The Posteromedial Impingement Lesion of the Ankle

Abstract

We report on a series of six cases of posteromedial impingement lesion of the ankle operated on during a 3-year period with excellent or good results and a return of the patients to preinjury levels of activity. This lesion occurs, on occasion, after a severe ankle-inversion injury in which the deep posterior fibers of the medial deltoid ligament become crushed between the medial wall of the talus and the medial malleolus. Initially, posteromedial symptoms do not predominate, compared with the symptoms of the lateral ligament disruption, and they usually resolve without specific treatment. Occasionally, however, thick, disorganized fibrotic scar tissue persists and impinges between the medial wall of the talus and the posterior margin of the medial malleolus. Clinically, the patient has persistent medial to posteromedial activity-related ankle pain after a severe inversion injury, despite a sound ankle rehabilitation program. There is deep soft tissue induration immediately behind the medial malleolus with localized tenderness and reproduction of symptomatic pain on provocative testing by palpating this site while moving the ankle into plantar flexion and inversion. The posteromedial impingement lesion has a distinct pathologic picture and can coexist with other ankle lesions that cause pain after lateral ligament injury.

Arthroscopic Management of Posteromedial Ankle Impingement

“…The subsequent fibrosis and thickening of the injured posterior tibiotalar ligament and posteromedial capsule cause impingement between the medial wall of the talus and posterior margin of the medial malleolus, resulting in formation of collagenous and fibrous meniscoid lesions and synovitis at the posteromedial ankle. 6,[8][9][10][11][12] The ankle usually shows deep soft-tissue induration and localized tenderness; pain is evocable by palpating the medial retromalleolar area while moving the ankle. 2 Posteromedial tenderness on inversion with the ankle in plantar flexion is an important sign to differentiate the ankle pain originating from the tibialis posterior tendon.…”

“…2 Posteromedial tenderness on inversion with the ankle in plantar flexion is an important sign to differentiate the ankle pain originating from the tibialis posterior tendon. 6,11 Magnetic resonance imaging has been shown to be an effective investigation in ankle impingement syndromes, 6,7 but it cannot replace careful clinical examination (Fig 1). Sometimes, the exact diagnosis of posterior ankle pain cannot be determined, and posterior ankle endoscopy is an effective diagnostic and therapeutic tool.…”

Impingement syndromes of the ankle

“…The exact aetiology and characteristic imaging features of posteromedial impingement have not been as completely defined as other impingement syndromes [5,38,39]. The condition develops after compression of the posteromedial tibiotalar capsule and posterior fibres of the tibiotalar ligament (PTTL) between the talus and medial malleolus during a supination injury [5].…”

“…Because of the large volume of acute ankle injuries chronic pain is a frequent clinical problem with the differential diagnosis including osteochondral injury, mechanical instability and impingement syndromes [1]. Originally described in the 1950s, impingement syndromes are now recognised as a significant cause of chronic ankle pain [2][3][4][5]. Impingement used to be considered a clinical diagnosis of exclusion, but the literature now shows it can coexist with other causes of chronic ankle dysfunction [5,6].…”

“…Anterolateral, anterior and posterior ankle impingement has been extensively described in the orthopaedic and radiology literature with more recent studies describing posteromedial and anteromedial impingement [2][3][4][5]9].…”