Ankle Impingement and Limited ROM

[ash422]

I sprained my left ankle 4 months ago and have limited ROM.

I did not believe that the injury was severe at the time and therefore completed recommended RICE treatment.
I can not achieve full dorsi-flexion on my left ankle. I am waiting for an MRI and need to know if there are any exercises I can do in the meantime to improve my condition.

I can not run as I feel a painful restriction, probably because of some tissue impinging in the joint. Should I apply ice or heat?

Should I consider surgery for my condition? Or will it wreck my joint completely? The Xray did not display any spurs.
Any advice from anyone that has had ankle impingement problems and subsequent arthroscopy would be appreciated.

Thanks,
Ash

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[rossdykes]

Hi Ash have you tryed Just simple movement of the ankle or is it to painfull
Regards
Ross

[ash422]

Movement of Ankle is fine. Initially there was clicking and pain, but that has subsided considerably.

On occasion, there is a dull pain between tibia/talus...especially when active or walking. Yesterday I was not even active, and bottom of tibia and fibula area was painful.

On dorsiflexion, I am not able to pull my toes up fully. There is a difference of 5 or 10 degrees comparing to right foot.

[kosh]

Hi
I have a client with similar problem. Try 2 things: 1st , if you or ask someone to stabilize your distal Tib-Fib jt , anteriorly and then try gently bring your calcaneus anteriorly (basically P>A, AS IF YOU ARE DOING ANT DRAWER Test) during that you can either do some active Dorsifexion or ask the 2nd person to do it passively for you.
2nd. Try or ask someone , to create some compression between distal Fibula and Tibia (Interosseous lig. instab.) and during that, again Passive or active Dorsiflexion.
Be very gentle and careful with all above.
Let me know how it goes

[ash422]

Tried the procedure:
There is no pain in ANT Draw Test. When I attempt dorsi-flexion during the exercise (active + passive), there is an obstruction and I cannot pull as far back as uninjured ankle.

I felt some discomfort walking next day.

I will persist with the exercise daily. In your experience, what time frame would you expect an improvement in range of motion typically?

[ash422]

Thanks for your help btw!.....................................

[rossdykes]

Has the swelling went away in the ankle And do you Have sharp pains going up or across ?

[ash422]

There is no swelling. The pain is sharp only when I exert myself or apply 'too' much pressure on dorsi-flexion. The pain is non-existent or dull when I am resting. The pain and obstruction is end of the tibia (distal) and between distal tibia/talus area - Going across - particular in central and antero-medial region.

I fear that I may have the following issue:
"Anteromedial...... ankle impingement: Common causes are inversion ankle injuries and sprains sustained while playing basketball (45%), volleyball (25%), or soccer (31%). Injury to the ligament or joint capsule may lead to synovitis, scar tissue, hypertrophied soft tissue, and, ultimately, impingement"

[Shane Arpas]

I have had a similar issue in the past of the tibio-talus jnt. I found long axis traction of the ankle very helpful, and also an ankle gapping procedure did wonders.

There is no swelling. The pain is sharp only when I exert myself or apply 'too' much pressure on dorsi-flexion. The pain is non-existent or dull when I am resting. The pain and obstruction is end of the tibia (distal) and between distal tibia/talus area - Going across - particular in central and antero-medial region.

I fear that I may have the following issue:
"Anteromedial...... ankle impingement: Common causes are inversion ankle injuries and sprains sustained while playing basketball (45%), volleyball (25%), or soccer (31%). Injury to the ligament or joint capsule may lead to synovitis, scar tissue, hypertrophied soft tissue, and, ultimately, impingement"

[ash422]

By ankle gapping procedure, do you mean strapping or a surgical procedure?
Thanks.

[Shane Arpas]

Sorry, the procedure was a Manipulation of the Subtalar joint: very much like a quick long axis traction.

[Musculoman]

Hey ash,

Have you tried a knee to wall stretch and regaining your dorsiflexion? (put your toes as far out from the wall as possible, keep your heel down and reach your knee to the wall, measure how far your toes are from the wall, normal is > 10cm give or take, compare it against your uninjured side)

Calf stretching/ knee to wall stretching / physio joint mobilisation etc. will likely be helpful. 4 months with restricted dorsiflexion will almost certainly lead to impingement. When you walk / run you require ~10-15 degrees Weightbearing dorsiflexion, if you don't have this your foot will tend to severely pronate post mid-stance phase of your running / gait cycle, impacting the anteromedial capsule / x / y / z... do this a thousand times / steps and wala! scar tissue / fibrosis / capsule degeneration .. you name it!

So post back your knee to wall measurement, if this is lacking a simple fix may be to improve your dorsiflexion with continuous stretching etc. you may have secondary changes to your local structures now as well which may cause problems for a while, but felt like the above required mentioning...

[ash422]

Tried the procedure; Measurement to toes on my uninjured leg measure back as far as approx 13 cm. My left ankle measures to 6.5 cm!! I can feel stresses that are impacted onto other structures in my left ankle at this point. That is a significant amount to regain.
Is it likely that regular stretching will improve dorsi-flexion?

How successful is debriment surgery in such a situation?

[Musculoman]

Yep stretching over a period should help unless you have foreign bodies locking in the joint etc. but definitely try:

Knee to wall stretch (as per the test procedure, hold for 30seconds 10+ times per day (not all at once, just throughout the day))
Calf stretch (normal calf stretch)
Calf stretch turning the foot in towards the front foot (when leaning forward against a wall etc.)
Calf stretch off a step (front of foot on a step and hang the heel off)
Joint mobilisation w/ your physio with active and passive dorsiflexion etc. as described in other posts.
Skateboard / Rolling foot forward and back as far as the ankle will go while holding the heel down

You can also try some active exercises which require joint movement to help loosen the ankle (try non weightbearing and progress) i.e. elastic band pushing your foot out and then bringing it up (with and against resistance, so band being held by you and band being held down past your foot while lying) to hydro (calf raises on a step in a pool etc...) then weightbearing (squats, single leg squats, walking lunges with a long heel on the ground hold) .. when you get some range back and symptoms ease hit me up I can actually specifically prescribe you some exercises...

In terms of surgery, properly conservatively manage it first, if that does not work get a specialist to r/v your investigations, they will tell you if surgery is required or not. No surgery is ever a "small" surgery, so take it very seriously if you are considering the option. I would suggest further conservative management... and go see a good physio!

[ash422]

I continued with physio/ROM exercises. It was revealed that I have a bone spur formation and that is causing the impingement. The surgeon says that removal of bone spurs is only for pain management, and will return, therefore surgery is not recommended as it is only a temporary fix.

If the bone spur is removed, does it always return?

[Musculoman]

Hi ash,
Bony remodelling is usually due to irritation / chronic inflammation which stimulates ossification of the bone leading to a spur. I won't get into too much details about the processes. We could assume the irritation was your chronic ankle sprain, and that removal of the bony spur MAY not come back if the ankle is correctly managed post op. We could also assume you will have increased response to injury / mechanical strain due to hypersensitivity of the central and peripheral nervous systems following a chronic injury which will lead to aggravation post op and a return of the bony spur!

So, to answer your quesion... wait, I didn't answer your question. How about, possibly? If it were me I would weight up the pros and cons of surgery, factoring in the chance of reoccurance. Cost, rehab time etc. vs. quality of life, sporting ambitions etc.

Again, being an extremely active individual, if it was reducing my quality of life I would get another recommendation firstly.

First step, get another reccomendation (don''t just find 100 reccomendations until someone tells your what you want to hear though). Have you had any further reduction of symptoms in the last 2 months following your stretching and physio? What is your knee to wall on your injured side now? (I assume not much of an increase due to a structural limitation being the bony spur).

As a side note... conservative management will likely not be successful from the information provided. If surgery fails, you will likely just be in the same spot... ?? Food for thought.

[Musculoman]

Yep stretching over a period should help unless you have foreign bodies locking in the joint etc

i.e. a bony spur ... sadface

Apprently my message is too short, so... lets get into some more food for thought. Orthotics may help push you out of pronation and reduce anterolateral impingement ?? Cutting off the foot may also lead to reduced impingement, however may slightly affect your gait.

[ash422]

Food for thought indeed! Even a chartered physiotherapist was apprehensive and did not want to treat a condition that can not be resolved (without surgery). Physio/Conservative treatment would probably make things worse. She advised that only I can make the crucial choice of yes/no to surgery.

There has not been any improvement in dorsiflexion. Over-stretching or lunging does cause pain, which means that return to normal sporting activity is unlikely without intervention.

I am fairly confident that surgery will be successful but it is likely that the spur will grow back. I would like to at least have a couple of years of competitive sport before "semi-retiring".

Cost and rehab time is not an issue. Just have to be on a waiting list for surgery. I will certainly look for further advise on correct rehab post op.

Thanks for your time and attention I will be going for an op in a couple of months... I hope...

[physiobob]

Working regularly with bakket dancers I can say that the surgery will be useful if it is an impingement. However as others have mentioned mibilisation of the talocrural joint through range or motion i.e. into dorsiflexion and not just at one fixed range should assist. Also it is a good idea to consider rear/midfoot support via an orthotic. even if that it to reduce the irritation. The advice in this tread has been rather good actually and the only bummer is the surgeon's comments. Try to see an ankle/ foot specialist who works with athletes for a functional opinion. A bone spur that formed from a trauma, rather than a chronic over tensioning of a tendon, should not reform as it was suggested.

[ash422]

An update.... I decided to go ahead with bone spur removal, and it has been "shaved" as stated by the consultant (yesterday). I am now waiting for bandages to be be removed before seeing a physio after a week.

Thanks to everyone that has commented on my condition.

If any one has any further advice as to limiting the re-occurrence of the bone spur (at this critical juncture), I would very much appreciate the help.

I will post my results and progress shortly. Many thanks.

[pinkjaybird]

An update.... I decided to go ahead with bone spur removal, and it has been "shaved" as stated by the consultant (yesterday). I am now waiting for bandages to be be removed before seeing a physio after a week.

Thanks to everyone that has commented on my condition.

If any one has any further advice as to limiting the re-occurrence of the bone spur (at this critical juncture), I would very much appreciate the help.

I will post my results and progress shortly. Many thanks.

Hello,

I have just been diagnosed with ankle impingement and would like to know your progress if possible?

I competitively roller skate and am very worried that I may no longer do so.

[ash422]

My operation results were very positive, although there was still some minor impingement in the joint. I never returned to full range of motion unfortunately.

There were no after-effects from surgery and no pain in the joint at all. I was able to return to playing football, although I have never quite gained the same amount of confidence. Doing things (such as sport) in moderation is key. I would recommend an MRI scan and a very detailed diagnosis. It is possible to recover from this type of problem, and my results from surgery were very positive.

I suffered another minor sprain a few months later on the same ankle, and have not returned to sport since. I will attempt do some further running in the short term (after rest). I will also look at perhaps another scan next year to see if there has been further degradation.

Good luck!! Do you feel that it is bone or tissue impingement?

[hepha99]

Hi Ash422

I know it's been a couple of years, but I wanted to check on your developement.
I have a very similar situation as yours, but many people keep telling me that after surgery, the spurs usually grow back.
I was infiltrated with cortisone and the effect was incredible, I was able to play basketball without any pain, but the effect wore out after 3 weeks and I'm at the same place as before.
Did you return to sports after your latest sprain? Did you have a new MRI or Xray to check if the spur was back? How are you feeling nowadays?

Thanks a lot!