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Ankle Impingement
A Critical Analysis Review

Dominic S. Carreira, MD Abstract

Thomas E. Ueland, BS
Investigation performed at Peachtree
Orthopedics, Atlanta, Georgia
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» Ankle impingement presents with painful and limited range of motion
with dorsiflexion or plantar flexion, originating from pathological
contact between bone and/or soft-tissue structures.
» Diagnosis is made primarily through clinical examination with
adjunct radiographs and magnetic resonance imaging, with care
taken to rule out a plethora of similarly presenting pathologies.

» Arthroscopic surgical approaches bring satisfactory short, mid, and

long-term outcomes, with the current body of evidence dominated
by Level-IV studies.

» Minimally invasive techniques offer improvements in time to return

to play and complication rates relative to open approaches.

» Recent advances in the arthroscopic management of ankle

impingement include long-term outcome studies, novel prognostic
classification systems, and strategies for concomitant lesion
management.

A
nkle impingement is charac-
terized broadly by limitations
in range of motion and pain
due to pathological contact
between structures. This abutment can be
among bone, soft tissue, or both. While
primarily affecting athletes, specific ana-
tomic variants or frequent extreme motions
of the ankle bring heightened susceptibility
in the general population1. Given the
extensive overlap in presentation with other
ankle pathologies, an understanding of the
clinical and operative treatments for
impingement is of critical importance for
the clinician who is treating ankle pain.
Impingement classification is defined by
the location in the tibiotalar joint and the
composition of the contacting structures.
Spatially,5 areas are delineatedwithinthe joint:
anteromedial, anterior, anterolateral, postero-
medial, and posterior2. Ankle impingement is
further described by the composition of the
involved structures, including soft tissue, bone,
or both. This review collates current standards
and recent advances in etiology and patho-
physiology, diagnosis, treatment, and arthro-
scopic outcomes for anterior and posterior
ankle impingement.
Anatomy
The ankle is a hinge-type synovial joint that is
responsible for plantar flexion and dorsiflex-
ion; it is formed by articulations among the
distal aspect of the tibia, the distal aspect of the
fibula, and the talar dome. It is divided into 3
regions anteriorly. The anteromedial recess is
bounded by the anterior tibiotalar portion of
the deltoid ligament inferiorly, the medial
malleolus medially, and the anteromedial
aspect of the talus laterally3. The anterolateral
recess is demarcated by the fibula laterally, the
anterior inferior tibiofibular ligament
(AITFL) medially, the calcaneofibular liga-
ment (CFL) inferiorly, and the anterior

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JBJS REVIEWS 2020;8(5):e0215 · http://dx.doi.org/10.2106/JBJS.RVW.19.00215 1

 | Ankle Imp in gement

ligament, superficially by the flexor hallu-

cis longus (FHL) and the neurovascular
bundle, and laterally by the posterior talar
process (Fig. 1-B). The posterior region is
comprised of the posterior talar process,
the posterior talofibular ligament
(PTFL), the posterior intermalleolar
ligament, and the posterior inferior tib-
iofibular ligament (PITFL); a postero-
lateral region has not been reported for
impingement.

Etiology and Pathophysiology

Generally, ankle impingement originates as
a sequela from acute macrotrauma or mi-
crotrauma from repetitive movements at
Fig. 1-A
extreme ranges of motion. Nearby struc-
tures in a normal ankle have the potential to
impinge with abnormal growth. Etiologies
often provide clues to the composition and
the location of the impinging lesion.

Anterior Impingement
Anterior impingement, which was col-
loquially dubbed “footballer’s ankle” by
McMurray in 19504, is classically
described in soccer players. Eversion and
inversion sprains are particularly rele-
vant for anteromedial and anterolateral
pathology, respectively, but micro-
trauma from recurrent dorsiflexion or
external impact also has been observed.

Fig. 1-B
Osseous Impingement
Anterior tibiotalar osteophytes or
Figs. 1-A and 1-B Ankle impingement anatomy. (Adapted from: Golanó P,Vega Jde “spurs” are osseous outgrowths that
Leeuw PA,Malagelada F,Manzanares MC,Götzens V,van Dijk CN. Anatomy of the ankle develop following damage to the joint,
ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010 May;18[5]: the result of a fibrotic healing response
557-6976. Copyright © The Author(s) 2010. Republished under open access license CC and subsequent calcification. They are a
BY-NC 4.0.) Fig. 1-A Anterior and anterolateral regions: (1) lateral malleolus, (2) tibia, (3) hallmark of joint degeneration but also
anterior tibiofibular ligament, (4) anterior inferior tibiofibular ligament, (5 and 6) often affect active individuals without
anterior talofibular ligament, (7) talus, and (8) calcaneofibular ligament. Fig. 1-B Pos- osteoarthritis; they exist in 45% to 60%
terior and posterolateral regions: (1) fibular tip, (2) peroneal groove, (3) tibia, (4) of professional athletes5. No consensus
superficial posterior tibiofibular ligament, (5) deep posterior tibiofibular ligament, (6) exists regarding spur prevalence ante-
posterior calcaneofibular ligament, (7) lateral talar process, (8) medial talar process, (9) romedially and anterolaterally on the
tunnel for flexor hallucis longus tendon, (10) flexor hallucis longus retinaculum, (11) cal- tibia and the talus6-8. The source of pain
caneofibular ligament, (12) subtalar joint, (13) posterior intermalleolar ligament, (14) flexor is usually not from abutting osseous
digitorum longus tendon (cut), (15) tibialis posterior tendon, and (16) peroneal tendons. outgrowths, but from crowding of space
in the joint and contact with other soft-
talofibular ligament (ATFL) and the joint Two posterior regions have been tissue structures. However, direct con-
capsule anteriorly (Fig. 1-A). The central specified in the context of impingement2,3. tact between overlapping osteophytes,
portion of the joint extends between these 2 The posteromedial recess is bounded known as “kissing lesions,” remains an
recesses in the area between the tibial pla- anteriorly by the medial malleolus and the established mechanism anteriorly9-11.
fond and the talar dome. posterior tibiotalar portion of the deltoid The original explanation behind spur

2 MAY 2020 · VOLUME 8, ISSUE 5 · e0215


formation implicated extreme plantar
flexion movements with traction to the
anterior joint capsule and an osseous
growth response, predicting that spurs
would be located at sites of capsule
attachment4. This explanation has since
fallen out of favor for anterior and
anteromedial osteophytes because of
their intra-articular localization12,13, but
remains plausible for lateral osseous
growths14. An accepted means of mi-
crotraumatic osteophyte origin is direct
impact between the foot and external
objects, which is especially relevant for
soccer players and others who perform
repetitive ball-kicking movements. Bio-
mechanical investigation suggests that this
contact has the requisite force and location
on the anteromedial aspect of the talus to
create maladaptive ossification15. Recur-
rent dorsiflexion alone can cause damage
to the anterior articular rim and lead to
spur development at the non-weight-
bearing portion of the joint16. Recently,
talofibular osseous impingement has been
suggested as a novel mechanism that often
is undetected on radiographs, but addi-
tional studies are needed to evaluate its
prevalence and burden relative to tibiotalar
osseous impingement17.
Soft-Tissue Impingement
Ligamentous, synovial, and capsular
hypertrophy are the culprits of soft-
tissue impingement anteriorly. Liga-
mentous impingement frequently is
encountered in the anterolateral recess,
occurring as a sequela in 2% of all
inversion sprains with ATFL or CFL
fibrosis18. Anteromedially, injury to the
deltoid ligament is less common19 but
follows both inversion and eversion
sprains20. Thickening of the synovium
can contribute to symptomatology and
is theorized to occur through synovial
absorption of hematomas following
trauma21. Hyalinized scar tissue resem-
bling the knee meniscus in cross-section
was termed a “meniscoid lesion” by
Wolin et al. in 195022. While originally
described as a coalescent mass secondary
to an ATFL tear, meniscoid lesions are
identified by arthroscopic appearance
rather than the involvement of a specific
MAY 2020 · VOLUME 8, ISSUE 5 · e0215
ligament, given that medial lesions also
have been described23. The Bassett lig-
ament, a distal fascicle of the AITFL that
usually contacts the talus asymptomati-
cally, is relevant with joint hyperlaxity or
abnormal fascicle dimensions.
Posterior Impingement
Anatomic variants, repeated plantar
flexion movements, and acute plantar
hyperflexion events are associated with
impingement posteriorly. Ballet dancers,
soccer players, and downhill runners are
particularly susceptible. Dancers make up
61% of athletic surgical patients with
posterior impingement24, with prolonged
time in the en pointe position contributing
to the onset of classic chronic impinge-
ment Overuse injuries are correlated with
better outcomes relative to acute trauma25.
Osseous Impingement
Between the ages of 8 and 13 years, a
secondary ossification center can form in
the posterolateral aspect of the talus,
followed by fusion to an elongated lat-
eral tubercle known as a Stieda process or
persistence as an unfused ossicle to
become an os trigonum. The Stieda
process and the os trigonum make up the
vast majority of hindfoot osseous
impingements, resulting from entrap-
ment between the posterior tibial lip and
the calcaneus in plantar flexion, and are
likened to a “nut in a nutcracker.” The
presence of a posterior talar process
variant does not necessarily foreshadow
clinical symptoms, as shown by an
investigation of 38 asymptomatic pro-
fessional dancers that found that 47% of
the dancers had a Stieda process or an os
trigonum26. The onset of pain likely
requires an inciting trauma or repetitive
movements beyond anatomic limits.
Other contributions to osseous pathol-
ogy are rare in comparison but may be
indicated in an acute setting with talar or
calcaneal avulsion fragments and frac-
tures of the posterior talar process20.
Soft-Tissue Impingement
There is disagreement about whether to
include FHL pathology under the
umbrella of posterior impingement9,24,27
Ankle Impingement |
or to consider it as a distinct entity28,29. We
elect to include it given the intra-articular
nature of the tendon sheath and the
potential for abutment with surrounding
structures. Because of its course between
the tubercles of the posterior talar process,
FHL-related impingement symptoms
often are reported with concomitant
osseous variants. Fibrotic synovial or liga-
mentous changes can cause posterior
impingement through hypertrophy of the
PITFL, the PTFL, and the posterior tib-
iotalar portion of the deltoid ligament.
Diagnosis
Anterior Impingement
Anterior impingement presents with
limited dorsiflexion, swelling, and pain
along the joint margins. Anterolaterally,
care must be taken to distinguish among
instability, osteochondral lesions of the
talus, peroneal tears, tarsal coalition, and
subtalar joint pathology30. Ante-
romedially, relevant considerations
include posterior tibial tendinopathy,
flexor retinaculum or spring ligament
abnormalities, and tarsal tunnel syn-
drome31. Concurrent pathologies are
common, although they often are diffi-
cult to separate from impingement
clinically. In chronic lateral instability,
Odak et al. reported a higher rate of soft-
tissue impingement (63%) relative to
osseous impingement (12%) in a retro-
spective case series of 100 patients32.
Özer and Yıldırım retrospectively re-
viewed magnetic resonance imaging
(MRI) from 300 patients with a clinical
diagnosis of isolated anterior impinge-
ment; they found concurrent osteochon-
dral lesions in 41% of patients33. Clinical
examination remains the most important
diagnostic tool for both osseous and soft-
tissue impingement.
Osseous Impingement
Tenderness over the anteromedial gutter
or palpable talar osteophytes create sus-
picion of impingement, although
quantification of diagnostic utility is
lacking11,34. Palpation of the anterior
joint line is less revealing than the medial
and lateral gutters because of overlying
tendons and neurovascular structures.
3
 | Ankle Imp in gement
Radiographs are typically sufficient
to visualize tibiotalar osteophytes.
Weight-bearing lateral views are made in
dorsiflexion or in neutral to capture
central osseous lesions, while antero-
posterior views locate abnormalities at
the joint periphery. Radiographic classifi-
cations have traditionally incorporated the
extent of the spur35 or joint degeneration12
as predictors of arthroscopic outcomes. To
improve detection of medial tibial and talar
spurs, Tol et al. proposed a modification of
the traditional lateral view with 30° of
external rotation36. This increased sensi-
tivity for tibial (40% to 85%) and talar
(32% to 73%) osteophytes, although at
the expense of specificity (tibial: 70% to
45%; talar: 82% to 68%) in their 60-
patient case series.
Soft-Tissue Impingement
A combination of 5 of 6 nonspecific
signs (chronic pain, recurrent swelling,
tenderness, pain with single-leg squat-
ting, anterolateral pain with eversion,
and absence of lateral ankle instability)
has provided 95% sensitivity and 75%
specificity for anterolateral soft-tissue
lesions, with arthroscopic confirmation
as the reference standard37. The Molloy-
Bendall test also is commonly used for
anterolateral soft-tissue impingement; a
positive sign is pain intensification with
plantar flexion and dorsiflexion while
the examiner palpates the anterolateral
gutter. Efficacy (94.8% sensitivity, 88%
specificity) has been demonstrated in 73
patients using arthroscopic evaluation as
the reference standard38. Ruling out a
posterior soft-tissue contracture as a
generator of limited dorsiflexion also is
appropriate through the Silfverskiöld
test39. In this test, ankle dorsiflexion is
measured with the knee extended and
then flexed to 90°; the test is positive if
dorsiflexion increases knee flexion rela-
tive to extension. This test along with
assessment of the potential for posterior
ankle capsular contracture or deep pos-
terior compartment muscle/tendon
contracture based on history and MRI
are important considerations in the
assessment of limited ankle dorsiflexion.
4 MAY 2020
MRI is a widely used adjunct in the
presence of clinical signs of soft-tissue
impingement. Despite variation in re-
ported sensitivity (39% to 100%) and
specificity (50% to 100%)37,40, recent
evidence indicates acceptable utility in
confirming anterolateral soft-tissue
impingement30. Quantification of
soft-tissue lesions anteriorly and ante-
romedially remains unknown.
Posterior Impingement
Posterior impingement typically pre-
sents with limited plantar flexion,
chronic pain, and hindfoot swelling.
Essential considerations in the differen-
tial diagnosis include chronic ankle
instability, osteochondral lesions,
fractures, retrocalcaneal bursitis,
Achilles tendon pathology, peroneal
tendon pathology, and posterior tibial
tendon dysfunction. Concomitant
osteochondral lesions are less common
in isolated posterior impingement
relative to anterior regions, with a rate
of 18% in Özer and Yıldırım’s retro-
spective MRI review33.
Osseous Impingement
The passive hyperflexion test is used for
posterior osseous lesions; it includes
rapid and repeated plantar hyperflexion
while the patient is seated with the knee
flexed to 90°. A negative result can rule out
impingement, but diagnostic confirma-
tion usually requires additional sensitivity
on palpation or injection relief.
Conventional lateral radiographs
are standard for posterior osseous
impingement. In a Level-II investigation
of 142 radiographic images, a posterior
impingement view, which modifies the
lateral view with 25° of external rotation,
distinguished an os trigonum from a Stieda
process, yielding superior diagnostic
accuracy, specificity, and sensitivity in
identifying the os trigonum41. MRI can be
an effective modality to visualize bone
marrow edema, which is indicative of
osseous pathology and soft-tissue
pathology, by means of heightened sig-
nal in ligamentous, capsular, and syno-
vial structures. Abnormal structures may
be observed in asymptomatic patients;
thus, imaging techniques are best em-
ployed as an adjunct to a thorough his-
tory and clinical examination.
Soft-Tissue Impingement
Pain with forced plantar hyperflexion
brings suspicion for soft-tissue im-
pingement. MRI is useful for identifi-
cation of soft-tissue impingement and
for evaluating the presence of other
generators of posterior ankle pain,
including occult fracture, cartilage
damage, loose bodies, and tendon dys-
function. Posteromedially, hypertrophy
of the posterior tibiotalar ligament
(PTTL) and the synovium can be visu-
alized. Inflammation from posterior
intermalleolar ligament entrapment or
ligamentous thickening can be found
posteriorly. To our knowledge, there has
been no quantification of sensitivity and
specificity for these specific classes of
impingement. Care in identifying
anomalous muscles such as the peroneus
quartus and the flexor digitorum acces-
sorius longus with MRI is especially
relevant for surgical planning teams.
Treatment
Nonoperative
The first line of treatment for impinge-
ment is nonoperative. A regimen con-
sisting of injections, nonsteroidal
anti-inflammatory drugs (NSAIDs),
activity modifications, and physical
therapy for 3 to 6 weeks is standard. The
use of a heel-lift orthotic to limit dorsi-
flexion also can be considered. In a case
series that included 134 injections for
anterior ankle impingement, Grice et al.
found that 90% of patients experienced
substantial benefit, and 46% were
asymptomatic at the 2-year follow-up42.
In a case series of 26 elite professional
football players with posterior ankle
impingement, 18 (69%) were effectively
treated with nonoperative modalities at a
mean time of 36 days43.
Operative
Open approaches for anterior44 and
posterior45 impingement have been
described. Comparative studies indicate
that there are reductions in time to
· VOLUME 8, ISSUE 5 · e0215

return to play and in complication rates
with minimally invasive impingement
resection anteriorly35 and posteriorly46.
The senior author (D.S.C.) prefers
arthroscopic management of all ankle
impingements unless impingement
occurs adjacent to the posteromedial
neurovascular structures in the setting of
substantially altered anatomy secondary
to trauma or previous surgery.
Arthroscopic Approach
Joint degeneration is a relative contra-
indication to arthroscopic correction of
impingement because of the correlation
between arthritis and a poorer out-
come47. The rising popularity of ankle
arthroscopy has brought a variation in
techniques with regard to portal place-
ment, approach, and patient position-
ings. We recommend joint distension
with saline solution or an anesthetic,
followed by a superficial “nick-and-
spread” technique, making superficial
incisions and completing subcutaneous
blunt dissection with a mosquito clamp,
thereby minimizing iatrogenic injury to
neurovascular structures. After intro-
duction of a 2.7 or 4.0-mm 30° arthro-
Fig. 2-B
Removal of an anterior tibial osteophyte before
(left) and after (right) resection. T 5 tibia, and
Ta 5 talus.
MAY 2020 · VOLUME 8, ISSUE 5 · e0215
scope, the secondary portal is established
under direct visualization. For both ante-
rior and posterior impingement, in the
presence of extensive scar tissue or large
osteophytes, larger shavers and burrs that
are .4.0 mm in diameter may be helpful.
Less commonly and in tight spaces at both
the ankle and the subtalar joints, smaller
2.0 to 3.0-mm arthroscopes and instru-
mentation are available.
Anterior: An anterior arthroscopic
approach with supine positioning is
common for anterior impingement. The
affected leg is elevated, with the optional
incorporation of a thigh or calf tourni-
quet. After placing the operative limb in
a well-leg holder, ankle distraction or
dorsiflexion opens the anterior working
space. Ankle distraction improves visu-
alization of intra-articular cartilage
lesions, although this is at the expense of
osteophyte access via tightening of the
anterior capsule and reducing the
working space. Cadaveric evidence sug-
gests that dorsiflexion poses less risk to
the anterior neurovascular bundle but
increases difficulty in identifying poste-
rior abnormalities48. The anteromedial
portal site is just medial to the tibialis
Ankle Impingement |
Fig. 2-A
Figs. 2-A, 2-B, and 2-C Arthroscopic visuali-
zation of anterior and posterior impingement.
Fig. 2-A Synovial infiltration into the joint
before (left) and after (right) resection.
* 5 hypertrophied synovium, T 5 tibia, and
Ta 5 talus.
anterior tendon at the level of the joint
line, and the anterolateral portal site is
immediately lateral to the peroneus ter-
tius tendon, avoiding the superficial
peroneal nerve. A systematic diagnostic
evaluation of the ankle joint is per-
formed to identify pathology that was
not detectable on preoperative exami-
nation and imaging. Ferkel and Fischer
proposed a 21-point examination for the
anterior regions49. Osteophytes and
soft-tissue abnormalities that are visual-
ized during arthroscopy are resected
with a hooded burr and a shaver,
respectively (Figs. 2-A and 2-B). Two
prior systematic reviews both noted a 4%
total rate of complications with arthro-
scopic resection of anterior or anterolateral
soft-tissue impingement50,51. Reported
complications include nerve injury,
infection, aberrant wound-healing,
instrument breakage, arthrofibrosis, and
revision.
Posterior: A 2-portal hindfoot
approach with the patient in the prone
position is standard for posterior
impingement; this was originally popu-
larized by van Dijk et al.52. The poster-
olateral and posteromedial portals are
5
 | Ankle Imp in gement
established immediately adjacent to the
Achilles tendon with the ankle in plantar
flexion and are level with a line con-
necting the medial and lateral malleoli.
The resection of osseous growths or
soft-tissue hypertrophy occurs through
the posteromedial working portal
(Fig. 2-C). Analogous to the anterior
regions, systematic diagnostic visualiza-
tions exist for posterior pathologies53.
This region poses a greater risk of neu-
rovascular injury, which is reflected in
higher complication rates with posterior
impingement management (7.2%) rel-
ative to anterior regions54.
Concomitant management: Given
that anterior and posterior impingement
often are encountered together, there
has been much interest in strategies for
simultaneous management. Marumoto
and Ferkel advocated for supine posi-
tioning (as described above), with
anteromedial and anterolateral portals
for anterior pathologies, and access to
posterior pathologies via a posterolateral
portal at the level of the tip of the fibula
between the fibula and the Achilles
tendon55. Wang et al. utilized lateral
positioning with posteromedial and
posterolateral portals for posterior
lesions, and then externally rotated the
affected hip to achieve a supine ankle
orientation for anterior arthroscopy56.
No adverse changes in outcomes or
complications were found in their 13-
patient case series. Song et al. performed
a comparative study with anterior
arthroscopy that was followed by either a
traditional prone 2-portal hindfoot
approach or a 45° recumbent position
and dual posterolateral portals57. There
were no statistically significant differences
6 MAY 2020
in short-term outcomes with their novel
approach. Addressing anterior and poste-
rior pathologies from the same approach
avoids repeated prepping and draping and
reduces surgical time. However, this must
be weighed against the required additional
surgical training, a surgeon’s comfort
using the technique, and fewer published
evaluations of complication rates and
outcomes.
Postoperative Protocol
Rehabilitation protocols are varied.
Patients with anterior impingement
bear weight as tolerated in a removable
boot immediately after surgery or
within 1 week8,58-60. Physical therapy
programs that are focused on ankle
strengthening and range-of-motion
improvement begin between 1 and 2
weeks after surgery8. Time to return to
sport is typically 6 to 8 weeks but varies
with the type and the level of sport.
Following posterior impingement
resection, rehabilitation includes partial
weight-bearing as tolerated or non-
weight-bearing for 1 week25,29,46,61.
Physical therapy programs are im-
plemented between 1 and 2 weeks
postoperatively46, followed by gradual
progression to higher-level activities.
Rehabilitation protocols for arthro-
scopic procedures are generally faster
when compared with open surgeries
since there is less need to protect the
incision and the pain is less restrictive.
Outcomes
Prior systematic reviews report favorable
results with arthroscopic intervention
for both anterior50 and posterior54
impingement. This review updates the
Fig. 2-C
Removal of an elongated posterior talar pro-
cess before (left) and after (right) resection.
Ta 5 talus, and C 5 calcaneus.
body of evidence through a query of the
MEDLINE and Embase databases using
identical search criteria to the systematic
reviews from Zwiers et al. (2013)54 and
Zwiers et al. (2015)50, with date modi-
fications to capture studies that were
published after the search dates of those
reviews. Quality assessment was per-
formed with the Downs and Black scale
for evaluation of randomized and
observational studies62. Inclusion crite-
ria were a study with a sample size of
$20 adult patients receiving arthro-
scopic resection for anterior or posterior
impingement and follow-up reported
for at least 1 validated patient-reported
outcome measure. Exclusion criteria
included combined open and arthro-
scopic approaches, concomitant
removal of anterior and posterior
impingement, mean follow-up of ,1
year, moderate or worse joint degenera-
tive changes, and a history of ankle
replacement or hemophilia (Appendix).
A total of 12 novel studies were included
in the qualitative synthesis of this review;
they were collated with studies from prior
reviews24,50,54,63 to present recommen-
dations for care regarding the arthro-
scopic resection of anterior and posterior
impingement.
Anterior Impingement
The systematic review from Zwiers et al.
(2015)50 yielded 20 Level-II, III, and IV
studies of short-term and midterm out-
comes following anterior impingement
arthroscopy. They found good to
excellent patient satisfaction (74% to
100%), good American Orthopaedic
Foot & Ankle Society (AOFAS) score
improvement (preoperative range, 34 to
· VOLUME 8, ISSUE 5 · e0215
 Ankle Impingement |

TABLE I Anterior and Posterior Impingement Arthroscopic Outcomes*

Return to
Sport
Follow-up† Complication Outcomes, or Full Methodological
Study Composition LOE No. (M, F) (yr) (No.) Preop; Postop† Activity† (wk) Quality Conclusions

Anterior
Parma Osseous IV 80 (55, 25) 8.7 Transient AOFAS: 50.9; 70.7 ‡ 21 Satisfactory long-term out-
(2014)10 numbness (2), comes, novel prognostic clas-
superficial sification system
wound infection
(5)
Walsh Osseous and IV 46 (42, 4) 5.1 (5-7.5) ‡ FFI: 20.5; 2.7 ‡ 17 Excellent midterm functional
(2014)64 soft tissue Dorsiflexion: improvement with 84%
24.7°; 27.0° osteophyte recurrence
Buda Soft tissue IV 42 (17, 25) 7.5 6 1 None AOFAS: 40.6 6 ‡ 21 Satisfactory mid and long-term
(2016)65 21.2; 74.8 6 24.3 outcomes, novel clinical classi-
fication system
Ahmad Soft tissue IV 27 (23, 4) 15 (12-240) Superficial AOFAS: 42 (34- ‡ 16 Satisfactory outcomes for
(2018)66 peroneal nerve 48); 88 (79-92) impingement secondary to
neurapraxia (2), acute inversion injuries
periportal
superficial
infection (2)
Posterior
López Osseous IV 20 (19, 1) 6.6 (2-10) None Pain VAS: 7.5 6 6.7 6 3.7 13 Rapid return to play in
Valerio 0.9; 0.8 6 1.36 competitive athletes
(2015)69
Vilá Osseous and IV 38 (21, 17) 2.3 (1.0-4.3) None AOFAS: 67.4 (41- 12.8 14 Excellent outcomes with
(2014)70 soft tissue 91); 97.1 (84-100) traditional hindfoot approach
Weiss Osseous IV 24 (13, 11) 2.2 (2-2.6) Posterior tibial AOFAS: 55.3 6 6.5 6 1.3 20 Statistically significant
(2015)71 nerve temporary 21; 92.3 6 7.5 improvement in outcomes
neurapraxia (1) SANE: ‡; 90 6 12 with posterior approach
modification
Dinato Osseous and III 32 (24, 8) Minimum 2 yr Infection (1), AOFAS: 62.9 6 15.6 6 13.7 16 No statistically significant
(2016)73 soft tissue hematoma (1) 14; 92.3 6 7.7 (professional differences in time to return to
(professional athletes); sport and outcomes between
athletes); 67.9 6 16.3 6 9.0 amateur and professional
19.7; 94 6 9.3 (amateur athletes
(amateur athletes)
athletes)
Carreira Osseous IV 20 (6, 14) 3.2 (1.2-4.9) Plantar neuritis AOFAS: 75 (55- ‡ 13 Statistically significant
(2016)25 (1), Achilles 87); 94.9 (85-100) improvement in functional
tightness (1) Pain VAS: 5.2 (2- outcomes at midterm follow-
8); 0.85 (0-3) up
Tegner: 7.8 (3-10);
7.75 (5-10)
Georgiannos Osseous II 26 (18, 8) 5 6 0.4 Recurrent pain (1) AOFAS: 65.8 6 7.12 6 2.25 25 Statistically significant
and Bisbinas 7.9; 92.4 6 6.6 reductions in complication
(2017)46 VAS-FA: 45.3 6 rates and time to return to play
14.9; 93.1 6 10.1 in arthroscopic relative to open
operations
Miyamoto Osseous and III 61 (46, 15) 2 None AOFAS: 73.4 6 9.2 6 2.0 19 Satisfactory functional
(2017)74 soft tissue 3.5; 95.4 6 4.7 outcomes; concomitant LAI
and OLT delayed return to play
Zwiers Osseous and IV 203 10.8 6 3.7 ‡ NRS satisfaction§: ‡ 18 Long-term improvements in
(2018)72 soft tissue (103,100) ‡; 8 (IQR 7-10) patient satisfaction and
functional outcomes; FHL
NRS function: ‡; 9
tendinopathy associated with
(IQR 7-10) FAOS
lower satisfaction and higher
symptoms: ‡; 80
recurrence rates
FAOS activities of
daily living: ‡; 100

*LOE 5 Level of Evidence, AOFAS 5 American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score, FFI 5 Foot Function Index, VAS 5 visual analog scale, SANE 5 Single
Assessment Numeric Evaluation, VAS-FA 5 visual analog scale foot and ankle, LAI 5 lateral ankle instability, OLT 5 osteochondral lesion of the talus, NRS 5 numeric rating scale, IQR 5
interquartile range, FAOS 5 Foot and Ankle Outcome Score, and FHL 5 flexor hallucis longus. †The values are given as the mean with or without the standard deviation, and with or
without the range in parentheses, unless otherwise specified. ‡Values not reported. §The values are given as the median score.

MAY 2020 · VOLUME 8, ISSUE 5 · e0215 7

 | Ankle Imp in gement

TABLE II Arthroscopic Impingement Resection Grades of Recommendation

Number of Studies†
Impingement
Region Recommendation Grade* Level I Level II Level III Level IV Level V

Anterior Satisfactory time to return to sport or functional B 2 21 Not quantified

outcomes with arthroscopic resection
Anterior Low complication rates with arthroscopic resection B 2 18 Not quantified
Posterior Satisfactory time to return to sport or functional B 1 3 28 Not quantified
outcomes with arthroscopic resection
Posterior Low complication rates with arthroscopic resection B 1 3 30 Not quantified

*According to Wright77, grade A indicates good evidence (Level-I studies with consistent findings) for or against recommending intervention; grade B,
fair evidence (Level-II or III studies with consistent findings) for or against recommending intervention; grade C, poor-quality evidence (Level-IV or V
studies with consistent findings) for or against recommending intervention; and grade I, insufficient or conflicting evidence not allowing a recom-
mendation for or against intervention. †Studies of nonidentical cohorts collated from literature reviews of current authors, Zwiers et al. (2013)54Zwiers
et al. (2015)50, Rietveld et al. (2018)63, and Ribbans et al. (2015)24. Studies reporting complication rates and outcomes are included in both rows.

75; postoperative range, 83.5 to 92), and
low complication rates (4.6%).
The 4 Level-IV anterior impinge-
ment studies that were identified in this
review10,64-66 reported similar ranges of
AOFAS score improvement (preopera-
tive range, 40.6 to 50.9; postoperative
range, 70.7 to 88) and complication
rates (mean, 4.8%) (Table I). In a case
series of 80 patients with anterior osse-
ous impingement, Parma et al. proposed
a novel radiographic classification sys-
tem incorporating osteophyte size and
location, with improved prognostic
utility relative to traditional classifica-
tion10. Buda et al. correlated soft-tissue
lesion location and mid and long-term
outcomes in a 42-patient case series65.
Anterolateral soft-tissue pathology was
associated with good to excellent out-
comes, syndesmotic pathology was associ-
ated with good outcomes, diffuse anterior
pathology was associated with fair to vari-
able outcomes, and anteromedial pathol-
ogy was associated with poor outcomes.
The case series by Walsh et al. suggested
that functional outcome improvements
persist, even with high rates of osteophyte
recurrence at midterm follow-up64, bol-
stering evidence that a combination of soft-
tissue and osseous pathology often is
implicated in symptomatology14,67.
Available systematic reviews50 and
studies that were included in this review
consist of primarily Level-IV evidence,
with consistent Level-II findings in favor
of efficacy and safety for arthroscopic
resection of anterior impingement
(Table II). Among the 2 Level-II inves-
tigations of unique cohorts67,68, there
were high percentages of good or excel-
lent results at midterm follow-up.
Posterior
Zwiers et al. (2013)54 systematically
identified 6 studies of open and 10
studies of arthroscopic surgical proce-
dures, all Level-IV, that reported poste-
rior impingement resection. Findings in
the arthroscopic studies included high
percentages of good to excellent satis-
faction (80.9%), successful postopera-
tive AOFAS scores (weighted mean of
98.6 at 23.3 months), and statistically
significant differences between open and
arthroscopic techniques with respect to
complication rates (15.9% versus 7.2%,
respectively) and time to return to full
activity (16.0 versus 11.3 weeks, respec-
tively). Similar reviews that focused on the
sporting population24 and on professional
dancers63 reported comparable postoper-
ative AOFAS outcomes, low complication
rates, and return to full activity.
Five Level-IV25,69-72, 2 Level-
III 73,74
, and 1 Level-II46 posterior
impingement resection studies were
identified in this review. The AOFAS
score improvements indicated surgical
success (preoperative range, 55.3 to 75;
postoperative range, 92.3 to 97.1). In a
large long-term cohort study of posterior
impingement in 203 patients who were
.10 years old72, key findings were high
patient satisfaction, low persistence of
pain and recurrence of clinical symp-
toms, and statistically significant asso-
ciations between FHL tendinopathy
and lower satisfaction (odds ratio [OR],
0.88; 95% confidence interval [CI],
0.78 to 0.98) and higher impingement
recurrence (OR, 2.42; 95% CI, 1.02 to
5.76). In a retrospective comparative
study, Miyamoto et al. assessed posterior
impingement alone relative to concom-
itant chronic ankle instability or talar
osteochondritis dissecans74. There were
statistically significant delays in time to
return to play in the combined groups
relative to either group alone. Geor-
giannos and Bisbinas conducted the first
randomized controlled trial comparing
open and minimally invasive procedures
for posterior impingement46. Their find-
ings align with comparative investigations
in other joints, with successful self-
reported outcomes for both techniques
but with improved time to return to play
and complication rates with arthroscopy.
Available systematic reviews24,50,63
and other studies that were included in this
review suggest primarily Level-IV evi-
dence, with consistent Level-II to III
findings in favor of safety and efficacy for
posterior impingement (Table II).
Acceptable outcomes and safety have been
established in 1 randomized controlled
trial46 and in 1 Level-III study75 for os
trigonum resection, as well as in 2 Level-III
investigations for osseous and soft-tissue
impingement73,74.

8 MAY 2020 · VOLUME 8, ISSUE 5 · e0215


Overview
Pathological contact between osseous
and soft-tissue structures in the anterior
and posterior regions of the ankle joint
can cause painful impingement. A
detailed history and proper clinical
examination with adjunct radiographs
and MRI drive the diagnostic process.
Symptoms often can be resolved with a
nonoperative regimen; arthroscopic and
open interventions are satisfactory alter-
natives if nonoperative treatment is not
successful. The current research is domi-
nated by limited-quality evidence that
favors the safety and successful outcomes
of arthroscopic resection of anterior and
posterior impingement. The paucity of
prospective comparative studies precludes
us from making strong recommenda-
tions. Heterogeneity in procedural tech-
nique, in inclusion and exclusion criteria
from outcome studies and reviews, and in
outcome end points limits the strength of
quantitative comparisons.
Appendix
Supporting material provided by the
authors is posted with the online version of
this article as a data supplement at jbjs.org
(http://links.lww.com/JBJSREV/A591).
Dominic S. Carreira, MD1,
Thomas E. Ueland, BS1
1Peachtree
Orthopedics, Atlanta, Georgia
Email address for D.S. Carreira:
carreira.research@gmail.com
ORCID iD for D.S. Carreira:
0000-0003-0887-7424
ORCID iD for T.E. Ueland:
0000-0001-6618-9318
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