Scoping Out Ankle Impingement

Ankle impingement is common in athletes, especially in running, jumping, and cutting activities. We present 2 clinical cases of impingement, anterior (AAI) and posterior (PAI), plus subfibular, demonstrating the utility of ankle arthroscopy and hindfoot endoscopy techniques.

AAI presents with pain at terminal dorsiflexion, tenderness over the anterior joint, and pain with passive hyperdorsiflexion. PAI presents with pain on repetitive plantarflexion, tenderness over the posterior talar process, and pain with passive hyperplantarflexion. Surgical indications include persistent pain or functional limitations refractory to conservative treatment. Contraindications include severe arthritis, poor vascular status, or a compromised soft tissue envelope.

For AAI, the patient is slightly lateral with the thigh in a foam-lined leg holder. Minimal traction is applied through an ankle stirrup attached to a noninvasive sterile distractor. Standard anteromedial and anterolateral portals are created, with accessory portals made to access the submalleolar spaces. Impinging soft tissue and bony spurs are resected using a radiofrequency wand, shaver, and/or bur, followed by arthroscopic confirmation of resolution of impingement. For hindfoot endoscopy, the patient is prone with the involved ankle off the operative table end. Standard portals are posterolateral and posteromedial. The crural fascia is identified and released with a radiofrequency wand. The flexor hallucis longus is identified and is the most medial extent of any dissection to avoid neurovascular injury. Impinging structures are identified and resected using small joint instruments.

AAI arthroscopy has shown improvements in the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale, Foot Functional Index, and dorsiflexion. The reported overall complication rate is 4%, with the most common being transient neurapraxia, superficial infection, and disturbed wound healing. PAI hindfoot endoscopy improves AOFAS scores and reduces time to return to play compared with open procedures. There is a reported 6% complication rate with transient sensory nerve symptoms, Achilles pain, and portal thickening being the most common.

Anterior and posterior ankle impingements are common in athletes and present with limited function, decreased range of motion, and localized pain. When conservative treatment fails, ankle arthroscopy and hindfoot endoscopy are effective surgical options that provide pain relief, modest improvement in range of motion, faster return to play, and low complication rates.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.