Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement

Abstract

IntroductionOs trigonum syndrome is often ignored in findings that can result in hind-foot pain. It results from numerous disorders and may in fact be associated with an os trigonum or posterior trigonal process.The differential diagnosis of this condition includes flexor hallucis longus tenosynovitis, peroneal tenosynovitis and tendinitis, intraarticular loose bodies and ankle synovitis [2,7,8,10,11,12,14,15,18].This pathology is frequently encountered in athletes such as ballet dancers, soccer players, javelin throwers and runners, who must perform repetitive movements of the foot in the extreme range of plantar flexion or dorsiflexion [1,2,11,16,20].The purpose of this paper is to present the "post-traumatic overload syndrome of os trigonum", to point to the differential diagnosis with other pathologies which are included in the ambit of "os trigonum syndrome". Anatomy, pathomechanics and clinical aspectsThe os trigonum in order of frequency is the second sesamoid after the sesamoid bones of the first metatarsal [20]. Its incidence is between 3% and 13% in the population [15,17] and is twice as common unilaterally as bilaterally [8].Abstract The purpose of this paper is to discuss the post-traumatic overload syndrome of the os trigonum as a possible cause of posterior ankle impingement and hindfoot pain. We have reviewed 19 athletes who were referred to our foot unit between 1995 and 2001 because of posterior ankle pain, and in whom a post-traumatic overload syndrome of os trigonum was diagnosed. All these patients were followed up over a period of 2 years. In 11 cases a chronic repetitive movements in forced plantar flexion was found. In the other eight cases the pain appeared to persist after a standard treatment of an ankle sprain in inversion plantar flexion. The diagnosis was based on clinical history, physical examination and X-rays that revealed a non-fused os trigonum. The confirmation of diagnosis was carried-out injecting local anaesthetic under fluoroscopic control. In all cases a corticosteroid injection as first line treatment was performed. In 6 cases a second injection was necessary to alleviate pain because incomplete recovery with the first injection. Three cases (16%) were recalcitrant to this treatment and in these three cases a surgical excision of the os trigonum was carried out. Our conclusion is that after some chronic athletic activity or an acute ankle sprain the os trigonum, if present, may undergo mechanical overload, remain undisrupted and become painful. Treatment by corticosteroid injection often resolves the problem.

Chronic Fracture of the Posteromedial Tubercle of the Talus Masquerading as Os Trigonum Syndrome

“…Displaced fractures can be managed with arthroscopic and/or open surgery to fix or excise the fracture fragment [ 3 ]. Treatment of PAIS related to os trigonum can be managed nonoperatively with activity modification, physical therapy, and corticosteroid injection with success in up to 84% of cases [ 14 ]. Nonoperative management was the plan for the last case we described.…”

Five-year follow-up of endoscopic resection of symptomatic os trigonum: a prospective interventional cohort study of a possible cause of ankle and big toe pain

“…4,24 Therefore, all patients continued conservative therapy for 6 mo. Although some authors would argue that local steroid injection has been found to be successful in relieving pain; 25 others, with whom the authors agree, discourage the use of corticosteroids injection in athletic patients because of the potential harmful effects on the posterior ankle structures. 4,23,24 Existing operative options for failed conservative therapy include posterior ankle endoscopy, subtalar arthroscopy, and open resection through posteromedial or posterolateral approaches.…”

“…Therefore, all patients continued conservative therapy for 6 mo. Although some authors would argue that local steroid injection has been found to be successful in relieving pain;25 others, with whom the authors agree, discourage the use of corticosteroids injection in athletic patients because of the potential harmful effects on the posterior ankle structures 4,23,24…”

Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes

“…Corticosteroid and anesthetic injection into a posterolateral capsule abnormality in athletes with clinical posterior impingement with ultrasonography guidance showed good results and rapid return to athletic activity in football players. 16 , 17 USG-guided corticosteroid injection for 12 patients who did not experience any improvement or even worsen with conservative treatment after 4 weeks was performed. However, symptomatic relief with corticosteroid injection was significantly lower in our group compared with the previous studies.…”