Ankle Impingement Test

Ankle Impingement Test is used to diagnose the impingement syndrome of the ankle, this test include anterior and posterior ankle impingement test.

Anterior Ankle Impingement Test

Anterior Ankle Impingement Test or Hyperdorsi flexion Test is done with the patient sits on the edge of the examination table with the legs hanging down loosely and the knee bent 90°. With one hand, the examiner grasps around and stabilizes the patient’s heel, and with the other hand grasps the mid and forefoot on the plantar side from below and then brings the foot into maximal dorsiflexion.

The test should be repeated using slightly internally and externally rotated positions of the foot.

Strong hyperdorsi flexion can provoke pain in the area around the anterior ankle joint. Local pain felt on palpation of the anterior joint line is most commonly located medial to the tendon of the tibialis anterior muscle or lateral to the tendons of the tibialis anterior and extensor digitorum longus muscles.

See Also: Ankle Anatomy

Posterior Ankle Impingement Test

Posterior Ankle Impingement Test or Hyperplantar Flexion Test is done with the patient sits on the edge of the examination table with the legs hanging down loosely and the knees flexed 90°. With one hand the examiner holds the patient’s heel and stabilizes it and with the other grasps the mid and forefoot over the dorsum of the foot. The examiner then forces the foot into maximum plantar flexion and repeats this action several times.

The test should be repeated using slightly externally and internally rotated positions.

The posterior Ankle Impingement Test is considered positive if the patient complains of pain at maximal plantar flexion, especially in the posterolateral region of the hindfoot. The cause of the pain is an impingement, which occurs when soft tissue or a bony protuberance become impacted between the tibia and the posterior margin of the calcaneus. The test should be repeated in various degrees of foot rotation.

A positive test combined with pain felt on posterolateral palpation should be followed by a diagnostic anesthetic injection. The infiltration of the joint capsule is carried out under sterile conditions on the posterolateral aspect of the foot between the posterior process of the talus and the posterior edge of the tibia. After the injection, the test is repeated; if the result is now negative (no pain on forced plantar flexion), the diagnosis is confirmed.

Ankle Impingement sign

With the patient in seated position, the examiner grasps calcaneus with one hand and uses the other hand to grasp forefoot and bring it into plantarflexion. The examiner uses his thumb to place pressure over the anterolateral region of the ankle. Foot is then brought from plantarflexion to dorsiflexion while thumb pressure is maintained.

Positive sign if pain provoked with pressure from examiner’s thumb is greater in dorsiflexion than plantarflexion.

A study on 73 patients with ankle pain, the sensitivity and specificity of ankle Impingement sign was (The reference standard was Arthroscopic visualization):

• Sensitivity: 95%
• Specificity: 88%

History and clinical examination

The examiner records aggravating factors and reports loss of motion.

Examination includes:

1. observation of swelling,
2. passive forced ankle dorsiflexion and eversion,
3. active range of motion and double-leg and single-leg squats.

Examination is positive if five or more findings are positive:

1. Anterolateral ankle joint tenderness.
2. Anterolateral ankle joint swelling.
3. Pain with forced dorsiflexion and eversion.
4. Pain with single-leg squat.
5. Pain with activities.
6. Ankle instability.

A study on 22 patients undergoing arthroscopic surgery for complaints of chronic ankle pain, the the sensitivity and specificity of the physical examination for Ankle Impingement Syndrome was:

• Sensitivity: 94%
• Specificity: 75%

Ankle Impingement Syndrome

Painful entrapment of joint structures in the ankle is known as an ankle impingement syndrome. In addition to identifying the involved joint structures, the pathologic cause of the impingement must be differentiated, whether osseous, soft tissue, or neutral.

In addition, an anterior (usually anterolateral) impingement is differentiated from a posterior impingement. The anterior and lateral areas of the ankle are more often affected than the posterior area. It can occur as a result of acute trauma as well as after chronic overuse with repeated microtrauma especially in soccer players (soccer player’s ankle) and in dancers.

The posterior ankle impingement syndrome due to overuse is most commonly seen in ballet dancers and runners. Jogging, especially downhill, is associated with continually repetitive plantar flexion movements, which can impose repetitive stresses to the posterior aspect of the ankle joint. In dancers, certain dance sequences, such as the “en pointe” or the “demi-pointe” position, are achieved by forceful plantar flexion, which results in soft-tissue and bony changes in the hindfoot; thus posterolateral foot pain in dancers is referred to as “dancer’s heel.”

The following anatomical and pathologic structures can lead to posterior impingement:

1. Displaced os trigonum.
2. Hypertrophic posterior talar process.
3. Loose bodies located in the posterior part of the ankle joint.
4. Osteophytes at the posterior margin of the tibia.
5. Posttraumatic scar tissue or calci cations.
   

References

1. Lavery KP, McHale KJ, Rossy WH, Theodore G. Ankle impingement. J Orthop Surg Res. 2016 Sep 9;11(1):97. doi: 10.1186/s13018-016-0430-x. PMID: 27608626; PMCID: PMC5016963.
2. Clinical Tests for the Musculoskeletal System 3rd Edition.