Ankle Impingement Syndrome

Background

Soft tissue impingement lesions of the ankle usually occur as a result of synovial or capsular irritation secondary to traumatic injuries, infection, or rheumatologic or degenerative disease states. They may also be congenital in origin. The leading causes of impingement lesions are posttraumatic injuries, usually ankle sprains, leading to chronic pain. Involved areas may include the anterolateral gutter, syndesmosis, and posterior ankle regions.

In 1950, Glassman et al reported on 9 patients presenting with chronic persistent pain and swelling around the anterolateral aspect of the ankle following an inversion ankle sprain. At the time of surgery, a massive hyalinized connective-tissue band extending from the anteroinferior region of the talofibular ligament into the ankle joint was found. They referred to this pathologic entity as a meniscoid lesion because of its resemblance to a torn meniscus of the knee. It was believed that repetitive tension on this tissue led to increasing hypertrophy and fibrosis, resulting in impingement on the talar cartilage and causing pain and swelling. Resolution of symptoms occurred in all cases with excision of the pathologic tissue.

In 1982, Waller described a pain syndrome along the anteroinferior border of the fibula and anterolateral talus following repetitive inversion injuries. Examination of his patients revealed foot pronation and heel valgus. He believed this pathology to be synovial compression or chondromalacia of the lateral talar dome and called it the anterolateral corner compression syndrome. Bassett et al found and described a separate pathologic fascicle of the anterior talofibular ligament (ATFL) in syndesmotic impingement. Following a tear of the ATFL, the anterolateral talar dome extrudes anteriorly with dorsiflexion, resulting in impingement. Hamilton described a labrum or pseudomeniscus of the posterior lip of the tibia, which can become torn or hypertrophied with ankle sprains and lead to posterior impingement.

Frequency

United States

After an ankle sprain, 20-40% of patients have chronic ankle pain; of these patients, approximately one third have pain related to impingement.

Sport Specific Biomechanics

The most common mechanism of acute injury is plantar flexion/inversion injury resulting in acute ankle sprain (eg, basketball player landing on opponent's shoe, cross-country runner stepping in a hole).

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Initial treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain, physical therapy, bracing, and orthotics.

Surgical Intervention

With failure of conservative modalities, surgical intervention is indicated. Arthroscopic excision and debridement is the treatment of choice.

Other Treatment

Occasionally, steroid injection into the affected area may give relief. Intra-articular anesthetic (lidocaine) ankle injection can be used as a differential tool to distinguish between ankle pain and subtalar pain.

Electrotherapeutic modalities also may be helpful.

In ballet dancers, technique assessment is helpful and essential to prevent further pain and injury.

Recovery Phase

Rehabilitation Program

Physical Therapy

Postoperatively, advise posterior splinting for 1 week and a supportive brace and elastic compression stocking. Physical therapy is initiated at 2-3 weeks for strengthening, range of motion, proprioception, and sports-specific rehabilitation.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions, may exist as well

Drug Name	Ibuprofen (Motrin, Ibuprin)
Description	DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	400-800 mg PO tid with food
Pediatric Dose	10 mg/kg PO tid with food
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Drug Name	Ketoprofen (Actron, Orudis, Oruvail)
Description	For relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Drug Name	Naproxen (Aleve, Naprosyn, Anaprox, Naprelan)
Description	For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose	500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Name	Sulindac (Clinoril)
Description	Decreases activity of cyclooxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.
Adult Dose	150-200 mg PO bid or 300-400 PO qd; not to exceed 400 mg/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; hypersensitivity to aspirin, iodides or other NSAIDs; GI bleeding; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia; caution in anticoagulation defects or are receiving anticoagulant therapy

Drug Name	Flurbiprofen (Ansaid)
Description	May inhibit cyclooxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult Dose	200-300 mg/d PO divided bid/qid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Category: Opioid analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Drug Name	Acetaminophen and codeine (Tylenol #3)
Description	May inhibit cyclooxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult Dose	30-60 mg/dose PO q4-6h (based on codeine content) or 1-2 tab PO q4h; not to exceed 4 g/d of acetaminophen
Pediatric Dose	0.5-1 mg/kg/dose PO q4-6h (based on codeine content); 10-15 mg/kg/dose PO (based on acetaminophen content); not to exceed 2.6 g/d of acetaminophen
Contraindications	Documented hypersensitivity
Interactions	Toxicity of codeine increases with CNS depressants, TCAs, MAOIs, neuromuscular blockers, phenothiazines, and opioid analgesics; rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Drug Name	Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab)
Description	Drug combination indicated for moderate to severe pain.
Adult Dose	1-2 tab or cap PO q4-6h prn
Pediatric Dose	<12 years: 10-15 mg/kg/dose PO q4-6h (based on acetaminophen content) prn; not to exceed 2.6 g/d acetaminophen >12 years: 750 mg PO q4h (based on acetaminophen content); not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/d
Contraindications	Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure
Interactions	Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or TCAs
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Drug Name	Hydrocodone and ibuprofen (Vicoprofen)
Description	Drug combination indicated for short-term (<10>
Adult Dose	1-2 tab PO q4-6h prn; not to exceed 5 tab/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; third trimester of pregnancy
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in elderly persons

Drug Name	Propoxyphene and acetaminophen (Darvocet-N 100, Propacet, Wygesic)
Description	Drug combination indicated for mild to moderate pain.
Adult Dose	1-2 tab PO q4h prn; not to exceed 600 mg/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	May increase serum concentrations of MAOIs, TCAs, carbamazepine, phenobarbital, and warfarin
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in patients dependent on opiates, substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction