Anterior Ankle Impingement in
Gymnasts
Jon Fravel, MS, ATC/L
Overview
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Clinical Interest
Anatomical Descriptions
Etiology
Gymnastics Overview
Conservative Treatment
Surgical Summary
Clinical Interest
• Ankle injuries are very common in sport
• As an outsider a few years ago it seemed there
were quite a few gymnasts with ankle “issues”
• First case I was involved with at the Univ of
Iowa
Defining Anterior Ankle Impingement
• Footballers Ankle
– Morris & McMurray
• Chronic anterior ankle pain is commonly caused by
talotibial osteophytes at the anterior portion of the ankle
joint.
• In general, osteophytes are the secondary manifestation
of osteoarthritic changes. However, repetitive minor
trauma in the ankle, as seen in athletes, can induce spur
formation, with radiographic characteristics similar to
osteophytes. – van Dijk
Exostoses Diagram
Hopper & Robinson 2008
Tol and van Dijk Classification of
Osteoarthritic Changes
Etiology
• Footballers Ankle (Traction Spurs)
– The anterior joint capsule attaches on the tibia at an average of
6 mm proximal to the joint level
– On the talar side, the capsule attaches approximately 3 mm
from the distal cartilage border
– The distance of capsular attachment to the most frequent
location of bony spurs is thus relatively large
– Traction spurs from recurrent traction to the joint capsule is not
plausible
– On top of this during arthroscopy the spurs are found within the
capsule
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van Dijk 2006. Tol JL, van Dijk CN. Etiology of the anterior ankle impingement syndrome: a descriptive anatomical study. Foot
Ankle Int 2004;25:382–6.
van Dijk CN, Tol JL, Verheyen CC.Aprospective study of prognostic factors concerning the outcome of arthroscopic surgery for
anterior ankle impingement.Am J Sports Med 1997;25: 737–45.
Tol JL, Verheyen CP, van Dijk CN. Arthroscopic treatment of anterior impingement in the ankle. J Bone Joint Surg Br
2001;83:9–13.
Footballer’s Ankle
• Examination of video showing only a minority
of individuals actually reached full
plantarflexion during kicking.
• Likely bones response to the trauma of the
ball contacting the tibia and the talus.
– Tol 2002
Etiology
• O’Donohue (1957) considered the osteophytes to
be related to direct mechanical trauma
associated with the impingement of the anterior
articular border of the tibia and the talar neck
during forced dorsiflexion of the ankle.
• Bone formation is considered to be a response of
the skeletal system to intermittent stress and
injury
– Wolff’s law of bone remodeling
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O’Donoghue DH. Impingement exostoses of the talus and tibia. J Bone Joint SurgAm1957; 39-A:835–52.
Etiology
• In cadavers a triangle of soft tissue- synovial fold,
synovial fat, and collage tissue were found along
the anterior jt line.
• Repetitive trauma may cause hypertrophy of the
synovial layer and and create subsynovial fibrotic
tissue also causing infiltration of inflammatory
cells.
• These osteophytes decrease anterior space and
compression of this tissue is more likely to occur.
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Berberian WS, Hecht PJ, Wapner KL, et al. Morphology of tibiotalar osteophytes in
anterior ankle impingement. Foot Ankle Int 2001;22:313–7.
Ferkel RD, Karzel RP, Del Pizzo W, et al. Arthroscopic treatment of anterolateral
impingement of the ankle. Am J Sports Med 1991;19:440–6.
Anteromedial and Anterolateral
Impingement
Posterior Ankle Impingement
• Chronic posterior ankle pain is commonly caused by an
os trigonum or other bony impediment
– hypertrophic posterior process of the talus.
– Hyperplantar flexion (with dancers en pointe or demi
pointe but with research does not seem to be the case)
• Traumatic event plus this hyperdorsiflexion to cause
post ankle impingement
– (hard floors, ankle sprains, supination trauma)
• Posterior talar prominence becomes compressed
between the tibia and the calcaneus during forced
plantarflexion. In the presence of an os trigonum, this
can lead to micromotion of the os trigonum, and pain.
Who
• Typically, patients with an anterior ankle impingement are relatively young
athletes with recurrent inversion injuries of the ankle
– St Pierre RK, Velazco A, Fleming LL. Impingement exostoses of the talus and
fibula secondary to an inversion sprain. A case report. Foot Ankle 1983;3:282–
5.
• Pt present with anterior ankle pain, swelling after activity, and (slightly)
limited dorsiflexion. The diagnosis of anterior impingement is clinical,
based on physical examination. Recognizable local pain on palpation is
present anteriorly, and the osteophytes may be palpable with the ankle
joint in slightplantarflexion.
– Van Dijk 2001
– If pain is anterormedial with palpation it is consiered anteromedial
impingement. If pain is anterolateral with palpation it is considered
anterolateral impingement
– Forced dorsiflexion can often provoke pain but sometimes false negatives.
Gymnastics
• Quite a few injuries in gymnastics
• Each gymnast reported an average of 3.64
injuries per 12 month period
– 4.19 for the elite gymnasts and 3.30 for the subelite
gymnasts
• In relation to training hours: the elite gymnasts
reported 2.63 injuries per 1000 training hours
while their subelite counterparts reported 4.11
injuries per 1000 hours
– Kolt and Kirby 1999
Univ of Iowa Gymnastics
• Over the past 1 yr we’ve had 3 surgical cases
on the men’s and women’s gymnastics teams.
– Most bilateral but not all.
– 2 more likely scheduled for the end of this year.
– 1/5 male
Univ of Iowa
• As I work mostly with the women’s team I
reviewed the hx of all of the women’s team
over the past 3 yrs.
• For that population 10/26 have been
diagnosed with these anterior impingement.
– 38.5%
How does this compare?
• How do you define injury?
– 1 NCAA
• Result from participation in practice
• AND Require attn from ATC or MD
• AND Restricted participation for 1 or more days
– 2 Kolt and Kirby (18 mos prospective survey)
• Also reviewed injury studies
– Snook- Bring attn to a doctor
– Sands- Damaged body part that affected training
How does this compare?
• Actual answer is we don’t know.
• When asked gymnasts say it is not
uncommon.
– Kolt and Kirby say 30.7% of the injuries are foot
and ankle.
– NCAA ISS 88-89 thru 03-04
• 23.0% foot and ankle at competition
• 18.2% foot and ankle at practice
When do we see these injuries?
• Unscientific and not a lot of evidence to base
this on
• Women/girls earlier than men/boys
• Why? Two thoughts.
– Age at peak
– Training
• Intertwined....
Age at Peak
• Females in the US peak elite at 15.7 yrs
– Must be 16 for Olympics by December of that year.
– (US levels) USA Gymnastics
• 1-3 (not often done)
• 4-10 (belt system in karate) accomplish certain skills or
certain scores
• Elite
• International elite FIG (Federation Internationale
Gymnastique)
• Most College gymnasts are Level 10, Elite, or International
Elite.
– Very few international elites at Univ of Iowa.
Training and Misc
• Problem with men as well, but is more frequently
seen with women
• Men have 6 events
(in my experience)
– FX, PH, SR, V, PB, HB (Olympic Order)
• Women have 4 events
– V, UB, BB, FX (Olympic Order)
• Both w/ 2 most LE events
– Men spend a different ratio of time dedicated to UE
events
• Ring strength, pommel strength.
• Years to be able to swing pommels.
Training and Misc
• Unfortunately no longer have an NCAA ISS for
MGM
– @ Iowa 294 Injuries over the past 5 yrs.
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29 ankle, 6 foot (for 35 injuries)
22 knee
12, elbow 36 shoulder 34 wrist (82 UE)
13 hand, and 7 clavicle
Training and Misc
• WGM Self Fulfilling
• Even before this many elite coaches predict age
16 as peak.
• Men no stats for peak, but most agree it is in the
late 20’s.
• Time to push and push hard.
• We now have foam pits in the world of
gymnastics but this means more reps.
• Safe reps?
Triple Double
How do we see these injuries
• Landing in a hyperdorsiflexed position.
– FX 31.1% of the injuries in NCAA ISS
– V 27.3% for a combined total of 58.4%.
• Warm up, cool down, S&C, other, UB, Beam
– Skills
• Mostly large skills...
• Mostly backwards skills.
– Double backflip (tucked, piked, laid out)
– Full-in, full-out, double-double, triple double.
Gymnastics Explained
• Need large skills for points (to reach a 10.0 for WGM or to
increase D Score for MGM)
– A-E skills
• Do backwards because it is easier to spot landings and
more consistent.
• Women have to do one forward skill and that’s all they
usually do.
• Men can do 1/2’s so you end up rolling out.
• Unfortunately lots of power to rotate twice and lots of
force c landing 5.0x body weight at take-offs and 17.5x BW
at landings
– McNitt-Gray J
– Same goes for vaulting
Landing Short
Backwards Over Rotation Video
Fwd Under Rotation Video
Fwd Over Rotation
Other Problem Events
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Vault!
Dismounts on Men’s Pbars
All other dismounting events
Not so much for twisting activities even for
back twisting
Treatment
• Acute Treatment
– Follow impingement tx’s of shoulder
– Bring down during inflammatory phase
– RICE and protect from activity.
– ROM Wall stretches, kneeling stretches,
• Toes under, toes out.
– Strengthening.
Chronic Treatment
• Bring down during the
inflamm phase
• Strengthening
• Assist in plantarflexion
anything
• SL Squats
• B Heel raise
• Step up plus
• Weighted bounces
• Toe Walks
• Eccentric heel raises
• Intrinsics to take up the
load
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Marbles
J’s
Towel Scrunches
Arch-ups
• Knee and Hip
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Candle stick jumps ups
lunge jump
Box jumps
Fails SL
Rehab
• All conservative rehab is stretching and
strengthening –Jackie Alvis
• We haven’t mentioned any stretching.
Mechanical problem
Textbook Orthopaedic
Recommendations
• Orthopaedic recommendations are
“appropriately placed injections or heel lifts”
• Dry needling with injection of steroid and local
anesthetic can be performed under
ultrasound guidance allowing a return to
previous levels of activity even in elite
athletes, but this technique has not been
evaluated in the literature
Goals
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Avoid Landing Short!
Extra power at take off
extra absorption of forces at landing
Landing technique
– rolling fails
– twisting fails
– fwd landing/backwards landing
Gymnastics Tricks of the Trade
• Appearance must be uniform
• 30 seconds for injury or blood
– beam and bars
• Taping no rules
– Appearance should be uniform
– Cover c coflex
• Posterior track straps
– place in plantar flexion
– Elastikon
– theraband
• Anterior limits
– Fx and vault events tennis ball in the front of the ankle.
– UCLA team NCAA champs 2010
Tennis Ball
Tennis Ball Tape
Surgery
• Do they all need them?
• No.
• Fwd skills
– no pain c ADL’s
– modify gym to avoid over rotation c forward skills
• Some do.
– limited function out of the gym
– failed conservative treatment
• Surgical treatment for more resistant cases has a low complication rate
and a high level of success.
• The previously unsuccessful results of nonoperative treatment for
impingement are well recognized in the literature.
– Van Dijk reported 62 patients with anterior ankle impingement who did not
respond to nonoperative treatment and thus underwent surgery.
– Ferkel also reported symptoms of impingement as unresponsive to
nonoperative treatment
UI Sports Medicine Rehab Protocol
WEIGHT BEARING
ROM
THERAPEUTIC EXERCISES
Initial post-op
1-14 days
Wt.bear as tolerated with
crutches. Expect to d/c
crutches as able to walk
without a limp (approx. 7
days).
0° dorsiflexion, 0-20°
plantarflexion.
AROM/AARPOM,
Alphabet exercises,
Towel stretches, towel
scrunches,
Progressive
Rehabilitation
(2-4 weeks)
Full weight bearing
without pain or limp.
10° dorsiflexion, 35°
plantarflexion.
Progress with
AROM/AAROM,
Progress with
strengthening, elastic
band exercises along
with previous exercises.
Toe (heel) raises, BAPS
board, balancing
exercises, biking/
stairmaster/pool. Begin
jogging.
Gradual return to sports
specific training and
exercises if all symptoms
have resolved and full,
functional ROM
obtained.
Increased Weight
bearing activities
(4-6 weeks)
Sport Related Activities
(6-8 weeks)
Full ROM
Surgery
• Bilateral scopes for the last three cases on the
gym teams
• Walking right away
• 4-6 wks of conservative rehab.
– 8-10 wks before return to sport
– from ROM, open chain, closed chain,
NM/perturbation, plyos, return to sport.
Rehab Protocols
• Postoperative management involves a compression bandage and partial
weight bearing for 3 to 5 days. Patients are instructed to actively dorsiflex.
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After surgery the patient was asked to be non-weightbearing for 2 days to
prevent fistula formation through the portal incisions and to allow the soft
tissues to settle.
Ankle pumps were encouraged the day after surgery for 20 minutes daily.
After 2 days, instruction was given to increase weight bearing as tolerated.
A postoperative AMI view radiograph was obtained at suture removal to
once again assess the removal of the osseous impingement. The soft
tissue aspect of AMI was evaluated clinically by pressing in the medial soft
spot and dorsiflexing the ankle joint at final follow-up.
Physical therapy was commenced 1 week to 10 days after surgery once
the sutures were removed.
Rehab Protocols
• Patients discharged from hospital same day
with a posterior splint. Non-weightbearing for
5 days. Treated w/ anti-inflammatory meds for
6 wks and postoperative physiotherapy
consisting of early passive and active ROM and
strengthening exercises, proprioceptive
training, and functional exercises specific to
dance technique.
Surgical Results
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From the late 1980s, several authors have published retrospective studies on management of
anterior ankle impingement. Good/excellent results varied between 57% and 67%, with an overall
complication rate from 10% to 15%.
90% of those without joint space narrowing had good or excellent results
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van Dijk 1997
15 soft tissue impingement and 14 anterior bony impingement cases out of a 79 ankle series.
Diagnosis
Procedure
Overall Result
VAS (mean ±
SD)
2-yr Follow Up
Overall Result
VAS (mean ±
SD)
p
Soft tissue
impingement
4.3 ± 3.7
8.3 ± 3.4
.02
Anterior bony
impingement
3.1 ± 3.7
7.7 ± 3.2
.008
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Amendola 1996
Recurrence?
• Coull and colleagues reported recurrence of osteophytes in all their 27
patients who underwent open debridement.
– Coull 2003
• At follow-up, most ankles in which osteophytes had recurred were
asymptomatic. It is not the osteophyte itself that is painful but the
compression of the synovial fold or fibrotic (scar) tissue causes pain.
– van Dijk 2001
• 1/11 Reccurence in elite dancers. 9 years following initial surgery.
– Nihal 2005.
• Patients who had osteophytes without joint space narrowing (grade I, 82%
good/excellent results) showed significantly better results than did
patients who had joint space narrowing (grade II, 50% good/excellent
results;
• 20/30 Recurrent exostoses in 5-8 years
– Tol 2006
Surgery
• This has allowed grade B recommendations for the use of
ankle arthroscopy for the treatment of ankle impingement
• Grading and Assigning a Category of Recommendation for
Summaries or Reviews of Orthopaedic Studies
– A Good evidence (Level I studies with consistent findings) for or
against recommending intervention
– B Fair evidence (Level II or III studies with consistent findings)
for or against recommending intervention
– C Poor-quality evidence (Level IV or V studies with consistent
findings) for or against recommending intervention
– I Insufficient or conflicting evidence not allowing
• Glazebrook 2009
Summary
• Anterior ankle impingement is relatively
common in gymnasts
• There are some conservative treatments that
can be used
• Surgery is effective in treating this condition
• Rehabilitation is relatively straight forward
Perfect Tumbling
Questions
• Questions?
• Comments?
• Concerns?