Treatment of Ankle Impingement Syndromes in Athletes

Abstract

BackgroundPainful limitation of ankle movement in athletes is commonly caused by soft-tissue or osseous formations. The impingement syndromes of the ankle are attributed to initial injuries which, undertreated, in a subacute or chronic basis, lead to development of thickenings within the ankle joint.AimTo present the outcome of arthroscopic excision of restrictors in ankle movement with concomitant anatomic ankle ligament reconstruction in athletes.Patients and MethodsEighteen athletes, twelve males and six females, (of which, nine basketball-players, four football-players, two dancers) were treated over the last ten years. The mean age was 22 years. The sports activities of all patients were dramatically deteriorated due to chronic ankle pain and/or a “giving way” feeling. The thorough clinical examination included reproduction of impingement pain (anterior, anterolateral, anteromedial, or posterior) and stability testing in comparison to the contralateral ankle. Radiographs included anteroposterior, lateral and oblique views in a weight-bearing position. Ultrasound and plain MRI testing was performed without exception. Each patient underwent arthroscopic evaluation. Arthroscopic debridement of hypertrophic tissue arising from AITFL, ATFL or deltoid was performed in 16 patients. Arthroscopic decompression of bony impingement (excision of tibial or talar osteophyte) was needed in ten patients. Ankle ligament reconstruction was performed in 13 cases (modified Brostrom in 11 athletes, deltoid reconstruction in two others). Excision of osseous and soft-tissue components of posterior impingement via open posterolateral approach was performed in two dancers. We also had to remove meniscoid lesions in four cases. In addition, debridement and microfractures were indicated in four patients with osteochondral lesions and to two patients was applied Autologous Chondrocyte Implantation. A custom rehabilitation program was utilized for each individual.ResultsPatients were followed up at one, three, six, nine, and twelve months postoperatively using the FADI score. The results at 12 months were ranged above 90 for 13 athletes, between 85–90 for 4 athletes and between 80–85 for one athlete. Poorer results are correlated with concomitant osteochondral lesions. The highest scores were achieved when ligament reconstruction had been performed.DiscussionChronic ankle instability should always be suspected in an athlete with chronic ankle pain and findings of ankle impingement. A clinical exam and an ultrasound exam contribute in a more accurate diagnosis for an ankle instability. The appearance of an injured ligament on plain MRI varies and is not reliable to estimate the functional sufficiency of the ligament. Ankle arthroscopy provides great visualization of joint pathology in impingement syndromes that is amenable to repair. Open ligament repair is reliable and optimizes the functional results.ConclusionArthroscopic treatment of anterior ankle impingement together with ankle ligament reconstruction, when indicated, is essential for obtaining a stable and functionally efficient ankle.