Anterior Ankle Impingement
(Also known as Ankle Impingement, Anterior Impingement Syndrome, Anterior Impingement of the Ankle)
What is anterior ankle impingement?
Anterior ankle impingement is a condition characterised by pain at the front of the ankle joint due to compression of bony or soft tissue structures during activities involving maximal ankle dorsiflexion (figure 2).
The ankle joint primarily comprises of the articulation of two bones, the tibia (shin bone) and a small bone which lies directly beneath it called the talus (figure 1). The surface of each bone is lined with cartilage, cushioning the impact of the tibia on the talus during weight bearing activity.
Figure 1 – Relevant Anatomy for Anterior Ankle Impingement
During the movement of ankle dorsiflexion (figure 2) i.e. when the foot and shin move towards each other, the bottom of the shin bone approaches the front of the talus. This places compressive forces on the structures at the front of the ankle joint. If these forces are excessive or beyond what the ankle can withstand, damage and inflammation of these structures may occur. This condition is known as anterior ankle impingement. Occasionally, bony spurs can also form at the front of the ankle joint which may contribute to the problem.
Figure 2 – Ankle Dorsiflexion
Causes of anterior ankle impingement
Anterior ankle impingement most commonly occurs following an ankle sprain (particularly those involving significant weight bearing forces). The condition may also occur gradually over time due to activities requiring repeated forced dorsiflexion of the ankle (figure 2) usually during weight bearing activity (such as repetitive landing from a jump, deep squatting, running uphills etc.).
Signs and symptoms of anterior ankle impingement
Patients with anterior ankle impingement typically experience pain at the front of the ankle that increases with excessive dorsiflexion or weight bearing activities. Symptoms may also increase after these activities with rest (especially at night or first thing in the morning) and may present as a dull ache or a more acute, sharper pain. Provocative activities may include:
- Walking or running excessively (especially up hills or on uneven surfaces)
- Deep squatting or lunging (especially with the knee moving forwards over the toes)
- Landing from a jump (particularly onto an incline or an uneven surface)
- Performing a calf stretch (particularly with the knee bent)
- Heavy lifting
- Twisting activities
Patients with this condition also often experience pain on firmly touching the front of the ankle joint and in some cases a clicking sensation may be experienced during certain ankle movements. Puffiness or swelling of the ankle joint may also be noticeable in some patients with this condition.
Treatment for anterior ankle impingement
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Contributing factors to the development of anterior ankle impingement
There are several factors which can predispose patients to developing anterior ankle impingement. These need to be assessed and corrected with direction from a physiotherapist. Some of the factors which may contribute to the development of this condition include:
- inadequate rehabilitation following a previous ankle injury
- joint stiffness or swelling
- muscle tightness
- bony anomalies
- poor foot biomechanics (e.g. “flat feet” or high arches)
- poor lower limb biomechanics
- inappropriate training (including technique, footwear or training surfaces)
- excessive training or activity
- inadequate recovery periods from training or activity
- inadequate warm up
- poor core stability
- poor proprioception or balance
Physiotherapy for anterior ankle impingement
Physiotherapy treatment is vital to hasten the healing process and ensure an optimal outcome in all patients with this condition. Treatment may comprise:
- soft tissue massage
- joint mobilisation
- electrotherapy (e.g. ultrasound)
- anti-inflammatory advice
- dry needling
- Achilles taping, ankle taping or arch support taping
- ankle bracing
- the use of crutches
- the use of heel wedges
- ice or heat treatment
- exercises to improve flexibility, strength and balance
- activity modification advice
- biomechanical correction
- a gradual return to activity program
Other intervention for anterior ankle impingement
Despite appropriate physiotherapy management, some patients with this condition do not improve and may require other intervention to ensure an optimal outcome. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigation such as an X-ray, ultrasound, MRI, CT scan or bone scan, extended periods of rest, pharmaceutical intervention, corticosteroid injection, referral to a podiatrist for footwear advice and possible orthotics, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition. For those patients with prominent bony spurs or significant soft tissue impingement, surgical intervention (such as an ankle arthroscopy) may be indicated to remove the bony spur or damaged tissue.
Exercises for anterior ankle impingement
The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 – 3 times daily and only provided they do not cause or increase symptoms.
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.
Foot and Ankle Up and Down
Move your foot and ankle up and down as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 3). Repeat 10 – 20 times provided the exercise is pain free.
Figure 3 – Foot and Ankle Up and Down
Foot and Ankle In and Out
Move your foot and ankle in and out as far as you can go without pain and provided you feel no more than a mild to moderate stretch (Figure 4). Repeat 10 – 20 times provided the exercise is pain free.
Figure 4 – Foot and Ankle In and Out
Foot and Ankle Circles
Move your foot and ankle in a circle as large as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 5). Repeat 10 – 20 times in each direction provided the exercise is pain free.
Figure 5 – Foot and Ankle Circles
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Rehabilitation Protocol for anterior ankle impingement
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Some of the most commonly recommended products by physiotherapist for patients with this condition include:
- Heel wedges
- Ankle Braces
- Sports Tape (for Ankle Taping or Arch Support Taping)
- Ice Packs or Heat Packs
- Wobbleboards or Duradiscs (for balance exercises)
- Foam Rollers (for self massage)
- Massage Balls (for self massage)
- Swiss Balls (for core stability exercises)
- Resistance Band (for strengthening exercises)
To purchase physiotherapy products for anterior ankle impingement click on one of the above links or visit the PhysioAdvisor Shop.
- View more Ankle Stretches.
- View more Ankle Strengthening Exercises.
- View more Balance Exercises.
- View more Leg Stretches.
- View more Leg Strengthening Exercises.
- View detailed information on How to use Crutches.
- View detailed information on when to use Ice or Heat.
- View detailed information on initial injury management and the R.I.C.E. Regime.
- View detailed information on Do I Need Orthotics.
- View detailed information on Choosing a Shoe.
- View detailed information on Returning to Sport.
- View detailed information on Returning to Running.
- View detailed information on Achilles Taping
- View our Ankle Diagnosis Guide.
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