Ankle Impingement in Runners

A 45-year-old male marathon runner came into my office with pain in the back of his ankle. It seemed to happen whenever he in

creases his mileage above 25 miles a week. Running downhill makes it worse. He had seen a podiatrist who told him to stop running and that he needed surgery for ankle impingement. He sought another opinion as he did not want to stop running.

One of the many causes of ankle pain in runners is impingement. What does that mean and what is the cause and treatment?

The ankle is made up of 2 bones (tibia and talus) that glide along each other. There is a capsule and joint fluid (synovial fluid) surrounding the joint. With repeated motions, there can be pressure on the bones which can lead to calcium deposits or swelling and injury to the bony tissue. The runners may then develop bone spurs (osteophytes) in the joint in response to the stress to the bone. These can cause pressure on the surrounding soft tissues including the tendons, ligaments and subcutaneous tissue.

Ankle impingement is a general term that simply means there is a limitation of range of motion. The limitation can be cause by bony issues or soft tissue abnormalities. Ankle impingement happens with bending the ankle. There are three areas the impingement can occur.

Anterior ankle impingement occurs in the front part of the ankle. Runners will experience pain in the front and outer (or rarely inner) side of the ankle. Pain can be worse with running uphill. Typical anterolateral (front outside) structures that can be impinged include the ATFL anterior talofibular ligament) and CFL (calcaneal fibular ligament). Anteromedial impingement is much less common and some physicians do not believe it exists. The structure impinged is usually subcutaneous tissue.

Posterior ankle impingement occurs in the back of the ankle. Runners may notice pain in the heel or higher in the ankle. The tendon most often impinged is the FHL (flexor hallicus longus). The third type is calcaneal- peroneal impingement which is also posterior but occurs a little lower and to the outside (lateral) area of the ankle and occurs when the impingement is on the peroneal tendons. All areas may cause ankle swelling along the trapped soft tissues. Runners can experience a feeling of instability as well as pain. The area may be tender to touch or feel hot.

Ankle impingement may be diagnosed simply by an examination from a sports medicine physician. X rays may be helpful to evaluate osteophytes. Occasionally there may be an extra bone (os trigonum) along the posterior ankle. Ultrasound can evaluate the surrounding synovium and tendons. Rarely MRI is needed to evaluate bony swelling. Sometimes an injection of anesthetic may be used to confirm the source of pain.

There are several ways to treat ankle impingement. Conservative treatment consists of resting, ice, and anti-inflammatories. Helpful anti-inflammatory medications may include ibuprofen, Voltaren gel CBD, arnica or similar. Physical therapy or exercises to strengthen the ankle muscles and tendons are helpful for both rehabilitation and prevention of further impingement. With conservative measures most runners can return to their previous level of training within 4-6 weeks. Often they do not have to take much time off, just relative rest. Occasionally a corticosteroid injection can be done to help the soft tissue inflammation if the previous measures fail. Finally, surgery is a last resort and rarely needed.

There are several ways to prevent impingement. Runners should mix up their terrain. Include some uphill and downhill but avoid long stretches of either. If the ankle gets twisted or sprained make sure it is fully rehabilitated with strength and balance (proprioception) exercises. Having proper fit for running shoes is essential.

So- what happened with the patient here? He had an x ray showing an os trigonum. We tried PT and topical anti- inflammatory cream. That helped some but not enough. We then did a steroid injection. He was able to complete his marathon training and qualified for Boston. He has continued to run and occasionally has pain which is well controlled with topical CBD. He was happy to avoid surgery.

Healthy Running to you all!