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FAS-749; No. of Pages 10 Foot and Ankle Surgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Review
The management of posterior ankle impingement syndrome in sport: A review William J. Ribbans PhD, FRCS(Tr and Orth), FFSEM(UK)a,*, Hannah A. Ribbans BSc(Hons), MBBSb, James A. Cruickshank BSc(Hons), MRCSb, Edward V. Wood FRCS(Tr and Orth)b a b
University of Northampton, Boughton Green Road, Northampton, NN2 7AL, United Kingdom Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 31 May 2014 Received in revised form 29 June 2014 Accepted 11 August 2014
A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Fortyseven papers have reported on the surgical outcomes of 905 procedures involving both open and arthoendoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers. ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Posterior ankle impingement syndrome Os trigonum Flexor hallucis longus tendon Stieda’s process Hindfoot endoscopy
Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History of PAIS publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology of PAIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology and natural history of PAIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How effective are conservative treatment options for PAIS?. . . . . . . . . . . . . . . . . . . . . . . Open surgery – which incision? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Endoscopic surgery – which portals? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is the overall outcome following arthro-endoscopic surgery better than open surgery?. Which sports are most commonly implicated in PAIS? . . . . . . . . . . . . . . . . . . . . . . . . . . . Do certain sports suffer from specific PAIS pathologies? . . . . . . . . . . . . . . . . . . . . . . . . . . Do certain sports recover more quickly than others from PAIS surgery? . . . . . . . . . . . . . Do professional/elite sports people recover better that amateur sports people? . . . . . . . Do soft-tissue causes of PAIS recover more quickly that osseous causes? . . . . . . . . . . . . Do overuse causes of PAIS do better than post-traumatic? . . . . . . . . . . . . . . . . . . . . . . . . Lateral ankle ligament instability in association with PAIS . . . . . . . . . . . . . . . . . . . . . . . . PAIS surgery in adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: School of Health The University of Northampton, c/o 57 Billing Road, Northampton, England, NN1 5DB, United Kingdom. Tel.: +44 1604 795414. E-mail addresses: [email protected], [email protected] (W.J. Ribbans). http://dx.doi.org/10.1016/j.fas.2014.08.006 1268-7731/ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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1. Introduction Posterior ankle impingement syndrome (PAIS) describes a collection of pathologies characterised by posterior ankle joint pain usually aggravated by plantarflexion and under repetitive load frequently leading to restriction of movement. Many different causes of PAIS have been described and the range of pathologies are depicted in Fig. 1. PAIS should be distinguished from other causes of hindfoot pain arising from the Achilles tendon and its insertion, Peroneal sheath contents, Tibialis Posterior tendon, primary ankle and subtalar joint pathology and damage to the Tibial and Sural nerves. Although PAIS is a relatively unusual cause of pain in the nonsporting population, it can be a cause of significant disability in certain sports and dance disciplines. The purpose of this paper is to review the evidence regarding both the natural history and efficacy and complications arising from different management strategies for PAIS. For a fuller description of the clinical features and investigation of PAIS, the reader is referred to excellent articles on the subject by the following authors [1–4]. 2. Materials and methods The primary medical search engines used for the study were MEDLINE/OVID and EMBASE databases. Keywords: and phrases such as ‘‘Posterior ankle impingement’’; ‘‘Posterior ankle pain’’; ‘‘Posterior ankle endoscopy’’; ‘‘Flexor hallucis longus’’; ‘‘Os trigonum’’; ‘‘Posterior talar tubercle’’; ‘‘treatment’’; ‘‘conservative’’ and ‘‘surgical’’ were used in mixed combinations to ensure the greatest possible variation. This was supplemented by manual searches of the bibliography of key papers. Combination; truncation and explode functions were used
where appropriate to enhance the search depth. Titles and abstracts were screened manually and were excluded if they were not studies relevant to the treatment – either conservative or surgical – of PAIS. Forty-seven papers were identified as suitable for further analysis containing 905 surgical cases. Two papers were identified detailing the outcomes of injection therapy containing 19 cases for analysis [5,6]. The quality of evidence within these papers was variable and, in particular, suffered from a lack of standardised outcomes. Certain conditions were included within papers that would not normally be considered as a cause of PAIS, e.g. peroneal tendons and tibiotalar and subtalar intra-articular pathology [7–9]. Additionally, some patients may have been included in more than one publication as certain surgeons’ clinical caseload expanded, e.g. Van Dijk [7,10] Hamilton [11–13], Ahn [14,15] and Jerosch [16,17]. Decisions as to the inclusion of cases were made by the senior authors (WJR and EVW) after careful review of the papers to minimise duplication risk. Patient details, sporting involvement, pathology, treatment details, outcomes, complications, and return to sport were recorded. The reported evidence does not rise above Level IV (case series and case reports) and Level V (expert opinion) [18]. Of the 47 papers reviewed only 7 gained information prospectively [7,10,15,16,19,20]. All of these papers described endoscopic/arthroscopic procedures. 3. History of PAIS publications The first paper on the surgical management of PAIS in our observed series was published in 1979 by Sammarco [21] although Hamilton highlighted the problem of Flexor Hallucis Longus (FHL)
Classificaon of causes of posterior impingement (PAIS)
Ankle and ST Joints
o o o o o o
Sloping posterior bial plafond Loose bodies PVNS Osteophytes Pseudomeniscus syndrome Post-traumac thickened capsule and synovis o Ligaments, especially o PITibF o PIntermalleolar o PTaloF o P Tibiotalar component of deltoid
So-ssue
Osseous Posterolateral talar tubercle o Large tubercle - Stieda’s o Os trigonum o Shepherd’s Fχ Posteromedial talar tubercle o Large tubercle o Fχ o Ossiication of FHL tunnel o Accessory ossicles Other Accessory Ossicles o Os post peronei o Os subperoneal/ibular Tibial o Malunion, avulsions & periosteal thickening post-posterior malleolar Fχ o Syndesmotic injury – including avulsion Fχ
FHL o o o o o o o o o o
Tendinopathy/Synovitis Stenosing Tenosynovitis Distal muscle insertion Hypertrophied muscle Nodules Tears Scars/Adhesions Ganglions/Cysts FHL ossicle Anomalous FHL
Accessory muscles o Peroneocalcaneus internus o Tibiocalcaneus o Long accessory of quadratus plantae o Peroneus Quartus Miscellaneous o Cysts/Ganglions
PITIBF = Posterior Inferior Tibiofibular ligament; Pintermalleolar = Posterior Intermalleolar ligament; PTaloF = Posterior Talofibular ligament; P Tibiotalar = Posterior biotalar component of deltoid ligament; Fig. 1. Classification of causes of posterior impingement (PAIS). PITIBF = posterior inferior tibiofibular ligament; Pintermalleolar = posterior intermalleolar ligament; PTaloF = posterior talofibular ligament; P Tibiotalar = posterior tibiotalar component of deltoid ligament;
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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Tendon problems in a 1976 presentation [22]. Fig. 2 outlines the subsequent history of PAIS scientific publications. From 905 surgical procedures for PAIS, 521 patients underwent endoscopic/arthroscopic procedures compared to 384 patients undergoing open procedures. The peak of reporting outcomes of open surgery was in the 1990s and early 2000s. Only 3 endoscopic/ arthroscopic papers were published before 2000 [23–25]. Since 2000, endoscopic and arthroscopic papers have dominated the literature suggesting that these techniques have significant benefits in terms of reduced complications and better outcomes, including more rapid return to sport (RTS) or dance. However, when analysing open and endoscopic procedures, one is not only comparing different techniques but different decades of clinical practice. Additionally, outcome reporting methods, patient-led expectations regarding rapidity of recovery, and post-operative rehabilitation techniques have changed since 1979 [21]. Where analysis was possible 51.5% of patients were male and 8.3% of patients underwent either staged or simultaneous bilateral surgery. 4. Pathology of PAIS Many conditions attributed to causing PAIS were identified. Diagnostic exclusions are outlined in the Materials and Methods section. During 905 procedures 1105 pathologies were recorded. Two broad, common groups of pathology were identified: Osseous (81% of surgeries) and soft-tissue (42%). The common causes of bony impingement and FHL pathology are shown in Figs. 3 and 4. The breadth and frequency of the pathologies described in the 47 papers are shown in Table 1. It is recognised that rarer conditions, such as anomalous muscles, are more likely to be reported and therefore their occurrence may be overestimated. Similarly, certain descriptions of pathology are vague, e.g. softtissue or osseous, defying further analysis. Other publications stress the need to debride an inflamed FHL when removing an os trigonum but provide no figures for how often this was required.
3
Fig. 3. Common causes of bony impingement. (a) Os-trigonum, (b) Shepherd’s fracture, (c) Enlarged Steida’s process.
prevalence of PAIS within Caribbean first class cricket but only identified 6 sportsmen of whom 4 required surgery. Albisetti [27] followed 186 trainee ballet dancers and identified a 6.5% prevalence of PAIS during a one-year period of observation. Hedrick [28] reported that 12 ankles out of 20 (60%) for a variety of sports responded to a variety of conservative treatments including ice, rest, anti-inflammatory medication, steroid injections and cast immobilisation. However, there are no longer-term prospective studies following dance companies and sporting organisations that have reported upon the frequency of PAIS and response to conservative treatment. Papers describing surgery for PAIS contain by their nature a group of patients who have failed conservative treatment and, hence, it is difficult to draw conclusions about how many athletes develop PAIS and how they respond to non-surgical measures. 6. How effective are conservative treatment options for PAIS? Conservative treatment options for the management of PAIS include:
5. Epidemiology and natural history of PAIS There is a paucity of work upon the prevalence and natural history of the various conditions contributing to PAIS and the outcomes of conservative treatment. Injury Audit Data from the English Cricket Board covering 18 1st Class County teams for the year 2001–2002 (unpublished data made available to one of the authors, WJR) revealed that PAIS was the most common cause for players deemed unfit to train or play secondary to foot and ankle problems. The condition represented 31% of all days lost for injury to this region – more than lateral ankle ligament injuries and Achilles disorders combined. It principally affects the front foot of fast bowlers with many requiring reparative surgery. However, our review of the literature, revealed only 1 paper from Mansingh [26] who described the
Rest. Cessation of activity. Technique modification. Physical therapy. Orthotics/footwear modification. NSAIDs. Injections.
The prevalence of PAIS in the community, both sporting and non-sporting, is unknown. Many patients do not present to
300 ≤1990
250 200
1991-2000
150
2001-2010
100
2011-2013
50
0 Open
Arthroscopic/Endoscopic
Fig. 2. Potted history of articles on PAIS. 47 Articles – case reports and series (1979– 2013)
Fig. 4. Flexor hallucis longus (FHL) pathology. Tendinopathy, stenosis tenosynovitis, nodules, distal muscle insertion, ossicle.
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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Table 1 Pathology of PAIS. 905 procedures. 1105 pathologies listed. Gross structure
Description
Numbers (% of patients)
Osseous
729 216 428 35 22
Unspecified Os trigonum Steida’s process Un-united fracture (Shepherd’s) Loose bodies or avulsion fragments Accessory ossicle Soft-tissue FHL
Anomalous muscles
27 (3%) 1 (0%) 376 (42%) 315 (35%) Unspecified Tenosynovitis (including stenosis) Partial tears Nodules Adhesions FHL ossicle Tendinosis Hypertrophied muscle Distal muscle insertion Flexor hallucis accessorius Ganglion/cysts of FHL Peroneocalcaneus Internus (4); long accessory of quadratus plantae (1); Peroneus quartus (1)
17 233 14 6 11 4 8 2 9 5 6 6
7. Open surgery – which incision? The open approach to the posterior ankle region can be undertaken via a posteromedial or posterolateral approach.
(2%) (26%) (2%) (1%) (1%) (0%) (1%) (0%) (1%) (1%) (1%) (1%)
7 (1%)
Posteromedial Impingement Other soft-tissue impingement or unspecified
Orthopaedic Surgeons preferring to self-manage by activity modification, or are successfully treated by family and sports physicians, physical therapists or podiatrists. In 1997, Marumoto and Ferkel [24] concluded that ‘‘Conservative treatment has been empirically recommended; however, its efficacy has not been well documented in the literature.’’ Our review of the literature suggests that little new information has been published in the subsequent seventeen years to allow any evidence-based recommendations to be made over the choice of non-surgical modalities. Steroid and local anaesthetic injections are often employed to reduce inflammation and pain. They can be undertaken in the clinic setting or more commonly under imaging guidance, either ultrasound or fluoroscopy [5,6,30]. Injections can be used for both diagnostic [24,28–33] and therapeutic purposes [2,3,13,19,26,34– 37]. Hamilton [12] would not inject FHL problems because of the vicinity of the Tibial nerve but 41% of dancers with osseous impingement had been subjected to steroid injections prior to surgery. In Calder’s series of soccer players, all 28 patients had at least 1 injection (average 2; range 1–5) before surgery. However, there was no correlation between the pre-operative number of injections and subsequent return to sport post-operatively [33]. Both Wredmark [38] and Ahn [15] stated that they did not use steroid injections but gave no explanation. Marotta [24] would not use steroid injections because of the risk of tendon rupture. Only 2 papers were identified which addressed the outcomes of injections–both using ultrasound guidance [5,6]. These small series suggest that injections can be curative for soft-tissue pathologies and may be used to temporarily ameliorate symptoms during busy sporting schedules.
(81%) (24%) (47%) (4%) (2%)
48 (5%)
Review of 384 open procedures in 26 papers revealed that 65.6% were undertaken through the posteromedial approach, 27.3% via the posterolateral approach, and in 7.1% of cases the exact approach was not recorded [2,3,11,12,21,26–31,35,36,38–50]. Four papers contained cases involving both approaches [11,12,31,40]. The open surgical papers were reviewed for complications. One paper was excluded from analysis as the presence or absence of complications was not stated [48] leaving 357 operations for analysis. The results are shown in Table 2. The overall complication rate was 7–3.9% for the medial approach and 14.7% for the lateral approach (Chi squared, p < 0.001). The overall nerve injury incidence was 4.2% with a lower incidence for the medial approach
Table 2 Complications of open surgery for PAIS. Conclusions: Overall reported complication rate: 7.0–4.0% for medial and 14.7% for lateral Overall neurological complication rate: 4% * Sural nerve injury rate in lateral approach: 11% * Majority of neurological problems resolve Infection and wound problem rate overall: 2.8% Medial
Complications Neurological
Wound Problems e.g. Haematoma, delayed healing Infection FHL iatrogenic injury Procedures
Overall Sural Tibial Dysthesia CRPS Other
2 (1.6%) 0 1 1 0 0 3
5 0 252
Lateral
Unknown Overall
13 (12.9%) 0 (0%) 11 (10.8%) 0 1 0 0 0 1 0 0 0 0 0
2 0 102
0 0 3
15 (4.2%) 11 2 1 1 0 3
7 0 357
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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(1.6%) compared to the lateral approach (12.9%). A sural nerve injury rate of 10.8% was reported using a lateral approach. However most neurological problems appear to resolve. The overall infection and wound problem rate was 2.8%. However, this is likely to be an underestimate as some papers acknowledged that wound complications and infections occurred, but did not give a numerical breakdown.
8. Endoscopic surgery – which portals? A number of different portal combinations have been described for PAIS surgery and 25 papers detailing 521 procedures were analysed for outcomes and complications [2,7–10,15– 17,19,20,23–27,32–34,37,50–55]. Endoscopy requires a minimum of two portals – one for the camera and the other for instrumentation. Other portals can be utilised for irrigation and additional instrumentation. Most techniques use two soft-tissue portals while a combination of arthroscopic (via the subtalar or ankle joint) and endoscopic portals have been described. Some confusion with regards to terminology arises with soft-tissue portals occasionally described as arthroscopic instead of endoscopic [19,32,52,55]. Portals include: Anterolateral (subtalar) and posterolateral [15,24]. Ankle arthroscopy [23]. Stacked posterolateral [25]. Posterolateral and accessory posterolateral [19,52]. Double posteromedial [20]. Posteromedial and posterolateral [2,7–10,15–17,32– 34,37,50,51,54]. Posterolateral and trans-Achilles [55].
Liu described resecting a posteromedial soft-tissue impingement using ankle arthroscopic portals in 1993 [23] and Marumoto and Ferkel in 1997 first described a combination of an anterolateral approach, through the subtalar joint, and an endoscopic posterolateral approach [24]. These can be augmented with accessory portals. Out of 521 procedures reviewed 77.2% of cases employed the posteromedial and posterolateral portal combination popularised by van Dijk in 2006 [7]. The plethora of papers using van Dijk’s technique [2,8–10,15–17,32–34,50,51,54] would suggest that this has become the approach of choice but there has only been 1 paper comparing different endoscopic approaches. Ahn et al. [15]
5
compared arthroscopic subtalar approach combined with a posterolateral portal compared with two endoscopic portals (posteromedial and posteolateral) in a small series of os-trigonum excisions. They concluded that both arthroscopic and posterior endoscopic excisions of an os trigonum was safe and effective. Arthroscopic procedures were felt to be more demanding, especially in cases of a large os trigonum, and the posterior endoscopic approach had the advantage of addressing problems in the posterior ankle joint and allowed a more extensive release of the FHL. The endoscopic and arthroscopic papers were reviewed for complications: the results are shown in Table 3. The overall complication rate was 4.8% with a nerve injury incidence of 3.7%. There was no significant difference in the complication rates observed when comparing all open procedures with arthroendoscopic procedures (p = 0.24). A 5.0% overall complication rate was reported using the most popular combination of posteromedial and posterolateral portals. There were only 2 reports of postoperative infection and 3 reports of other wound healing problems. The most serious concern of endoscopic surgery – that of tibial nerve injury – was not reported in any of the reviewed papers. Zengerink [56] reported a 2.3% overall complication rate for hindfoot endoscopy on van Dijk’s series of patients. Nickisch [9] reported complications in 8.5% but this large series combined posterior ankle, subtalar and hindfoot procedures. 9. Is the overall outcome following arthro-endoscopic surgery better than open surgery? One of the problems in comparing surgical results is a lack of standardised outcomes, especially for open surgery. The AOFAS Ankle-Hindfoot scoring system was first published in 1994 and is a commonly used rating system in the assessment of surgical outcomes [57]. For the open series, only 2 of the 26 papers contained a post-operative AOFAS score [39,50] and only one a VAS (Visual Analogue Pain scale) [50]. Most papers have their own non-validated rating system such as poor-fair-good-excellent. The results of open surgery are summarised in Table 4. The various papers report in excess of 66% good or excellent outcomes with a number reporting 100% pain relief and return to sport. It should be noted that the overwhelming physical activity undertaken in the open group is dance and more specifically ballet (see section 10). A more precise indicator for athletes is a return to sport (RTS). In the open surgery group, accurate RTS could
Table 3 Complications of arthroscopic/endoscopic surgery for PAIS. Conclusions: Overall reported complication rate 4.8% Overall neurological complication rate: 3.7% * Neurological complication rate for PM/PL portals: 4.0% * NO reports of tibial nerve injury Complications Neurological
Wound Problems e.g. Haematoma, delayed healing Infection FHL iatrogenic injury Procedures
AL/PL (Arthro) Overall Sural Tibial Dysthesia CRPS
2 2 0 0 0 0
0 0 27
PM/PL 16 (4.0%) 4 0 9 2 2
2 0 402
PM x 2
PL + Trans-Achilles
Unknown
0 0 0 0 0 0
PL x 2 1 1 0 0 0 0
Stacked PL x 2 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 0 32
0 0 23
0 1 10
0 0 1
0 0 2
Overall 19 (3.7%) 7 0 9 2 3
2 1 521
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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6 Table 4 Outcomes of PAIS open surgery. Author
Year
Nos
Pre-op score AOFAS (VAS)
Post-op score AOFAS (VAS)
Return to sport (weeks) Average
Liu Marumoto Lomba‘6 rdi Fadel Yilmaz Jerosch
1993 1997 1999 2006 2006 2006
1 11 10 2 1 10
** 45 ** ** ** 43
** 86 ** ** ** 87
8
Van Dijk
2006
76
**
90
9
Albisetti
2008
1
**
**
9
Scholten
2008
55
75
90
8
Willits
2008
15
**
91
25
Horibe Richards Phisitkul Noguchi Allegra
2008 2010 2010 2010 2010
11 1 2 12 32
71 ** ** 68 56
99 ** ** 93 87
Guo
2010
25
**
Calder
2010
27
Ogut Mansingh Galla Nikisch Smyth Ahn
2011 2011 2011 2012 2013 2013
Park Roche Liu Marumoto Lombardi Fadel Yilmaz Jerosch Van Dijk
Range
4 8 ALL < 8
2–52
4–102 ALL < 13
6 6
3–13
93 (0.80)
6
4–10
**
**
6
4–10
25 1 30 86 22 28
57 ** 7.2
86 ** 3.1
8
6–12
59 FAOS 64 (6.5–6.7)
86 FAOS 90 (1.2)
13 8
6–32
FAS-749; No. of Pages 10 Foot and Ankle Surgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Review
The management of posterior ankle impingement syndrome in sport: A review William J. Ribbans PhD, FRCS(Tr and Orth), FFSEM(UK)a,*, Hannah A. Ribbans BSc(Hons), MBBSb, James A. Cruickshank BSc(Hons), MRCSb, Edward V. Wood FRCS(Tr and Orth)b a b
University of Northampton, Boughton Green Road, Northampton, NN2 7AL, United Kingdom Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 31 May 2014 Received in revised form 29 June 2014 Accepted 11 August 2014
A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Fortyseven papers have reported on the surgical outcomes of 905 procedures involving both open and arthoendoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers. ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Posterior ankle impingement syndrome Os trigonum Flexor hallucis longus tendon Stieda’s process Hindfoot endoscopy
Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History of PAIS publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology of PAIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology and natural history of PAIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How effective are conservative treatment options for PAIS?. . . . . . . . . . . . . . . . . . . . . . . Open surgery – which incision? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Endoscopic surgery – which portals? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is the overall outcome following arthro-endoscopic surgery better than open surgery?. Which sports are most commonly implicated in PAIS? . . . . . . . . . . . . . . . . . . . . . . . . . . . Do certain sports suffer from specific PAIS pathologies? . . . . . . . . . . . . . . . . . . . . . . . . . . Do certain sports recover more quickly than others from PAIS surgery? . . . . . . . . . . . . . Do professional/elite sports people recover better that amateur sports people? . . . . . . . Do soft-tissue causes of PAIS recover more quickly that osseous causes? . . . . . . . . . . . . Do overuse causes of PAIS do better than post-traumatic? . . . . . . . . . . . . . . . . . . . . . . . . Lateral ankle ligament instability in association with PAIS . . . . . . . . . . . . . . . . . . . . . . . . PAIS surgery in adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: School of Health The University of Northampton, c/o 57 Billing Road, Northampton, England, NN1 5DB, United Kingdom. Tel.: +44 1604 795414. E-mail addresses: [email protected], [email protected] (W.J. Ribbans). http://dx.doi.org/10.1016/j.fas.2014.08.006 1268-7731/ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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1. Introduction Posterior ankle impingement syndrome (PAIS) describes a collection of pathologies characterised by posterior ankle joint pain usually aggravated by plantarflexion and under repetitive load frequently leading to restriction of movement. Many different causes of PAIS have been described and the range of pathologies are depicted in Fig. 1. PAIS should be distinguished from other causes of hindfoot pain arising from the Achilles tendon and its insertion, Peroneal sheath contents, Tibialis Posterior tendon, primary ankle and subtalar joint pathology and damage to the Tibial and Sural nerves. Although PAIS is a relatively unusual cause of pain in the nonsporting population, it can be a cause of significant disability in certain sports and dance disciplines. The purpose of this paper is to review the evidence regarding both the natural history and efficacy and complications arising from different management strategies for PAIS. For a fuller description of the clinical features and investigation of PAIS, the reader is referred to excellent articles on the subject by the following authors [1–4]. 2. Materials and methods The primary medical search engines used for the study were MEDLINE/OVID and EMBASE databases. Keywords: and phrases such as ‘‘Posterior ankle impingement’’; ‘‘Posterior ankle pain’’; ‘‘Posterior ankle endoscopy’’; ‘‘Flexor hallucis longus’’; ‘‘Os trigonum’’; ‘‘Posterior talar tubercle’’; ‘‘treatment’’; ‘‘conservative’’ and ‘‘surgical’’ were used in mixed combinations to ensure the greatest possible variation. This was supplemented by manual searches of the bibliography of key papers. Combination; truncation and explode functions were used
where appropriate to enhance the search depth. Titles and abstracts were screened manually and were excluded if they were not studies relevant to the treatment – either conservative or surgical – of PAIS. Forty-seven papers were identified as suitable for further analysis containing 905 surgical cases. Two papers were identified detailing the outcomes of injection therapy containing 19 cases for analysis [5,6]. The quality of evidence within these papers was variable and, in particular, suffered from a lack of standardised outcomes. Certain conditions were included within papers that would not normally be considered as a cause of PAIS, e.g. peroneal tendons and tibiotalar and subtalar intra-articular pathology [7–9]. Additionally, some patients may have been included in more than one publication as certain surgeons’ clinical caseload expanded, e.g. Van Dijk [7,10] Hamilton [11–13], Ahn [14,15] and Jerosch [16,17]. Decisions as to the inclusion of cases were made by the senior authors (WJR and EVW) after careful review of the papers to minimise duplication risk. Patient details, sporting involvement, pathology, treatment details, outcomes, complications, and return to sport were recorded. The reported evidence does not rise above Level IV (case series and case reports) and Level V (expert opinion) [18]. Of the 47 papers reviewed only 7 gained information prospectively [7,10,15,16,19,20]. All of these papers described endoscopic/arthroscopic procedures. 3. History of PAIS publications The first paper on the surgical management of PAIS in our observed series was published in 1979 by Sammarco [21] although Hamilton highlighted the problem of Flexor Hallucis Longus (FHL)
Classificaon of causes of posterior impingement (PAIS)
Ankle and ST Joints
o o o o o o
Sloping posterior bial plafond Loose bodies PVNS Osteophytes Pseudomeniscus syndrome Post-traumac thickened capsule and synovis o Ligaments, especially o PITibF o PIntermalleolar o PTaloF o P Tibiotalar component of deltoid
So-ssue
Osseous Posterolateral talar tubercle o Large tubercle - Stieda’s o Os trigonum o Shepherd’s Fχ Posteromedial talar tubercle o Large tubercle o Fχ o Ossiication of FHL tunnel o Accessory ossicles Other Accessory Ossicles o Os post peronei o Os subperoneal/ibular Tibial o Malunion, avulsions & periosteal thickening post-posterior malleolar Fχ o Syndesmotic injury – including avulsion Fχ
FHL o o o o o o o o o o
Tendinopathy/Synovitis Stenosing Tenosynovitis Distal muscle insertion Hypertrophied muscle Nodules Tears Scars/Adhesions Ganglions/Cysts FHL ossicle Anomalous FHL
Accessory muscles o Peroneocalcaneus internus o Tibiocalcaneus o Long accessory of quadratus plantae o Peroneus Quartus Miscellaneous o Cysts/Ganglions
PITIBF = Posterior Inferior Tibiofibular ligament; Pintermalleolar = Posterior Intermalleolar ligament; PTaloF = Posterior Talofibular ligament; P Tibiotalar = Posterior biotalar component of deltoid ligament; Fig. 1. Classification of causes of posterior impingement (PAIS). PITIBF = posterior inferior tibiofibular ligament; Pintermalleolar = posterior intermalleolar ligament; PTaloF = posterior talofibular ligament; P Tibiotalar = posterior tibiotalar component of deltoid ligament;
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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Tendon problems in a 1976 presentation [22]. Fig. 2 outlines the subsequent history of PAIS scientific publications. From 905 surgical procedures for PAIS, 521 patients underwent endoscopic/arthroscopic procedures compared to 384 patients undergoing open procedures. The peak of reporting outcomes of open surgery was in the 1990s and early 2000s. Only 3 endoscopic/ arthroscopic papers were published before 2000 [23–25]. Since 2000, endoscopic and arthroscopic papers have dominated the literature suggesting that these techniques have significant benefits in terms of reduced complications and better outcomes, including more rapid return to sport (RTS) or dance. However, when analysing open and endoscopic procedures, one is not only comparing different techniques but different decades of clinical practice. Additionally, outcome reporting methods, patient-led expectations regarding rapidity of recovery, and post-operative rehabilitation techniques have changed since 1979 [21]. Where analysis was possible 51.5% of patients were male and 8.3% of patients underwent either staged or simultaneous bilateral surgery. 4. Pathology of PAIS Many conditions attributed to causing PAIS were identified. Diagnostic exclusions are outlined in the Materials and Methods section. During 905 procedures 1105 pathologies were recorded. Two broad, common groups of pathology were identified: Osseous (81% of surgeries) and soft-tissue (42%). The common causes of bony impingement and FHL pathology are shown in Figs. 3 and 4. The breadth and frequency of the pathologies described in the 47 papers are shown in Table 1. It is recognised that rarer conditions, such as anomalous muscles, are more likely to be reported and therefore their occurrence may be overestimated. Similarly, certain descriptions of pathology are vague, e.g. softtissue or osseous, defying further analysis. Other publications stress the need to debride an inflamed FHL when removing an os trigonum but provide no figures for how often this was required.
3
Fig. 3. Common causes of bony impingement. (a) Os-trigonum, (b) Shepherd’s fracture, (c) Enlarged Steida’s process.
prevalence of PAIS within Caribbean first class cricket but only identified 6 sportsmen of whom 4 required surgery. Albisetti [27] followed 186 trainee ballet dancers and identified a 6.5% prevalence of PAIS during a one-year period of observation. Hedrick [28] reported that 12 ankles out of 20 (60%) for a variety of sports responded to a variety of conservative treatments including ice, rest, anti-inflammatory medication, steroid injections and cast immobilisation. However, there are no longer-term prospective studies following dance companies and sporting organisations that have reported upon the frequency of PAIS and response to conservative treatment. Papers describing surgery for PAIS contain by their nature a group of patients who have failed conservative treatment and, hence, it is difficult to draw conclusions about how many athletes develop PAIS and how they respond to non-surgical measures. 6. How effective are conservative treatment options for PAIS? Conservative treatment options for the management of PAIS include:
5. Epidemiology and natural history of PAIS There is a paucity of work upon the prevalence and natural history of the various conditions contributing to PAIS and the outcomes of conservative treatment. Injury Audit Data from the English Cricket Board covering 18 1st Class County teams for the year 2001–2002 (unpublished data made available to one of the authors, WJR) revealed that PAIS was the most common cause for players deemed unfit to train or play secondary to foot and ankle problems. The condition represented 31% of all days lost for injury to this region – more than lateral ankle ligament injuries and Achilles disorders combined. It principally affects the front foot of fast bowlers with many requiring reparative surgery. However, our review of the literature, revealed only 1 paper from Mansingh [26] who described the
Rest. Cessation of activity. Technique modification. Physical therapy. Orthotics/footwear modification. NSAIDs. Injections.
The prevalence of PAIS in the community, both sporting and non-sporting, is unknown. Many patients do not present to
300 ≤1990
250 200
1991-2000
150
2001-2010
100
2011-2013
50
0 Open
Arthroscopic/Endoscopic
Fig. 2. Potted history of articles on PAIS. 47 Articles – case reports and series (1979– 2013)
Fig. 4. Flexor hallucis longus (FHL) pathology. Tendinopathy, stenosis tenosynovitis, nodules, distal muscle insertion, ossicle.
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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Table 1 Pathology of PAIS. 905 procedures. 1105 pathologies listed. Gross structure
Description
Numbers (% of patients)
Osseous
729 216 428 35 22
Unspecified Os trigonum Steida’s process Un-united fracture (Shepherd’s) Loose bodies or avulsion fragments Accessory ossicle Soft-tissue FHL
Anomalous muscles
27 (3%) 1 (0%) 376 (42%) 315 (35%) Unspecified Tenosynovitis (including stenosis) Partial tears Nodules Adhesions FHL ossicle Tendinosis Hypertrophied muscle Distal muscle insertion Flexor hallucis accessorius Ganglion/cysts of FHL Peroneocalcaneus Internus (4); long accessory of quadratus plantae (1); Peroneus quartus (1)
17 233 14 6 11 4 8 2 9 5 6 6
7. Open surgery – which incision? The open approach to the posterior ankle region can be undertaken via a posteromedial or posterolateral approach.
(2%) (26%) (2%) (1%) (1%) (0%) (1%) (0%) (1%) (1%) (1%) (1%)
7 (1%)
Posteromedial Impingement Other soft-tissue impingement or unspecified
Orthopaedic Surgeons preferring to self-manage by activity modification, or are successfully treated by family and sports physicians, physical therapists or podiatrists. In 1997, Marumoto and Ferkel [24] concluded that ‘‘Conservative treatment has been empirically recommended; however, its efficacy has not been well documented in the literature.’’ Our review of the literature suggests that little new information has been published in the subsequent seventeen years to allow any evidence-based recommendations to be made over the choice of non-surgical modalities. Steroid and local anaesthetic injections are often employed to reduce inflammation and pain. They can be undertaken in the clinic setting or more commonly under imaging guidance, either ultrasound or fluoroscopy [5,6,30]. Injections can be used for both diagnostic [24,28–33] and therapeutic purposes [2,3,13,19,26,34– 37]. Hamilton [12] would not inject FHL problems because of the vicinity of the Tibial nerve but 41% of dancers with osseous impingement had been subjected to steroid injections prior to surgery. In Calder’s series of soccer players, all 28 patients had at least 1 injection (average 2; range 1–5) before surgery. However, there was no correlation between the pre-operative number of injections and subsequent return to sport post-operatively [33]. Both Wredmark [38] and Ahn [15] stated that they did not use steroid injections but gave no explanation. Marotta [24] would not use steroid injections because of the risk of tendon rupture. Only 2 papers were identified which addressed the outcomes of injections–both using ultrasound guidance [5,6]. These small series suggest that injections can be curative for soft-tissue pathologies and may be used to temporarily ameliorate symptoms during busy sporting schedules.
(81%) (24%) (47%) (4%) (2%)
48 (5%)
Review of 384 open procedures in 26 papers revealed that 65.6% were undertaken through the posteromedial approach, 27.3% via the posterolateral approach, and in 7.1% of cases the exact approach was not recorded [2,3,11,12,21,26–31,35,36,38–50]. Four papers contained cases involving both approaches [11,12,31,40]. The open surgical papers were reviewed for complications. One paper was excluded from analysis as the presence or absence of complications was not stated [48] leaving 357 operations for analysis. The results are shown in Table 2. The overall complication rate was 7–3.9% for the medial approach and 14.7% for the lateral approach (Chi squared, p < 0.001). The overall nerve injury incidence was 4.2% with a lower incidence for the medial approach
Table 2 Complications of open surgery for PAIS. Conclusions: Overall reported complication rate: 7.0–4.0% for medial and 14.7% for lateral Overall neurological complication rate: 4% * Sural nerve injury rate in lateral approach: 11% * Majority of neurological problems resolve Infection and wound problem rate overall: 2.8% Medial
Complications Neurological
Wound Problems e.g. Haematoma, delayed healing Infection FHL iatrogenic injury Procedures
Overall Sural Tibial Dysthesia CRPS Other
2 (1.6%) 0 1 1 0 0 3
5 0 252
Lateral
Unknown Overall
13 (12.9%) 0 (0%) 11 (10.8%) 0 1 0 0 0 1 0 0 0 0 0
2 0 102
0 0 3
15 (4.2%) 11 2 1 1 0 3
7 0 357
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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(1.6%) compared to the lateral approach (12.9%). A sural nerve injury rate of 10.8% was reported using a lateral approach. However most neurological problems appear to resolve. The overall infection and wound problem rate was 2.8%. However, this is likely to be an underestimate as some papers acknowledged that wound complications and infections occurred, but did not give a numerical breakdown.
8. Endoscopic surgery – which portals? A number of different portal combinations have been described for PAIS surgery and 25 papers detailing 521 procedures were analysed for outcomes and complications [2,7–10,15– 17,19,20,23–27,32–34,37,50–55]. Endoscopy requires a minimum of two portals – one for the camera and the other for instrumentation. Other portals can be utilised for irrigation and additional instrumentation. Most techniques use two soft-tissue portals while a combination of arthroscopic (via the subtalar or ankle joint) and endoscopic portals have been described. Some confusion with regards to terminology arises with soft-tissue portals occasionally described as arthroscopic instead of endoscopic [19,32,52,55]. Portals include: Anterolateral (subtalar) and posterolateral [15,24]. Ankle arthroscopy [23]. Stacked posterolateral [25]. Posterolateral and accessory posterolateral [19,52]. Double posteromedial [20]. Posteromedial and posterolateral [2,7–10,15–17,32– 34,37,50,51,54]. Posterolateral and trans-Achilles [55].
Liu described resecting a posteromedial soft-tissue impingement using ankle arthroscopic portals in 1993 [23] and Marumoto and Ferkel in 1997 first described a combination of an anterolateral approach, through the subtalar joint, and an endoscopic posterolateral approach [24]. These can be augmented with accessory portals. Out of 521 procedures reviewed 77.2% of cases employed the posteromedial and posterolateral portal combination popularised by van Dijk in 2006 [7]. The plethora of papers using van Dijk’s technique [2,8–10,15–17,32–34,50,51,54] would suggest that this has become the approach of choice but there has only been 1 paper comparing different endoscopic approaches. Ahn et al. [15]
5
compared arthroscopic subtalar approach combined with a posterolateral portal compared with two endoscopic portals (posteromedial and posteolateral) in a small series of os-trigonum excisions. They concluded that both arthroscopic and posterior endoscopic excisions of an os trigonum was safe and effective. Arthroscopic procedures were felt to be more demanding, especially in cases of a large os trigonum, and the posterior endoscopic approach had the advantage of addressing problems in the posterior ankle joint and allowed a more extensive release of the FHL. The endoscopic and arthroscopic papers were reviewed for complications: the results are shown in Table 3. The overall complication rate was 4.8% with a nerve injury incidence of 3.7%. There was no significant difference in the complication rates observed when comparing all open procedures with arthroendoscopic procedures (p = 0.24). A 5.0% overall complication rate was reported using the most popular combination of posteromedial and posterolateral portals. There were only 2 reports of postoperative infection and 3 reports of other wound healing problems. The most serious concern of endoscopic surgery – that of tibial nerve injury – was not reported in any of the reviewed papers. Zengerink [56] reported a 2.3% overall complication rate for hindfoot endoscopy on van Dijk’s series of patients. Nickisch [9] reported complications in 8.5% but this large series combined posterior ankle, subtalar and hindfoot procedures. 9. Is the overall outcome following arthro-endoscopic surgery better than open surgery? One of the problems in comparing surgical results is a lack of standardised outcomes, especially for open surgery. The AOFAS Ankle-Hindfoot scoring system was first published in 1994 and is a commonly used rating system in the assessment of surgical outcomes [57]. For the open series, only 2 of the 26 papers contained a post-operative AOFAS score [39,50] and only one a VAS (Visual Analogue Pain scale) [50]. Most papers have their own non-validated rating system such as poor-fair-good-excellent. The results of open surgery are summarised in Table 4. The various papers report in excess of 66% good or excellent outcomes with a number reporting 100% pain relief and return to sport. It should be noted that the overwhelming physical activity undertaken in the open group is dance and more specifically ballet (see section 10). A more precise indicator for athletes is a return to sport (RTS). In the open surgery group, accurate RTS could
Table 3 Complications of arthroscopic/endoscopic surgery for PAIS. Conclusions: Overall reported complication rate 4.8% Overall neurological complication rate: 3.7% * Neurological complication rate for PM/PL portals: 4.0% * NO reports of tibial nerve injury Complications Neurological
Wound Problems e.g. Haematoma, delayed healing Infection FHL iatrogenic injury Procedures
AL/PL (Arthro) Overall Sural Tibial Dysthesia CRPS
2 2 0 0 0 0
0 0 27
PM/PL 16 (4.0%) 4 0 9 2 2
2 0 402
PM x 2
PL + Trans-Achilles
Unknown
0 0 0 0 0 0
PL x 2 1 1 0 0 0 0
Stacked PL x 2 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 0 32
0 0 23
0 1 10
0 0 1
0 0 2
Overall 19 (3.7%) 7 0 9 2 3
2 1 521
Please cite this article in press as: Ribbans WJ, et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surg (2014), http://dx.doi.org/10.1016/j.fas.2014.08.006
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6 Table 4 Outcomes of PAIS open surgery. Author
Year
Nos
Pre-op score AOFAS (VAS)
Post-op score AOFAS (VAS)
Return to sport (weeks) Average
Liu Marumoto Lomba‘6 rdi Fadel Yilmaz Jerosch
1993 1997 1999 2006 2006 2006
1 11 10 2 1 10
** 45 ** ** ** 43
** 86 ** ** ** 87
8
Van Dijk
2006
76
**
90
9
Albisetti
2008
1
**
**
9
Scholten
2008
55
75
90
8
Willits
2008
15
**
91
25
Horibe Richards Phisitkul Noguchi Allegra
2008 2010 2010 2010 2010
11 1 2 12 32
71 ** ** 68 56
99 ** ** 93 87
Guo
2010
25
**
Calder
2010
27
Ogut Mansingh Galla Nikisch Smyth Ahn
2011 2011 2011 2012 2013 2013
Park Roche Liu Marumoto Lombardi Fadel Yilmaz Jerosch Van Dijk
Range
4 8 ALL < 8
2–52
4–102 ALL < 13
6 6
3–13
93 (0.80)
6
4–10
**
**
6
4–10
25 1 30 86 22 28
57 ** 7.2
86 ** 3.1
8
6–12
59 FAOS 64 (6.5–6.7)
86 FAOS 90 (1.2)
13 8
6–32
