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Impingement lesions

Lateral ligament injuries are very common, with 1 ankle sprain per 10,000 occurring per day (8). Some 10-50% have some chronic pain (9,10,11).

Anterolateral impingement is the commonest soft tissue impingement lesion and cause of pain after ankle inversion injury (12). Wolin coined the term ‘the meniscoid lesion’ for the arthroscopic appearance of the lateral gutter in these patients.

Arthroscopic treatment is very successful in alleviating chronic pain (13,14,15,16) in 84% both subjectively and objectively. A recent survey by Urg’den M et al (17) in 2005 of 41 patients showed good or excellent results in 37 of the group. Also Henderson et al in 2004 showed similar results for combined anterior and posterior impingement syndrome (18).

During dorsiflexion of the ankle, the malleoli are separated and the syndesmosis is stressed. Syndesmotic injuries are undoubtably underestimated (19). Syndesmotic injuries can be diagnosed by a localised tenderness and a positive squeeze test (20, 21) - pressing the tibia and fibula together proximal to the syndesmosis half way up the calf.

However, Lui T H et al (22) showed in November 2005 that ankle arthroscopy excels stress radiographs in detecting syndesmotic injuries, even though intra-operative x-rays still play an important role in assessing fracture reduction and longitudinal orientation of the syndesmosis. Syndesmotic impingement is also associated with a separate distal fascicle to the anterior talo-fibular ligament (23). The incidence of syndesmotic injury is 3% of all ankle sprains (24).

Posterior impingement does occur and was first described by Hamilton (25) with posterior ‘meniscus’ displacing inferiorly. Also a labrum on the posterior lip of the tibia can hypertrophy when injured.

Click here for video of lateral gutter impingment

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(8) Jackson D W, Ashley R D, Powell Jr, ‘Ankle sprains in young athletes: relation of severity and disability’ Clin Orth 1974; 101:201
(9) Smith R W, Reischl S F, ‘Treatment of ankle sprains in young athletes’ Am J Sports Med 1986; 14:465
(10) Anderson M E, ‘Reconstruction of the lateral ligaments of the ankle using the plantaris tendon’ JBJS 1985; 67A:930
(11) Freeman M A R, ‘Instability of the foot after injuries to the lateral ligament of the ankle’ JBJS 1965; 47B:669
(12) Wolin I, Glassman F, Sideman S, ‘Internal derangement of the talofibular component of the ankle’ Surg Gynecol Obstet 1950; 91:193
(13) Ferkel R D, Karzel R P, Del Pizzo W et al, ‘Arthroscopic treatment of anterolateral impingement of the ankle’ Am J Sports Med 1991; 19:440
(14) Liu S H, Raskin B S, Osti L et al, ‘Arthroscopic treatment of anterolateral ankle impingement’ Arthrosopy 1994; 10:215
(15) Martin D F, Baker C L, Curl W W et al, ‘Operative ankle arthroscopy : long term follow up’ Am J Sports Med 1989; 17:16.
(16) Meislin R J, Rose D J, Parisien S, Springer S, ‘Arthroscopic treatment of synovial impingement of the ankle’ Am J Sports Med 1993; 21:186
(17) Urg’den M, S’y’nc’ Y, Ozdemir H, Sekban H, Akyildiz F F, Aydin A T, ‘Arthroscopic treatment or anterolateral soft tissue impingement of the ankle: evaluation of factors affecting outcome’ Arthroscopy: the journal of arthroscopic and related surgery: AANA and IAA 2005; 21:3; 317-22
(18) Henderson I, La Vallette D, ‘Ankle Impingement: combined anterior and posterior impingement syndrome of the ankle’ Foot and Ankle International / Am Orthropaedic Foot and Ankle Soc 2004; 25:9; 632-8
(19) Kapandji I A, ‘The physiology of the joints’ Edinburgh: Churchill Livingstone, 1987:164
(20) Hopkinson W J, St Pierre P, Ryan J B, Wheeler J H, ‘Syndesmosis sprains of the ankle’ Foot Ankle 1990; 10:325
(21) Boytim M J, Fischer D A, Neumann L ‘Syndesmotic ankle sprains’ Am J Sports Med 1991; 19:294
(22) Lui T H, Ip K Y, Chow H T, ‘Comparison of radiographic and arthroscopic diagnoses of distal tibiofibular syndemosis disruption in acute ankle fracture’ Arthroscopy: the journal of arthroscopic and related surgery: AANA and IAA 2005; 21:11; 1370
(23) Bassett F H, Gates H S, Billys J B, et al ‘Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain’ JBJS 1990; 72A:55
(24) Ferkel R D ‘Arthroscopic Surgery, The Foot and Ankle’ Lipincott Raven 1996. 132-133
(25) Hamilton W G, ‘Foot and ankle injuries in dancers’ Clin sports med 1988; 7:160