Weight bearing x-rays are obtained in the dancer who meets the criteria of posterior ankle impingement on examination. These include anterior-posterior, lateral, oblique, and lateral demi-pointe positions, with the foot in full plantarflexion. These films will help to view the amount of bony approximation and show the size and dimensions of the os trigonum or Stieda process (Fig. 16).
Magnetic resonance imaging (MRI) of the ankle also is recommended when a dancer presents with posterior ankle impingement to further evaluate the extent and dimensions of the os trigonum, Stieda process, stress injury, and/or soft tissue mass or synovial hypertrophy causing the impingement (Fig. 17). The MRI can be used to further identify the areas of edema and inflammation, and, consequently, the structures in the posterior aspect of the ankle being impinged.
Treatment for posterior ankle impingement in the dancer can be surgical or nonsurgical depending on the cause. When symptomatic, osseous structures such as an os trigonum or Stieda process may require surgical intervention to treat (2-5,8,11,17,30,36,39,41). These structures, previously asymptomatic, are assumed to have been stressed or exacerbated by an injury or biomechanical fault of the dancer.
This author speculates that in some dancers, with repetitive trauma of the foot and ankle with demi-pointe and en pointe positions throughout their career or training, soft tissue structures that can lead to impingement in the posterior aspect of the ankle may form. These tissues include ganglion cysts, hypertrophic masses, or development of synovial hypertrophy. These soft tissue masses initially can be treated with a steroid and anesthetic injection from the posterolateral approach of the ankle along with appropriate physical therapy. If the symptoms and restriction are not resolved, surgical intervention may be necessary to correct.
The purpose of this article was to review the causes, potential treatments, and clinical presentation of posterior impingement of the ankle in dancers. The causes may be soft tissue or osseous in nature as discussed. Treatment for these conditions can be surgical or nonsurgical depending on the causative nature of the impingement. A symptomatic osseous impinging structure such as an os trigonum or large Stieda process may require surgical treatment to relieve both the pain and restriction. However, a soft tissue mass that is causing posterior ankle impingement may respond initially to a steroid and local anesthetic injection. These too may lead to surgery if the pain and restriction continue despite this intervention. More studies need to be done to implicate the ligamentous structures of the posterior ankle as causes of posterior impingement.
Posterior ankle impingement in the dancer often is underrecognized. Larger, more extensive outcomes studies need to be performed to assist in determining the appropriate treatment required for the dancer with posterior ankle impingement. A proper history and evaluation of the dancer should be performed if the examiner is suspicious of posterior ankle impingement.
When this condition is unrecognized and consequently not treated appropriately, the dancer's career and long-term abilities, potential, and success will be compromised.
The author declares no conflict of interest and does not have any financial disclosures.
1. Albisetti W, Ometti M, Pascale V, De Bartolomeo O. Clinical evaluation and treatment of posterior impingement in dancers. Am. J. Phys. Med. Rehabil.
2. Bureau N, Cardinal E, Hobden R, Aubin B. Posterior ankle impingement syndrome: MR imaging findings. Radiology
. 2000; 215:497-503.
3. Calder J, Sexton S, Pearce C. Return to training and playing after posterior ankle arthroscopy for posterior impingement in elite professional soccer. Am. J. Sports Med.
4. De Asla R, O'Malley M, Hamilton W. Flexor hallucis tendonitis and posterior ankle impingement in the athlete. Tech. Foot Ankle Surg.
5. Fiorella D, Helms CA, Nunley JA 2nd. The MR imaging features of the posterior intermalleolar ligament in patients with posterior impingement syndrome of the ankle. Skeletal Radiol.
6. Garrick JG. Early identification of musculoskeletal complaints and injuries among female ballet students. J. Dance Med. Sci.
7. Garrick JG, Requa R. Ballet injuries. An analysis of epidemiology and financial outcome. Am. J. Sports Med.
8. Hamilton W. Stenosing tenosynovitis of the flexor hallucis longus tendon and posterior impingement upon the os trigonum in ballet dancers. Foot Ankle
. 1982; 3:74-80.
9. Hamilton W. Foot and ankle injuries in dancers. Clin. Sports Med.
10. Hamilton W. Posterior ankle pain in dancers. Clin. Sports Med.
11. Hamilton W, Geppert M, Thompson F. Pain in the posterior aspect of the ankle in dancers. Differential diagnosis and operative treatment. J. Bone Joint Surg. Am.
12. Hardaker W. Foot and ankle injuries in ballet dancers. Orthop. Clin. North Am.
13. Hedrick M, McBryde A. Posterior ankle impingement. Foot Ankle Int.
14. Kadel NJ. Excision of os trigonum. Oper. Tech. Orthop.
15. Kadel NJ, Micheli LJ, Solomon R. Os trigonum impingement syndrome in dancers. J. Dance Med. Sci. 2000; 4:99-102.
16. Khan K, et al
. Overuse injuries in classical ballet. Sports Med.
17. Lee J, Calder J, Healy J. Posterior impingement syndromes of the ankle. Semin. Musculoskelet. Radiol.
18. Liebler WA. Injuries of the foot in dancers. In: Bateman J, editor. Foot Science. Philadelphia (PA): WB Saunders; 1976. p. 284-7.
19. Macintyre J, Joy EA. Foot and ankle injuries in dance. Clin. Sports Med.
21. Marotta J, Micheli L. Os trigonum impingement in dancers. Am. J. Sports Med.
22. McDougall A. The os trigonum. J. Bone Joint Surg. Br.
23. Meck C, Hess R, Helldobler R, et al
. Pre-pointe evaluation components used by dance schools. J. Dance Med. Sci.
24. Nilsson C, et al
. The injury panorama in a Swedish professional ballet company. Knee Surg. Sports Traumatol. Arthrosc.
25. Noguchi H, et al. Arthroscopic excision of posterior ankle bony impingement for early return to the field: short-term results. Foot Ankle Int. 2010; 31:398-403.
26. Peace KA, et al
. MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. Clin. Radiol.
27. Robinson P, Bollen S. Posterior ankle impingement in professional soccer players: effectiveness of sonographically guided therapy. AJR Am. J. Roentgenol.
28. Rosenberg ZS, et al
. Posterior intermalleolar ligament of the ankle: normal anatomy and MR imaging features. AJR Am. J. Roentgenol.
29. Rosenmuller JC. De non Nullis Musculorum Corporis Humani Varietatibus
. Leipzig (Germany): Klaubarthia; 1804. p. 8.
30. Russell J, Kruse D, Koutedakis Y, et al
. Pathoanatomy of posterior ankle impingement in ballet dancers. Clin. Anat.
31. Shah S. Determining a young dancer's readiness for dancing on pointe. Curr. Sports Med. Rep.
32. Shepherd FJ. A hitherto undescribed fracture of the Astragalus
. J. Anat. Physiol
. 1882; 17:79-81.
33. Smith W, Berlot G. Posterior ankle impingement. Tech. Foot Ankle
. 2009; 8:94-8.
34. Tsuruta T, et al
. Radiological study of the accessory skeletal elements in the foot and ankle. Nihon Seikeigeka Gakkai Zasshi
. 1981; 55:357-404. Japanese.
35. Turner W. A secondary Astragalus
in the human foot. J. Anat. Physiol.
36. van Dijk C. Anterior and posterior ankle impingement. Foot Ankle Clin.
37. van Dijk C, de Leeuw PA, Scholten P. Hindfoot endoscopy for posterior ankle impingement. Surgical technique. J. Bone Joint Surg. Am.
38. van Dijk C, Scholten P, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy. 2000; 16:871-6.
39. van Giffen N, Seil R, Pape D, Nuhrenborger C. The athlete's foot: the grey zone behind the ankle. Bull. Soc. Sci. Med. Grand Duche Luxemb.
40. Weiss D, Shah S, Burchette R. A profile of the demographics and training characteristics of professional modern dancers. J. Dance Med. Sci.
41. Wredmark T, Carlstedt C, Bauer H, Saartok T. Os trigonum syndrome: a clinical entity in ballet dancers. Foot Ankle
. 1991; 11:404-6.