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.
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