term followup. Am J Sports Med17:16–23; discussion 23

27. Tol JL, Verheyen CP, van Dijk CN(2001) Arthroscopic treatment of ante-rior impingement in the ankle. J BoneJoint Surg Br 83:9–13

28. Cheng JC, Ferkel RD (1998) The role ofarthroscopy in ankle and subtalar degen-erative joint disease. Clin Orthop 65–72

29. Berberian WS, Hecht PJ, Wapner KL,DiVerniero R (2001) Morphology oftibiotalar osteophytes in anterior ankleimpingement. Foot Ankle Int 22:313–317

30. Tol JL, Verhagen RA, Krips R et al(2004) The anterior ankle impingementsyndrome: diagnostic value of obliqueradiographs. Foot Ankle Int 25:63–68

31. Karasick D, Schweitzer ME (1996) Theos trigonum syndrome: imaging features.AJR Am J Roentgenol 166:125–129

32. Bureau NJ, Cardinal E, Hobden R,Aubin B (2000) Posterior ankle im-pingement syndrome: MR imagingfindings in seven patients. Radiology215:497–503

33. Abramowitz Y, Wollstein R, Barzilay Yet al (2003) Outcome of resection of asymptomatic os trigonum. J Bone JointSurg Am 85-A:1051–1057

34. Meislin RJ, Rose DJ, Parisien JS,Springer S (1993) Arthroscopic treat-ment of synovial impingement of theankle. Am J Sports Med 21:186–189

35. Wakeley CJ, Johnson DP, Watt I (1996)The value of MR imaging in thediagnosis of the os trigonum syndrome.Skeletal Radiol 25:133–136

36. Peace KA, Hillier JC, Hulme A, HealyJC (2004) MRI features of posteriorankle impingement syndrome in balletdancers: a review of 25 cases. ClinRadiol 59:1025–1033

37. Mitchell MJ, Bielecki D, Bergman AG,Kursunoglu-Brahme S, Sartoris DJ,Resnick D (1995) Localization of spe-cific joint causing hindfoot pain: valueof injecting local anesthetics into in-dividual joints during arthrography.AJR Am J Roentgenol 164:1473–1476

38. Koulouris G, Connell D, Schneider T,Edwards W (2003) Posterior tibiotalarligament injury resulting in posterome-dial impingement. Foot Ankle Int24:575–583

39. Liu SH, Mirzayan R (1993) Posterome-dial ankle impingement. Arthroscopy9:709–711

40. Mosier-La Clair SM, Monroe MT,Manoli A (2000) Medial impingementsyndrome of the anterior tibiotalarfascicle of the deltoid ligament on thetalus. Foot Ankle Int 21:385–391

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Impingement syndromes of the ankle

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