Posterior Ankle Impingement and Posterior Process

Posterior ankle impingement is a condition that causes pain and swelling at the back of the ankle where the back of the shin bone (tibia) meets the top bone of the ankle (talus). It can happen when soft tissue gets caught between these bones. Some people have an abnormal bone growth on the back of the talus (os trigonum or posterior process). This can also become enlarged or swollen and painful.

This condition is common in athletes who forcefully and repeatedly bend their foot downward (plantar flexion) or push off their foot forcefully.

What are the causes?

This condition can result from athletic activities that require you to get up on your toes or push off your feet forcefully. These movements cause the back of the tibia and the top of the talus to come together. Over time, this can cause swelling and irritation (inflammation).

What increases the risk?

This condition is more likely to develop in:

• People who have an os trigonum.
• Athletes who participate in certain sports, including:
  • Soccer.
  • Football.
  • Gymnastics.
  • Ballet.
  • Trail running or cross country.
  • Track and field throwing sports, such as javelin and shot put.

What are the signs or symptoms?

Symptoms of this condition include:

• Pain behind the ankle that gets worse with plantar flexion.
• Swelling at the back of the ankle.
• Pain when pushing on the back of the ankle (tenderness).
• Ankle stiffness.

How is this diagnosed?

This condition may be diagnosed based on:

• Your symptoms and medical history, especially if you recently had an ankle injury.
• A physical exam. During the exam, your health care provider will test for stiffness, tenderness, and pain on plantar flexion. He or she may be able to feel a bone enlargement at the back of the talus.
• Imaging studies of your ankle. These may include:
  • Ankle X-rays and a CT scan to check for bone damage and a posterior process, or os trigonum.
  • MRI to check for soft tissue damage.
  • Ultrasound to check for swelling of an os trigonum.

How is this treated?

Treatment for this condition may include:

• Wearing a cast or boot to keep your ankle still during healing (immobilization).
• Using crutches or a walker to keep weight off the ankle.
• Using ice to reduce swelling.
• Taking NSAIDs for pain.
• Having medicines injected into the back of your ankle joint to reduce pain (anesthetic) and swelling (steroid). This injection may also be done as part of your diagnosis to find the cause of your pain.
• Starting range-of-motion and strengthening exercises (physical therapy) after immobilization.

You may need surgery if pain does not improve after these treatments. Surgery may be done to remove bone and enlarge the joint space.

Follow these instructions at home:

If you have a boot:

• Wear the boot as told by your health care provider. Remove it only as told by your health care provider.
• Loosen the boot if your toes tingle, become numb, or turn cold and blue.
• If your boot is not waterproof:
  • Do not let it get wet.
  • Cover it with a watertight covering when you take a bath or a shower.
• Keep the boot clean.
• Ask your health care provider when it is safe to drive with a boot on your foot.

If you have a cast:

• Do not stick anything inside the cast to scratch your skin. Doing that increases your risk of infection.
• Check the skin around the cast every day. Tell your health care provider about any concerns.
• You may put lotion on dry skin around the edges of the cast. Do not put lotion on the skin underneath the cast.
• If your cast is not waterproof:
  • Do not let it get wet.
  • Cover it with a watertight covering when you take a bath or a shower.
• Keep the cast clean.
• Ask your health care provider when it is safe to drive with a cast on your foot or leg.

Managing pain, stiffness, and swelling

• If directed, put ice on the injured area:
  • Put ice in a plastic bag.
  • Place a towel between your skin and the bag.
  • Leave the ice on for 20 minutes, 2–3 times a day.
• Raise (elevate) your ankle above the level of your heart while you are sitting or lying down.

Activity

• Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
• Do not use the injured ankle to support your body weight until your health care provider says that you can. Use crutches or a walker as told by your health care provider.
• Do not do any activities that make pain or swelling worse.
• Do exercises as told by your health care provider.

General instructions

• Take over-the-counter and prescription medicines only as told by your health care provider.
• Keep all follow-up visits as told by your health care provider. This is important.

How is this prevented?

• Wear supportive footwear that is appropriate for your athletic activity.
• Warm up and stretch before being active.
• Start any new athletic activity gradually.
• Avoid athletic activities that cause ankle pain or swelling.
• See your health care provider if you have an ankle sprain that causes pain and swelling for more than a few days.
• Maintain physical fitness, including:
  • Strength.
  • Flexibility.

Contact a health care provider if:

• Your symptoms get worse.
• Your symptoms do not improve at home.
• You develop new, unexplained symptoms.
• Your cast or boot becomes damaged.

Posterior Ankle Impingement and Posterior Process Rehab

Ask your health care provider which exercises are safe for you. Do exercises exactly as told by your health care provider and adjust them as directed. It is normal to feel mild stretching, pulling, tightness, or discomfort as you do these exercises, but you should stop right away if you feel sudden pain or your pain gets worse. Do not begin these exercises until told by your health care provider.

Stretching and range of motion exercises

These exercises warm up your muscles and joints and improve the movement and flexibility of your ankle. These exercises also help to relieve pain, numbness, and tingling.

Exercise A: Toe extension/toe flexion

1. Sit with your left / right leg crossed over your opposite knee.
2. With your left / right hand, hold your toes and gently pull them toward the top of your foot. You should feel a stretch at the bottom of your toes and foot.
3. Hold this stretch for __________ seconds.
4. Gently pull your toes toward the bottom of your foot. You should feel a stretch on the top of your toes and foot.
5. Hold this stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise B: Ankle dorsiflexion, active-assisted

1. Sit on a chair that is placed on a non-carpeted surface.
2. Place your left / right foot on the floor, directly under your knee. Extend your other leg for support.
3. Keeping your heel down, slide your left / right foot back toward the chair until you feel a stretch at your ankle or the back of your lower leg (calf). If you do not feel a stretch, slide your buttocks forward to the edge of the chair while keeping your heel down.
4. Hold this stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise C: Gastroc stretch, standing

1. Stand with your hands against a wall.
2. Extend your left / right leg behind you, and bend your front knee slightly. Your heels should be on the floor.
3. Point the toes on your back foot slightly inward.
4. Keeping your heels on the floor and your back knee straight, shift your weight toward the wall. You should feel a gentle stretch in your calf.
5. Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise D: Soleus stretch, standing

1. Stand with your hands against a wall.
2. Extend your left / right leg behind you, and bend your front knee slightly. Your heels should be on the floor.
3. Point the toes on your back foot slightly inward.
4. Keeping your heels on the floor, bend your back knee and slightly shift your weight over the back leg. You should feel a gentle stretch deep in your calf.
5. Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise E: Gastroc and soleus stretch, standing

1. Stand on the edge of a step on the balls of your feet. The ball of your foot is on the walking surface, right under your toes. Hold onto a rail or a chair for balance.
2. Slowly lift your uninjured foot, allowing your body weight to press your left / right heel down over the edge of the step. You should feel a stretch in your left / right calf.
3. Hold this position for __________ seconds.

Repeat __________ times with your left / right knee straight and __________ times with your left / right knee bent. Complete this exercise __________ times a day.

Strengthening exercises

These exercises build strength and endurance in your ankle. Endurance is the ability to use your muscles for a long time, even after they get tired.

Exercise F: Plantar flexors, seated

1. Sit on the floor with your left / right leg extended.
2. Loop a rubber exercise band or tube around the ball of your left / right foot. The ball of your foot is on the walking surface, right under your toes. The band or tube should be slightly tense when your foot is relaxed.
3. Slowly point your toes downward, pushing them away from you.
4. Hold this position for __________ seconds.
5. Let the band or tube slowly pull your foot back to the starting position.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise G: Plantar flexors, standing

1. Stand with your feet shoulder-width apart.
2. Keep your weight spread evenly over the width of your feet while you rise up on your toes. Use a wall or table to steady yourself, but try not to use very much for support.
3. If this exercise is too easy, try these options:
   1. Shift your weight toward your left / right leg until you feel challenged.
   1. If told by your health care provider, stand on your left / right leg only.
4. Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise H: Towel curls

1. Sit in a chair on a non-carpeted surface, and put your feet on the floor.
2. Place a towel in front of your feet. If told by your health care provider, add __________ to the end of the towel.
3. Keeping your heel on the floor, put your left / right foot on the towel.
4. Pull the towel toward you by grabbing the towel with your toes and curling them under. Keep your heel on the floor.

Repeat __________ times. Complete this exercise __________ times a day.