578515
research-articleXXXX
FASXXX10.1177/1938640015578515Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 9 / no. 1
Foot & Ankle Specialist
〈 Case Report 〉 Ankle Impingement Caused by an Intra-articular Plica A Report of 2 Cases Abstract: Entrapment of soft tissues in the anterolateral gutter of the ankle can cause impingement. When symptomatic, patients complain of chronic ankle pain exacerbated with dorsiflexion. Symptoms of instability and a history of recurring ankle sprains are common findings. Plain radiographs and magnetic resonance imaging may assist clinicians in identifying associated pathology. We present 2 cases of ankle impingement occurring in the setting of equivocal examination and imaging findings. In both cases, arthroscopy revealed a likely congenital, intra-articular plica. Levels of Evidence: Therapeutic, Level IV: Case Study Keywords: unstable ankle; heel; rearfoot; ankle; ankle injuries
Introduction Ankle impingement (AI) is a debilitating condition that develops following recurring episodes of minor trauma, such as lateral ankle sprains, and activities requiring repetitive ankle dorsiflexion, such as dance and soccer.1,2 The repeated trauma is theorized to cause an accumulation of scar and
Andrew J. Rosenbaum, MD, Rock G. Positano, DPM, MSc, MPH, Rock C. J. Positano, BA, and Joshua S. Dines, MD
hypertrophic synovial tissue, with pain exacerbated by stairs and the marathon training she was involved in at impingement developing as these tissues become entrapped in the anterolateral the time of presentation. The patient gutter of the ankle.3-5 denied any specific inciting event but A combination of physical examination stated that as a former collegiate runner and imaging is used to identify the and current marathoner, she had specific cause of AI. Individuals with AI sustained numerous ankle sprains, all of often complain of chronic ankle pain, which were self-remedied with activity activity-related swelling, and have a modification and nonsteroidal history of recurrent ankle sprains. Physical The repeated trauma is theorized to examination frequently reveals tenderness with cause an accumulation of scar and palpation of the ankle joint and pain with forced hypertrophic synovial tissue, with dorsiflexion.6 Although radiographs and magnetic impingement developing as these resonance imaging (MRI) typically aide the clinician tissues become entrapped in the in diagnosis, they are at times nondiagnostic.7-10 anterolateral gutter of the ankle.” In the present report, we describe 2 cases of symptomatic AI associated with anti-inflammatory drugs (NSAIDs). She equivocal imaging findings. In both described her current pain as sharp, instances, arthroscopy revealed a likely localized to the anterolateral ankle, and congenital, intra-articular plica. refractory to rest and NSAIDs. On examination, she had normal hindfoot alignment and full range of Case 1 motion. There was no swelling, A 34-year-old woman complained of a erythema, or instability. However, 1-year history of intermittent left ankle anterolateral joint line tenderness was
“
DOI: 10.1177/1938640015578515. From the Albany Medical College, Division of Orthopaedic Surgery, Albany, New York (AJR); Joe DiMaggio Sports Medicine Foot and Ankle Center, Hospital for Special Surgery, New York (RGP); NY College of Podiatric Medicine, New York (RCJP); and Hospital for Special Surgery, New York (JSD). Address correspondence to: Joshua S. Dines, MD, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
79
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Feb 2016
Foot & Ankle Specialist
present with palpation, in addition to pain with forced dorsiflexion. Plain radiographs, obtained at her initial visit, were normal. After failing an additional 4-week trial of activity limitations and NSAIDs and an additional 4 weeks of physical therapy, MRI was obtained. The study revealed synovitis in the anterolateral aspect of the joint and no evidence of ligamentous damage or osteochondral lesions. Based on these findings, an intraarticular injection of 3 mL of 1% lidocaine and 1 mL of corticosteroid (40 mg/mL methylprednisolone) was administered. The patient initially reported significant symptomatic relief and was able to gradually return to running. However, 6 weeks following the injection, her symptoms had recurred. Ankle arthroscopy was performed thereafter because the patient failed a 3-month trial of conservative interventions. Arthroscopy identified a soft-tissue band resembling an intraarticular plica, beginning within an osteocartilaginous gutter between the anterior fibula, just distal to the fibular insertion of the anterior inferior tibiofibular ligament (AITFL), and anterolateral talar dome (Figure 1). Synovitis was also present in this region. The plica traversed the anterior ankle joint, ultimately becoming contiguous with the soft tissues of the medial gutter, just anterior to the distal portion of the medial malleolus. A small 10 × 5 mm2 foci of chondromalacia was noted on the talus directly adjacent to the fossa at which the plica originated (Figure 2). A shaver was used to completely excise the plica and debride the hypertrophic synovium. The osteochondral fossa where the plica originated was not debrided because it was a small foci and covered with a thin layer of cartilage. The postoperative protocol included early mobilization with protected weight bearing in a boot. At the patient’s 2-week postoperative visit, she was found to have significant symptom relief. At the 6-week visit, the swelling had resolved, and the patient remained symptom free. At 12 weeks, the patient was allowed to return to full activity, which she was able
Figure 1.
Figure 3.
Arthroscopy of the Left Ankle Demonstrating an Intra-articular Plica (P) Traversing the Ankle Joint and Inserting Into the Soft Tissues of the Medial Gutter.
Arthroscopy of the Right Ankle Demonstrating an Intra-articular Plica (P) Inserting Into the Soft Tissues of the Medial Gutter (MG).
Abbreviations: TP, tibial plafond; MM, medial malleolus.
to do sans any symptoms of impingement. After 2 years of surgery, there has been no recurrence of pain or instability symptoms.
examination was unremarkable, with the exception of anterolateral ankle pain with forced dorsiflexion. Plain radiographs were normal. MRI of the right ankle revealed synovitis in the anterolateral gutter and a small osteochondral lesion in the lateral talar dome (10 × 3 mm2). Over the ensuing 4 months, conservative interventions, which included an intra-articular lidocaine/ corticosteroid injection, failed to provide significant relief; the injection provided only 2 weeks of moderate relief. Arthroscopy was performed at that time. In addition to the synovitis and osteochondral lesion seen on MRI, a plica was identified and debrided that extended from the region of synovitis in the anterolateral gutter, across the joint, and into the medial gutter (Figure 3). At the 12-week follow-up, the patient’s pain was no longer present, and she had an uneventful return to all activities. At the 1-year follow-up, the patient remained symptom free.
Case 2
Discussion
A healthy 67-year-old woman presented with chronic right ankle pain localized to the anterolateral aspect of the joint exacerbated by stairs and rising from a seated position. There was no inciting event, and she denied any history of trauma to the ankle. Physical
The hypertrophic soft tissues responsible for AI have traditionally been described as the result of repetitive trauma and/or recurring ankle sprains.1,2 Although this is frequently the case, these findings may also be observed in patients with other causes of
Figure 2. Arthroscopy of the Left Ankle Demonstrating the Plica (P) at Its Origin in the Anterolateral Gutter (ALG). The Foci of Chondromalacia Is Also Evident (*).
vol. 9 / no. 1
impingement. AITFL pathology is one such example and is either a result of ligamentous incompetence after trauma or the presence of an accessory AITFL (Bassett’s ligament).11,12 As elucidated in this case series, congenital plica can also be the source of soft-tissue impingement, even in patients with a history of ankle sprains and injuries. Our first case is a common presentation of AI because the patient had experienced recurring ankle sprains and developed impingement symptoms while training for a marathon. Despite this, her history of prior injuries was merely an incidental finding because a congenital plica was ultimately determined to be the culprit and also the cause of her symptoms. In the second case, a unique presentation of AI is described, because the 67-year-old woman denied any inciting event or history of ankle injuries, experiencing a delayed onset of symptoms. Although an atypical presentation in the ankle, this is a common manifestation of symptomatic plica in other joints, such as the knee. The delayed onset of plica-related symptoms in any joint is a result of the decrease in tissue elasticity with age, which leads to progressive scarring and fibrosis of the plica. Such structural changes make plica more likely to impinge on surrounding structures.13 Regardless of the underlying pathology, AI is a debilitating condition, with up to 91% of those afflicted experiencing moderate to severe activity limitations.6 In the early stages, AI presents with activity-related pain that is relieved with rest. These symptoms gradually become more significant and persistent and include instability, stiffness, and pain with squatting, sprinting, and stair climbing.14 A thorough physical examination must be performed in patients with presumed AI. Palpation of the ankle will typically elicit pain with forced dorsiflexion, and inspection of the ankle may reveal swelling, erythema, and/or malalignment.6 A ligamentous assessment is also important because ankle instability may contribute to AI.15 The
Foot & Ankle Specialist
anterior talofibular, calcaneofibular, posterior talofibular, syndesmotic, and deltoid ligaments must be evaluated. A Silfverskiöld test should also be used to identify an isolated gastrocnemius contracture and is considered positive when ankle dorsiflexion is greater with knee in flexion than in extension. Imaging studies can be of great utility in the evaluation of suspected soft-tissue impingement of the ankle. Although plain radiographs fail to delineate soft-tissue sources of impingement, anteroposterior and lateral radiographs of the ankle should be the first imaging obtained and can identify sources of osseous impingement, among other pathology that may be contributing to a patient’s symptoms.14 The role of advanced imaging, such as MRI, in the evaluation of AI is controversial, but evolving.7-10 Huh et al16 found MRI to have a 92% sensitivity and 64% specificity for detecting synovitis and a 77% sensitivity and 97% specificity for detecting soft-tissue impingement in the ankle. These findings support our patients’ MRI findings because synovitis, but not plica, was delineated in both cases. Of note, the accuracy of MRI in diagnosing soft-tissue impingement is thought to improve in the presence of a substantial joint effusion.7-10 Although we did not employee MR arthrography in the assessment of our patients, it has been proven to be an effective tool for the identification of sources of soft-tissue impingement in the anterolateral recess of the ankle.8,9 Ultrasound has also been used successfully for this diagnosis.17 Management of AI includes both nonsurgical and surgical interventions. Nonsurgical modalities should be tried first and include activity restriction, physical therapy (lateral ankle stability protocols), NSAIDs, steroid injections, and use of heel-lift orthoses to prevent dorsiflexion. Surgery involves debridement of all osseous and softtissue structures that can cause impingement. Both open and arthroscopic techniques have been described. In our practice, arthroscopic debridement is offered to patients who
have failed a minimum of 3 months of conservative interventions. Using standard anterolateral and medial portals, an arthroscopic examination is performed and potential sources of AI debrided. When exostoses and soft tissue cannot be adequately debrided arthroscopically, either portal can be extended to create an open arthrotomy, facilitating complete debridement. Adjunctive procedures may also be performed at the time of arthroscopy (eg, lateral ligament reconstruction, gastrocnemius lengthening). Arthroscopic osteophyte resection and soft-tissue debridement is an effective treatment, with 12 of 13 patients in one retrospective study experiencing complete resolution of AI symptoms at a mean of 15 months after arthroscopic intervention.18 In another work by Ogilvie-Harris et al,19 15 of 17 patients were able to return to sporting activities with a substantial improvement in pain following this procedure. In this case series, we describe AI likely caused by a congenital, intra-articular plica. We believe that the plica was congenital because it was not associated with injury or instability. In both cases, the plica originated within an osteocartilaginous fossa between the fibula and anterolateral talar dome, traversed the anterior joint, and ultimately became contiguous with the soft tissues of the medial gutter, just distal to the medial malleolus. This soft-tissue structure is different from the accessory AITFL described by Bassett et al,11 because the plica described by us followed a different trajectory in the ankle. The plicas described in this case series are also a distinct entity from the “meniscoid” lesion of the ankle described by Wolin et al,20 which consisted of a mass of hyalinized tissue that developed following an inversion sprain of the ankle and remained entrapped between the fibula and talus; congenital plica are not limited to the anterolateral gutter and can present in the absence of an ankle injury. Although Somorjai et al21 also present a case of AI attributed to a congenital plica, their findings were different from
81
82
Feb 2016
Foot & Ankle Specialist
ours because the patient in that report sustained repetitive ankle trauma and had focal, MRI findings. Additionally, the plica described by Somorjai et al had different anatomical features because it originated from an osteochondral fossa in the anteromedial tibial plafond, extending to the medial malleolus. We described 2 cases of AI caused by a likely congenital, intra-articular plica. It is crucial that orthopedic surgeons consider this etiology in their differential for AI, particularly in the setting of nondiagnostic imaging and when all other causes have been excluded.
References 1. O’Kane JW, Kadel N. Anterior impingement syndrome in dancers. Curr Rev Musculoskelet Med. 2008;1:12-16. 2. Massada JL. Ankle overuse injuries in soccer players: morphological adaptation of the talus in the anterior impingement. J Sports Med Phys Fitness. 1991;31: 447-451. 3. Robinson P. Impingement syndromes of the ankle. Eur Radiol. 2007;17:3056-3065. 4. Ferkel RD, Karzel RP, Del Pizzo W, et al. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med. 1991;19:440-446.
5. Cutsuries AM. Arthroscopic arthroplasty of the ankle joint. Clin Podiatr Med Surg. 1994;11:449-467.
13. Griffith CJ, LaPrade RF. Medial plica irritation: diagnosis and treatment. Curr Rev Musculoskeletal Med. 2008;1:53-60.
6. Branca A, Di Palma L, Bucca C, Visconti CS, Di Mille M. Arthroscopic treatment of anterior ankle impingement. Foot Ankle Int. 1997;18:418-423.
14. Hawkins RB. Arthroscopic treatment of sports-related anterior osteophytes in the ankle. Foot Ankle. 1988;9:87-90.
7. Umans H. Ankle impingement syndromes. Semin Musculoskeletal Radiol. 2002;6: 133-139.
15. Cannon LB, Hackney RG. Anterior tibiotalar impingement associated with chronic ankle instability. J Foot Ankle Surg. 2000;39: 383-386.
8. Robinson P, White LM. Soft-tissue and osseous impingement syndromes of the ankle: role of imaging in diagnosis and management. Radiographics. 2002;22: 1457-1469.
16. Huh YM, Suh JS, Lee JW. Synovitis and soft-tissue impingement of the ankle: assessment with enhanced threedimensional FSPGR MR imaging. J Magn Reson Imaging. 2004;19:108-116.
9. Robinson P, White LM, Salonen DC, Daniels TR, Ogilvie-Harris D. Anterolateral ankle impingement: MR arthrographic assessment of the anterolateral recess. Radiology. 2001;221:186-190.
17. Vaseenon T, Amendola A. Update on anterior ankle impingement. Curr Rev Musculoskeletal Med. 2012;5:145-150.
10. Rudin DA, Tishkoff NW, Britton CA, Conti SF, Towers JD. Anterolateral soft-tissue impingement in the ankle: diagnosis using MR imaging. AJR Am J Roentgenol. 1997;169:829-835. 11. Bassett FH III, Gates HS III, Billys JB, et al. Talar impingement by the anteroinferior tibiofibular ligament: a cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am. 1990;72:55-59. 12. Subhas N, Vinson EN, Cothran RL, et al. MRI appearance of surgically proven abnormal accessory anterior-inferior tibiofibular ligament (Bassett’s ligament). Skeletal Radiol. 2008;37:27-33.
18. Bauer T, Breda R, Hardy P. Anterior ankle bony impingement with joint motion loss: the arthroscopic resection option. Orthop Traumatol Surg Res. 2010;96:462-468. 19. Ogilvie-Harris DJ, Mahomed N, Demazière A. Anterior impingement of the ankle treated by arthroscopic removal of bony spurs. J Bone Joint Surg Br. 1993;75: 437-440. 20. Wolin I, Glassman F, Sideman S, Levinthal DH. Internal derangement of the talofibular component of the ankle. Surg Gynecol Obstet. 1950;91:193-200. 21. Somorjai N, Jong B, Draijer WF. Intraarticular plica causing ankle impingement in a young handball player: a case report. J Foot Ankle Surg. 2013;52:750-753.
research-articleXXXX
FASXXX10.1177/1938640015578515Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 9 / no. 1
Foot & Ankle Specialist
〈 Case Report 〉 Ankle Impingement Caused by an Intra-articular Plica A Report of 2 Cases Abstract: Entrapment of soft tissues in the anterolateral gutter of the ankle can cause impingement. When symptomatic, patients complain of chronic ankle pain exacerbated with dorsiflexion. Symptoms of instability and a history of recurring ankle sprains are common findings. Plain radiographs and magnetic resonance imaging may assist clinicians in identifying associated pathology. We present 2 cases of ankle impingement occurring in the setting of equivocal examination and imaging findings. In both cases, arthroscopy revealed a likely congenital, intra-articular plica. Levels of Evidence: Therapeutic, Level IV: Case Study Keywords: unstable ankle; heel; rearfoot; ankle; ankle injuries
Introduction Ankle impingement (AI) is a debilitating condition that develops following recurring episodes of minor trauma, such as lateral ankle sprains, and activities requiring repetitive ankle dorsiflexion, such as dance and soccer.1,2 The repeated trauma is theorized to cause an accumulation of scar and
Andrew J. Rosenbaum, MD, Rock G. Positano, DPM, MSc, MPH, Rock C. J. Positano, BA, and Joshua S. Dines, MD
hypertrophic synovial tissue, with pain exacerbated by stairs and the marathon training she was involved in at impingement developing as these tissues become entrapped in the anterolateral the time of presentation. The patient gutter of the ankle.3-5 denied any specific inciting event but A combination of physical examination stated that as a former collegiate runner and imaging is used to identify the and current marathoner, she had specific cause of AI. Individuals with AI sustained numerous ankle sprains, all of often complain of chronic ankle pain, which were self-remedied with activity activity-related swelling, and have a modification and nonsteroidal history of recurrent ankle sprains. Physical The repeated trauma is theorized to examination frequently reveals tenderness with cause an accumulation of scar and palpation of the ankle joint and pain with forced hypertrophic synovial tissue, with dorsiflexion.6 Although radiographs and magnetic impingement developing as these resonance imaging (MRI) typically aide the clinician tissues become entrapped in the in diagnosis, they are at times nondiagnostic.7-10 anterolateral gutter of the ankle.” In the present report, we describe 2 cases of symptomatic AI associated with anti-inflammatory drugs (NSAIDs). She equivocal imaging findings. In both described her current pain as sharp, instances, arthroscopy revealed a likely localized to the anterolateral ankle, and congenital, intra-articular plica. refractory to rest and NSAIDs. On examination, she had normal hindfoot alignment and full range of Case 1 motion. There was no swelling, A 34-year-old woman complained of a erythema, or instability. However, 1-year history of intermittent left ankle anterolateral joint line tenderness was
“
DOI: 10.1177/1938640015578515. From the Albany Medical College, Division of Orthopaedic Surgery, Albany, New York (AJR); Joe DiMaggio Sports Medicine Foot and Ankle Center, Hospital for Special Surgery, New York (RGP); NY College of Podiatric Medicine, New York (RCJP); and Hospital for Special Surgery, New York (JSD). Address correspondence to: Joshua S. Dines, MD, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
79
80
Feb 2016
Foot & Ankle Specialist
present with palpation, in addition to pain with forced dorsiflexion. Plain radiographs, obtained at her initial visit, were normal. After failing an additional 4-week trial of activity limitations and NSAIDs and an additional 4 weeks of physical therapy, MRI was obtained. The study revealed synovitis in the anterolateral aspect of the joint and no evidence of ligamentous damage or osteochondral lesions. Based on these findings, an intraarticular injection of 3 mL of 1% lidocaine and 1 mL of corticosteroid (40 mg/mL methylprednisolone) was administered. The patient initially reported significant symptomatic relief and was able to gradually return to running. However, 6 weeks following the injection, her symptoms had recurred. Ankle arthroscopy was performed thereafter because the patient failed a 3-month trial of conservative interventions. Arthroscopy identified a soft-tissue band resembling an intraarticular plica, beginning within an osteocartilaginous gutter between the anterior fibula, just distal to the fibular insertion of the anterior inferior tibiofibular ligament (AITFL), and anterolateral talar dome (Figure 1). Synovitis was also present in this region. The plica traversed the anterior ankle joint, ultimately becoming contiguous with the soft tissues of the medial gutter, just anterior to the distal portion of the medial malleolus. A small 10 × 5 mm2 foci of chondromalacia was noted on the talus directly adjacent to the fossa at which the plica originated (Figure 2). A shaver was used to completely excise the plica and debride the hypertrophic synovium. The osteochondral fossa where the plica originated was not debrided because it was a small foci and covered with a thin layer of cartilage. The postoperative protocol included early mobilization with protected weight bearing in a boot. At the patient’s 2-week postoperative visit, she was found to have significant symptom relief. At the 6-week visit, the swelling had resolved, and the patient remained symptom free. At 12 weeks, the patient was allowed to return to full activity, which she was able
Figure 1.
Figure 3.
Arthroscopy of the Left Ankle Demonstrating an Intra-articular Plica (P) Traversing the Ankle Joint and Inserting Into the Soft Tissues of the Medial Gutter.
Arthroscopy of the Right Ankle Demonstrating an Intra-articular Plica (P) Inserting Into the Soft Tissues of the Medial Gutter (MG).
Abbreviations: TP, tibial plafond; MM, medial malleolus.
to do sans any symptoms of impingement. After 2 years of surgery, there has been no recurrence of pain or instability symptoms.
examination was unremarkable, with the exception of anterolateral ankle pain with forced dorsiflexion. Plain radiographs were normal. MRI of the right ankle revealed synovitis in the anterolateral gutter and a small osteochondral lesion in the lateral talar dome (10 × 3 mm2). Over the ensuing 4 months, conservative interventions, which included an intra-articular lidocaine/ corticosteroid injection, failed to provide significant relief; the injection provided only 2 weeks of moderate relief. Arthroscopy was performed at that time. In addition to the synovitis and osteochondral lesion seen on MRI, a plica was identified and debrided that extended from the region of synovitis in the anterolateral gutter, across the joint, and into the medial gutter (Figure 3). At the 12-week follow-up, the patient’s pain was no longer present, and she had an uneventful return to all activities. At the 1-year follow-up, the patient remained symptom free.
Case 2
Discussion
A healthy 67-year-old woman presented with chronic right ankle pain localized to the anterolateral aspect of the joint exacerbated by stairs and rising from a seated position. There was no inciting event, and she denied any history of trauma to the ankle. Physical
The hypertrophic soft tissues responsible for AI have traditionally been described as the result of repetitive trauma and/or recurring ankle sprains.1,2 Although this is frequently the case, these findings may also be observed in patients with other causes of
Figure 2. Arthroscopy of the Left Ankle Demonstrating the Plica (P) at Its Origin in the Anterolateral Gutter (ALG). The Foci of Chondromalacia Is Also Evident (*).
vol. 9 / no. 1
impingement. AITFL pathology is one such example and is either a result of ligamentous incompetence after trauma or the presence of an accessory AITFL (Bassett’s ligament).11,12 As elucidated in this case series, congenital plica can also be the source of soft-tissue impingement, even in patients with a history of ankle sprains and injuries. Our first case is a common presentation of AI because the patient had experienced recurring ankle sprains and developed impingement symptoms while training for a marathon. Despite this, her history of prior injuries was merely an incidental finding because a congenital plica was ultimately determined to be the culprit and also the cause of her symptoms. In the second case, a unique presentation of AI is described, because the 67-year-old woman denied any inciting event or history of ankle injuries, experiencing a delayed onset of symptoms. Although an atypical presentation in the ankle, this is a common manifestation of symptomatic plica in other joints, such as the knee. The delayed onset of plica-related symptoms in any joint is a result of the decrease in tissue elasticity with age, which leads to progressive scarring and fibrosis of the plica. Such structural changes make plica more likely to impinge on surrounding structures.13 Regardless of the underlying pathology, AI is a debilitating condition, with up to 91% of those afflicted experiencing moderate to severe activity limitations.6 In the early stages, AI presents with activity-related pain that is relieved with rest. These symptoms gradually become more significant and persistent and include instability, stiffness, and pain with squatting, sprinting, and stair climbing.14 A thorough physical examination must be performed in patients with presumed AI. Palpation of the ankle will typically elicit pain with forced dorsiflexion, and inspection of the ankle may reveal swelling, erythema, and/or malalignment.6 A ligamentous assessment is also important because ankle instability may contribute to AI.15 The
Foot & Ankle Specialist
anterior talofibular, calcaneofibular, posterior talofibular, syndesmotic, and deltoid ligaments must be evaluated. A Silfverskiöld test should also be used to identify an isolated gastrocnemius contracture and is considered positive when ankle dorsiflexion is greater with knee in flexion than in extension. Imaging studies can be of great utility in the evaluation of suspected soft-tissue impingement of the ankle. Although plain radiographs fail to delineate soft-tissue sources of impingement, anteroposterior and lateral radiographs of the ankle should be the first imaging obtained and can identify sources of osseous impingement, among other pathology that may be contributing to a patient’s symptoms.14 The role of advanced imaging, such as MRI, in the evaluation of AI is controversial, but evolving.7-10 Huh et al16 found MRI to have a 92% sensitivity and 64% specificity for detecting synovitis and a 77% sensitivity and 97% specificity for detecting soft-tissue impingement in the ankle. These findings support our patients’ MRI findings because synovitis, but not plica, was delineated in both cases. Of note, the accuracy of MRI in diagnosing soft-tissue impingement is thought to improve in the presence of a substantial joint effusion.7-10 Although we did not employee MR arthrography in the assessment of our patients, it has been proven to be an effective tool for the identification of sources of soft-tissue impingement in the anterolateral recess of the ankle.8,9 Ultrasound has also been used successfully for this diagnosis.17 Management of AI includes both nonsurgical and surgical interventions. Nonsurgical modalities should be tried first and include activity restriction, physical therapy (lateral ankle stability protocols), NSAIDs, steroid injections, and use of heel-lift orthoses to prevent dorsiflexion. Surgery involves debridement of all osseous and softtissue structures that can cause impingement. Both open and arthroscopic techniques have been described. In our practice, arthroscopic debridement is offered to patients who
have failed a minimum of 3 months of conservative interventions. Using standard anterolateral and medial portals, an arthroscopic examination is performed and potential sources of AI debrided. When exostoses and soft tissue cannot be adequately debrided arthroscopically, either portal can be extended to create an open arthrotomy, facilitating complete debridement. Adjunctive procedures may also be performed at the time of arthroscopy (eg, lateral ligament reconstruction, gastrocnemius lengthening). Arthroscopic osteophyte resection and soft-tissue debridement is an effective treatment, with 12 of 13 patients in one retrospective study experiencing complete resolution of AI symptoms at a mean of 15 months after arthroscopic intervention.18 In another work by Ogilvie-Harris et al,19 15 of 17 patients were able to return to sporting activities with a substantial improvement in pain following this procedure. In this case series, we describe AI likely caused by a congenital, intra-articular plica. We believe that the plica was congenital because it was not associated with injury or instability. In both cases, the plica originated within an osteocartilaginous fossa between the fibula and anterolateral talar dome, traversed the anterior joint, and ultimately became contiguous with the soft tissues of the medial gutter, just distal to the medial malleolus. This soft-tissue structure is different from the accessory AITFL described by Bassett et al,11 because the plica described by us followed a different trajectory in the ankle. The plicas described in this case series are also a distinct entity from the “meniscoid” lesion of the ankle described by Wolin et al,20 which consisted of a mass of hyalinized tissue that developed following an inversion sprain of the ankle and remained entrapped between the fibula and talus; congenital plica are not limited to the anterolateral gutter and can present in the absence of an ankle injury. Although Somorjai et al21 also present a case of AI attributed to a congenital plica, their findings were different from
81
82
Feb 2016
Foot & Ankle Specialist
ours because the patient in that report sustained repetitive ankle trauma and had focal, MRI findings. Additionally, the plica described by Somorjai et al had different anatomical features because it originated from an osteochondral fossa in the anteromedial tibial plafond, extending to the medial malleolus. We described 2 cases of AI caused by a likely congenital, intra-articular plica. It is crucial that orthopedic surgeons consider this etiology in their differential for AI, particularly in the setting of nondiagnostic imaging and when all other causes have been excluded.
References 1. O’Kane JW, Kadel N. Anterior impingement syndrome in dancers. Curr Rev Musculoskelet Med. 2008;1:12-16. 2. Massada JL. Ankle overuse injuries in soccer players: morphological adaptation of the talus in the anterior impingement. J Sports Med Phys Fitness. 1991;31: 447-451. 3. Robinson P. Impingement syndromes of the ankle. Eur Radiol. 2007;17:3056-3065. 4. Ferkel RD, Karzel RP, Del Pizzo W, et al. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med. 1991;19:440-446.
5. Cutsuries AM. Arthroscopic arthroplasty of the ankle joint. Clin Podiatr Med Surg. 1994;11:449-467.
13. Griffith CJ, LaPrade RF. Medial plica irritation: diagnosis and treatment. Curr Rev Musculoskeletal Med. 2008;1:53-60.
6. Branca A, Di Palma L, Bucca C, Visconti CS, Di Mille M. Arthroscopic treatment of anterior ankle impingement. Foot Ankle Int. 1997;18:418-423.
14. Hawkins RB. Arthroscopic treatment of sports-related anterior osteophytes in the ankle. Foot Ankle. 1988;9:87-90.
7. Umans H. Ankle impingement syndromes. Semin Musculoskeletal Radiol. 2002;6: 133-139.
15. Cannon LB, Hackney RG. Anterior tibiotalar impingement associated with chronic ankle instability. J Foot Ankle Surg. 2000;39: 383-386.
8. Robinson P, White LM. Soft-tissue and osseous impingement syndromes of the ankle: role of imaging in diagnosis and management. Radiographics. 2002;22: 1457-1469.
16. Huh YM, Suh JS, Lee JW. Synovitis and soft-tissue impingement of the ankle: assessment with enhanced threedimensional FSPGR MR imaging. J Magn Reson Imaging. 2004;19:108-116.
9. Robinson P, White LM, Salonen DC, Daniels TR, Ogilvie-Harris D. Anterolateral ankle impingement: MR arthrographic assessment of the anterolateral recess. Radiology. 2001;221:186-190.
17. Vaseenon T, Amendola A. Update on anterior ankle impingement. Curr Rev Musculoskeletal Med. 2012;5:145-150.
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