Injury, 1 1 , 4 3 - 4 4
Printed in Great Britain
43
Talotibial impingement exostoses causing osteochondromatosis of the ankle K. P. Boardman Orthopaedic Senior Registrar. North Manchester General Hospital Summary A case of osteochondromatosis of the ankle is described in a football player.
CASE REPORT A 24-year-old amateur football player came to the orthopaedic clinic complaining of discomfort in his right ankle, which had troubled him intermittently for several years. His pain was vaguely localized around the anterior aspect of the joint, developed after prolonged exercise and was associated with a feeling of impaired 'drive" whilst sprinting. There were no severe episodes of pain and he denied any swelling or locking of the ankle. He was otherwise well. On examination there was slight discomfort from pressure over the anterior joint line of the ankle, but no swelling or instability. There was 30 ° of plantar flexion at the ankle, but no active or passive dorsiflexion beyond the neutral position. Forced dorsiflexion was painful and reproduced his symptoms. The foot was otherwise normal. Biochemical and haematological investigations showed no abnormality. Radiographs of the ankle revealed exostoses along the anterior margin of the lower end of the tibia and on the top of the neck of the talus. There were also numerous intracapsular loose bodies (Fig. I). The opposite ankle was clinically and radiologically normal. The ankle was explored through an incision medial and parallel to the tendon of tibialis anterior. The tibialis anterior tendon sheath and the ankle capsule were normal. Numerous loose bodies were located and removed from the anterior, medial and lateral recesses of the ankle (Fig. 2). An osteocbondral excrescence filled the anterior inferior margin of the tibia between the reflection of the capsule and the joint surface of the ankle. There was also a large exostosis on the dorsum of the neck of the talus so that on dorsiflexing the ankle the talar and tibial exostoses came together and blocked further movement (Fig. 3). There were no degenerative changes in
Fig. 1. Talotibial impingement exostoses and loose bodies in the ankle.
• =~,
~1~
1Jo
i~0
. . . . . i I 140 150 160
170
180
Fig. 2. Loose bodies removed from ankle.
19(3
~00
44
Injury: the British Journal of Accident Surgery Vol. 11/No. 1
',
:
|
Fig. 3. Talotibial impingement exostoses preventing ankle dorsiflexion beyond neutral.
the cartilage. The exostoses were excised after which dorsiflexion returned to normal. The wound was closed and wool and a crepe bandage were applied with the foot plantigrade. Normal activity was encouraged after t he sutures were removed ten days later. Active sport was resumed two months after operation and the patient remains symptom free.
DISCUSSION The anterior margin of the tibia slopes backwards for half an inch above the ankle to accommodate the head of the talus during dorsiflexion. Repeated, forced dorsiflexion, as occurs during sprinting, may lead to exostoses at the points of contact between the tibia and talus. In a radiological survey of 120 ankles in athletes, O'Donoghue (1957) demonstrated talotibial exostoses in 54 (45 per cent), of which only 6 caused symptoms. When established changes are present continuing activity may lead to loose bodies if exostoses break free.
McMurray (1950) first described the surgical management of'footballer's ankle'. O'Donoghue (1957) introduced the term impingement exostosis and he and subsequently Nicholas (1974) described the pathophysiology and biomechanics of their formation around the ankle. Symptoms are often vague and may be expressed in dynamic terms such as 'impaired drive'. Examination commonly elicits pain in the anterior talotibial sulcus on palpation and on forced dorsiflexion of the ankle. Plain radiographs may reveal bony exostoses around the ankle although arthrographs are sometimes required to demonstrate fibrocartilaginous bars which may be the cause of an impingement syndrome. O'Donoghue (1957) described 7 patients who were treated surgically by removing the projections and a further 4 examples of cases treated without operation. The prognosis is good and sport can be resumed after treatment. Degenerative changes are rarely present in the cartilage of the ankle and arthritis does not appear to be a common complication.
Acknowledgements I thank M r A. Glass, Consultant Orthopaedic Surgeon, for permission to report this case, and the Department of Medical Illustrations, North Manchester General Hospital for providing the figures. REFERENCES McMurray T. P. (1950) Footballer's ankle. J. Bone Joint Surg. 32, 68. Nicholas J. A. (1974) Ankle injuries in athletes. Orthop. Clin. North Am. 5, 153. O'Donoghue D. H. (1957) Impingement exostoses of the talus and tibia. J. Bone Joint Surg. 39A, 835.
Requests for reprints should be addressed to: Mr K. P. Boardman.FRCS, OrthopaedicSeniorRegistrar,North ManchesterGeneral Hospital, Manchester, M8 6RB.
Printed in Great Britain
43
Talotibial impingement exostoses causing osteochondromatosis of the ankle K. P. Boardman Orthopaedic Senior Registrar. North Manchester General Hospital Summary A case of osteochondromatosis of the ankle is described in a football player.
CASE REPORT A 24-year-old amateur football player came to the orthopaedic clinic complaining of discomfort in his right ankle, which had troubled him intermittently for several years. His pain was vaguely localized around the anterior aspect of the joint, developed after prolonged exercise and was associated with a feeling of impaired 'drive" whilst sprinting. There were no severe episodes of pain and he denied any swelling or locking of the ankle. He was otherwise well. On examination there was slight discomfort from pressure over the anterior joint line of the ankle, but no swelling or instability. There was 30 ° of plantar flexion at the ankle, but no active or passive dorsiflexion beyond the neutral position. Forced dorsiflexion was painful and reproduced his symptoms. The foot was otherwise normal. Biochemical and haematological investigations showed no abnormality. Radiographs of the ankle revealed exostoses along the anterior margin of the lower end of the tibia and on the top of the neck of the talus. There were also numerous intracapsular loose bodies (Fig. I). The opposite ankle was clinically and radiologically normal. The ankle was explored through an incision medial and parallel to the tendon of tibialis anterior. The tibialis anterior tendon sheath and the ankle capsule were normal. Numerous loose bodies were located and removed from the anterior, medial and lateral recesses of the ankle (Fig. 2). An osteocbondral excrescence filled the anterior inferior margin of the tibia between the reflection of the capsule and the joint surface of the ankle. There was also a large exostosis on the dorsum of the neck of the talus so that on dorsiflexing the ankle the talar and tibial exostoses came together and blocked further movement (Fig. 3). There were no degenerative changes in
Fig. 1. Talotibial impingement exostoses and loose bodies in the ankle.
• =~,
~1~
1Jo
i~0
. . . . . i I 140 150 160
170
180
Fig. 2. Loose bodies removed from ankle.
19(3
~00
44
Injury: the British Journal of Accident Surgery Vol. 11/No. 1
',
:
|
Fig. 3. Talotibial impingement exostoses preventing ankle dorsiflexion beyond neutral.
the cartilage. The exostoses were excised after which dorsiflexion returned to normal. The wound was closed and wool and a crepe bandage were applied with the foot plantigrade. Normal activity was encouraged after t he sutures were removed ten days later. Active sport was resumed two months after operation and the patient remains symptom free.
DISCUSSION The anterior margin of the tibia slopes backwards for half an inch above the ankle to accommodate the head of the talus during dorsiflexion. Repeated, forced dorsiflexion, as occurs during sprinting, may lead to exostoses at the points of contact between the tibia and talus. In a radiological survey of 120 ankles in athletes, O'Donoghue (1957) demonstrated talotibial exostoses in 54 (45 per cent), of which only 6 caused symptoms. When established changes are present continuing activity may lead to loose bodies if exostoses break free.
McMurray (1950) first described the surgical management of'footballer's ankle'. O'Donoghue (1957) introduced the term impingement exostosis and he and subsequently Nicholas (1974) described the pathophysiology and biomechanics of their formation around the ankle. Symptoms are often vague and may be expressed in dynamic terms such as 'impaired drive'. Examination commonly elicits pain in the anterior talotibial sulcus on palpation and on forced dorsiflexion of the ankle. Plain radiographs may reveal bony exostoses around the ankle although arthrographs are sometimes required to demonstrate fibrocartilaginous bars which may be the cause of an impingement syndrome. O'Donoghue (1957) described 7 patients who were treated surgically by removing the projections and a further 4 examples of cases treated without operation. The prognosis is good and sport can be resumed after treatment. Degenerative changes are rarely present in the cartilage of the ankle and arthritis does not appear to be a common complication.
Acknowledgements I thank M r A. Glass, Consultant Orthopaedic Surgeon, for permission to report this case, and the Department of Medical Illustrations, North Manchester General Hospital for providing the figures. REFERENCES McMurray T. P. (1950) Footballer's ankle. J. Bone Joint Surg. 32, 68. Nicholas J. A. (1974) Ankle injuries in athletes. Orthop. Clin. North Am. 5, 153. O'Donoghue D. H. (1957) Impingement exostoses of the talus and tibia. J. Bone Joint Surg. 39A, 835.
Requests for reprints should be addressed to: Mr K. P. Boardman.FRCS, OrthopaedicSeniorRegistrar,North ManchesterGeneral Hospital, Manchester, M8 6RB.
