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Pathoanatomy of anterior ankle impingement in dancers.

Posterior impingement has been well described as a consequence of the extreme plantar flexion required of dancers, (1-18) especially for the en pointe position of classical ballet. However, many genres of dance also require repetitive and forceful movement of the ankle into weightbearing dorsiflexion (during demi-plie, grand plie, and landing from a jump). When this occurs, anterior ankle impingement can result. (19) The purposes of this paper are to evaluate the medical literature pertaining to anterior ankle impingement and highlight the various pathoanatomical etiologies of anterior impingement that may affect dancers. An understanding of this subject is important in order to provide excellent healthcare to dancers.

Historical Context

The first known description of anterior ankle impingement was actually a one paragraph note about a presentation by L.H. Morris at the 1942 annual meeting of the British Orthopaedic Association. (20) Morris suggested that new bone formation on the dorsal talus that he diagnosed in five athletes resulted from traction of the anterior joint capsule during extreme plantar flexion. In 1945, Piatt identified trauma as the initiator of calcification in the periarticular tissues of the ankle. (21) Several other early articles are related to sports injuries of the ankle, (22-25) and one of these, published in 1961, includes ballet dancers. (25) Kleiger, in 1982, was the first to specifically address anterior impingement in ballet dancers. (26)

Wolin and colleagues (27) published a widely cited article on ankle sprains that proposed onset of a "fibrocartilaginous 'meniscoid'" lesion subsequent to lateral ankle sprain. The presence of this post-traumatic band of tissue extending into the ankle joint promotes chronic ankle symptoms when the tissue is compressed by surrounding structures. Furthermore, these investigators reported that the signs and symptoms associated with this meniscoid tissue were not necessarily related to ankle instability.

Anatomical Landmarks

The distal tibia and distal fibula are bound together at their syndesmosis by the anterior and posterior inferior tibiofibular ligaments, and these bones form a three-sided compartment called the mortise (Fig. 1). The articular surface of the distal tibia is called the plafond. The talus, the bone that is most superior in the foot as it rests on the calcaneus, fits into the mortise and is stabilized by ligaments. Together the tibia, fibula, and talus compose the ankle joint. The trochlea, or dome, of the talus (its articular surface) articulates with the tibial plafond. The medial surface of the lateral malleolus of the fibula articulates with the lateral surface of the talus, and the lateral surface of the medial malleolus of the tibia articulates with the medial surface of the talus.



The neck of the talus extends anteriorly and slightly inferiorly from the body of the talus toward the talar head, which articulates with the navicular. A sulcus, or depression, runs side-to-side on the dorsal surface of the talar neck. It is designed to receive the anterior edge of the tibial plafond during dorsiflexion. The talus sits on the superior surface of the calcaneus; the articulation between these two bones is the subtalar joint. Figure 2 shows the ankle from the lateral view and includes the main supporting ligaments.

The arc from the anterolateral ankle to the anteromedial ankle contains the anterior talofibular ligament, the distal portion of the anterior inferior tibiofibular ligament, the anterior ankle joint capsule, and the tibiotalar (anterior) portion of the deltoid ligament (Fig. 3). The lateral gutter, as it is known in the orthopaedic vernacular, is a space on the lateral ankle bordered medially by the talus, laterally by the medial surface of the lateral malleolus, and superiorly by the tibia. It is enclosed also by the inner surfaces of the lateral ankle ligaments. (28) The lateral gutter is clinically important because the anterior portion of this area is where much anterolateral soft tissue impingement occurs. (28-32)


Causes of Anterior Impingement

Several sources of anterior impingement symptoms have been identified in the literature, including tibial and talar exostoses, (19,24,26,33-39) the anterior inferior tibiofibular ligament, (19,36,38-44) and anterior soft tissue inflammation and hypertrophy following a typical lateral ankle sprain. (27,28,45-49) Symptoms can be initiated simply by bony impingement or by thickened and inflamed soft tissue caught between exostoses on the tibia and talus. (35,36,38) Soft tissue impingement occurs when ligaments or other tissues are abraded by bone or are trapped in areas where bones approach one another during ankle motion. The anterior talofibular ligament is worthy of special note because it is the most commonly injured ankle ligament. (50-57) Its frequent involvement in lateral ankle injuries makes it a relatively common source of anterolateral ankle impingement symptoms. Both osseous and soft tissue sources of anterior impingement are presented below.

Osseous Causes of Anterior Impingement

Anterior ankle exostoses (also called "spurs," or "osteophytes") are generally regarded as sequelae of bony impingement of the anterior edge of the tibial plafond impacting the neck of the talus. However, Tol and coworkers suggest that these developments often occur in conjunction with soft tissue impingement. (35,36,38) Kleiger reported that the anterior tibial margin barely reaches the dorsal sulcus of the talar neck when the ankle is in extreme dorsiflexion. (26) He found that at maximum dorsiflexion these landmarks do not normally impinge, and the articular surfaces of the tibia and talus remain congruent. However, he also observed that if impingement does occur at this site--as in demi-plie--the result is the establishment of an anterior fulcrum that allows the posterior ankle joint space to widen (thus making the joint surfaces incongruent). Indeed, osseous impingement of the ankle has been characterized as a "vocational hazard" in dance. (58)

An early debate involved the etiological origin of anterior exostoses on the neck of the talus. Some investigators suggested that such outgrowths resulted from traction of the anterior ankle joint capsule on the neck of the talus. (20,22,23,59-61) If true, this mechanism would easily explain anterior talar exostoses found in dancers' ankles because of the repetitive forced plantar flexion that induces such capsular traction in ballet. Yet, it is possible that these exostoses could be confused with a normal ridge found dorsally on the talus approximately at the insertion sites of the anterior capsule, the talonavicular ligament, and the anterior talofibular ligament because a normal ridge and hypertrophied ridge vary from one another only in size. (61)

Piatt described calcific deposition about the ankle following trauma. (21) He utilized serial x-rays to make his diagnoses because such films allowed mapping of the progression of the deposits. O'Donoghue observed that talar exostoses were positioned inside the margin of the anterior capsule on the talus. (24) He proposed, therefore, that these bony outgrowths occurred in response to impingement trauma of the anterior edge of the distal tibia's articular surface with the neck of the talus. This also has been described elsewhere, (61,62) and one investigator clearly differentiated it as post-traumatic arthritis that is unrelated to the dorsal talar ridge. (61) Interestingly and contrary to other investigators, Hayeri and associates (63) suggested from their paleopathologic and cadaveric study that talar exostoses arise from dual causes. Those on the medial aspect appear to be intra-articular and based in a repetitive trauma mechanism, while those on the lateral aspect are extra-articular and originate from recurrent capsular traction. Cheng and Ferkel indicated that a spur on the anterior edge of the distal tibia often occurs together with what they called a "kissing lesion of the talar neck." (64) The repetitive traumatic mechanism certainly is plausible for dance-related impingement, especially in light of the dorsiflexion required in classical ballet that causes contact between the tibia and talus. (26,33) Similar impact-initiated exostoses may occur on the anterior margin of the tibia's articular surface. (26,33,34,36-38) Anterior impingement exostoses in ballet dancers have been observed significantly more often than in non-dancers. (33) A deepened sulcus was found on the dorsal talar necks of professional ballet dancers, particularly females, implying repetitive demi-plie as the causative factor. (60)

Exostoses also can arise on the inside of the medial malleolus and the medial surface of the talus, because maximum weightbearing dorsiflexion generally forces the foot into pronation against the medial malleolus. (26) Berberian and colleagues analyzed the positions of both tibial and talar osteophytes and concluded that they do not impinge on one another. (34) They found that the tibial osteophytes generally occurred lateral to the sagittal midline of the ankle and talar osteophytes occurred medial to the midline. In addition, lesions of the talar articular cartilage may accompany bony anterior impingement regardless of the size of the exostoses, and the size of the cartilage defects are directly proportional to the size of the bone spurs. (65) Importantly, these investigators also suggest chronic ankle instability as a contributing factor to the lesions.


A lateral radiograph taken in full dorsiflexion may be helpful in visualizing the impinging structures. (19,30) This view may increase the ability to see anterior exostoses, but their size likely will be underestimated because of overlap of the structures. (30) It is important to realize in diagnosing exostosis formation that true lateral radiographs may be insufficient to identify the pathology in many cases. (37,50,66,67) Tol and coworkers showed that the sensitivity of x-rays to diagnose tibial osteophytes could be improved from 40% to 85% by the addition of a special oblique anteromedial impingement view (37) (Fig. 4). Similarly in their study, the sensitivity to reveal talar osteophytes was improved from 32% to 73%. Though this x-ray view is more useful for finding anteromedial osteophytes than anterolateral ones, they and other investigators (39,67) recommend utilizing both it and a standard lateral view for greatest diagnostic accuracy.

Radiological Measurements Related to Bony Impingement

Anterior exostoses caused by impingement are more likely to develop in dancers with pes cavus (high arch) (26,56) and subtalar motion limitations, (26) although more research of these anatomical and mechanical factors in dancers is required. In such feet, the longitudinal axis of the talus is more horizontal than normal, which places the talus' dorsal surface closer to the anterior edge of the distal tibia, thus making it more likely that the two bones will impinge.

Such skeletal variations are easily detectable on lateral foot x-rays. Radiological markings pertinent to bony anterior impingement include the following:

* Plane of support (PS): the line tangential to the most inferior aspect of the calcaneal tuberosity and the most inferior aspect of the head of the fifth metatarsal;

* Calcaneal inclination axis (CIAx): the line tangential to the most inferior aspect of the plantar calcaneal tuberosity and the most distal and inferior aspect of the anterior calcaneus at the calcaneocuboid joint;

* Collum tali axis (CTA): the line that bisects the talar neck and head along the long axis of the talus;

* Calcaneal inclination angle (CIA): the angle between PS and CIAx; and

* Lateral talocalcaneal angle (LTCA): the angle between CTA and CIAx. (68,69)


Pes planus is present when the CIAx is less than 20[degrees] and the CTA is more vertical than normal, thus yielding a LTCA greater than 50[degrees]. (68) Pes cavus is present when the CTA is more horizontal than normal and the CIA exceeds 40[degrees]. (68) Figure 5 illustrates measurement of the CIA and LTCA.

Soft Tissue Causes of Anterior Impingement

Ferkel (28) outlined a sequence of inflammatory and incomplete restorative events that lead to soft tissue hypertrophy in the lateral gutter of the ankle, a condition that subsequently develops into anterolateral ankle impingement. This resembles Wolin and colleagues' original "meniscoid" sequela of ankle sprain, (27) which is consistent with others' descriptions of the pathology. (31,49)

An inversion ankle injury appears to be one instigator of soft tissue impingement. (31,40,46,48,49,70-72) As many as 3% of all ankle sprains may proceed to anterolateral impingement. (30) DeBerardino and coworkers found impingement in 1.2% of all ankle sprains, (71) and Ferkel and associates found this rate to be 2%. (28) However, it is noteworthy that impingement can occur independently of ankle instability. (28,31,47,48,71)

Kim and Ha consistently discovered anterolateral hypertrophic tissue in their series of 52 patients who sustained an inversion ankle sprain. (47) They found that the presence of such a lesion was not related to the amount of stability in the ankle. Rather, they attributed it to slight instability from the injury coupled with a repetitive subluxation and reduction of the talus during gait that impinges the anterolateral corner of the talus against the anterior inferior tibiofibular ligament and elicits the hypertrophic tissue response.

Some investigators propose that certain variations of normal ankle ligamentous anatomy are to blame for soft tissue impingement symptoms. (40,43,44,72-75) Apart from a hypertrophic response to injury, the involved structures likely would not elicit symptoms as readily in an individual who does not require the forced maximum dorsiflexion seen in ballet. Therefore, these ligaments must be considered as sites of anterior impingement syndrome in dancers.

According to Bassett and coworkers originally (72) and then other investigators, (40,41,44) a distal fascicle of the anterior inferior tibiofibular ligament is usually present. It normally contacts the anterolateral articular surface of the talus at between 9[degrees] and 17[degrees] of dorsiflexion (mean: 12[degrees]). (72) This structure is a common finding (in 83%41 to 92% (72) of ankles), and it also is a potential cause of anterolateral impingement. It impinged on the anterolateral talus during dorsiflexion in every cadaver ankle studied in which the ligamentous fascicle was present. (73) However, according to Ray and Kriz the presence of this separate distal fascicle may not be necessary for impingement symptoms to occur, as 61% of their anatomical specimens that demonstrated impingement did not have such a fascicle. (76) In a further development during their categorization of anterior inferior tibiofibular ligament configurations, they reported finding a triangular beveled area of the anterolateral edge of the talar trochlea that was associated with impingement, a feature of the trochlea alluded to by Bartonfcek, as well. (75) Ray and Kriz also noted a wear pattern of the chondral surface in those ankles where the ligament impinged in this region of the trochlea. (76)

In cadaver studies, it was observed that the presence of lateral ankle instability, such as occurs following lateral ligament sprain, increases the likelihood that the inferior part of the tibiofibular ligament will impinge upon the talus. (41) Another clinical study reported an "arthroscopic impingement test" which, in each of 21 cases, revealed contact between the distal fascicle of the anterior inferior tibiofibular ligament and the dome of the talus throughout the ankle's full range of motion. (40)

Interestingly, in a clinical series of seven patients with anterior inferior tibiofibular ligament impingement on the talus, all patients had a history of inversion ankle sprain. (72) Another series of patients suffered both an inversion ankle sprain and anterior inferior tibiofibular ligament impingement. (40) Thus, lateral ankle injuries may frequently initiate or exacerbate impingement sequelae. Kim and Ha reported that anterior inferior tibiofibular ligament impingement rarely occurs on its own; they suggest that it is usually associated with the scarring that accompanies anterior talofibular ligament injury. (47)

Keller and associates (77) identified an anterior tibiotalar ligament as a potential source of anterolateral impingement, and stated that theirs was the first mention in the literature of the structure being an independent ligament. They dissected this anterolateral ligamentous band in 26 of 33 (79%) cadaver specimens and demonstrated its difference from the anteromedial tibiotalar portion of the deltoid ligament, despite its similar tibiotalar name. These investigators described four morphologies of the ligament, which generally coursed from the area near the tibial attachment of the anterior tibiofibular ligament downward toward the lateral gutter, with a talar attachment near that of the anterior talofibular ligament. They suggested that the orientation of the ligament's fibers, its location, and its susceptibility to trauma and inflammation, especially from excessive plantar flexion, make it a likely contributor to anterior ankle impingement. In a dancer, then, the requisite repetitive forced plantar flexion of the ankle during releve, demi-pointe, and en pointe--if it results in an inflammatory hypertrophy of this ligament--could precipitate involvement of the ligament in an impingement syndrome when the dancer executes forced dorsiflexion, as in a demi-plie.

Similar to anteromedial bony impingement, reports of soft tissue ankle impingement in the medial or anteromedial regions are relatively rare, but the cause--hypertrophied, inflamed soft tissue--is analogous to the anterolateral impingement mechanism described previously. Egol and Parisien published what apparently is the first case report of this condition in 1997.78 They described fibrotic meniscoid tissue arising from the anterior deep deltoid ligament as a sequela of a lateral ankle sprain. In 2000, Mosier-La Clair and colleagues (79) reported their experiences with impingement of the anterior portion of the deltoid ligament. Of 11 patients, five sustained an ankle fracture, and six had a history of lateral ankle sprain. Based on these two studies, it seems prudent to consider lateral ankle injury as a potential mechanism for anteromedial ankle impingement.

The Role of Magnetic Resonance Imaging in Assessing Soft Tissue Impingement

Anterior soft tissue impingement should be suspected in dancers with a history of ankle sprains and recalcitrant anterior ankle pain. In such cases, magnetic resonance imaging is often used as an adjunct diagnostic tool. MRI may increase clinicians' ability to confirm a diagnosis of soft tissue impingement; (29,30,32,42,45,49,80-85) but Umans and Cerezal (86) suggest that MRI should be used judiciously for identifying specific pathological signs that could corroborate a clinical finding of impingement, and that conventional MRI does not offer advantages for diagnosis of anteromedial impingement. Research studies to date that utilized MRI to assess ankle injuries solely in dancers have evaluated posterior, not anterior, ankle impingement. (1,4) Only one article could be located that described MRI findings in anterior impingement of dancers: a pictorial review by Hillier and coworkers. (46)

Lee and colleagues studied an MRI method ("contrast-enhanced, fat-suppressed, three-dimensional, fast-gradient-recalled acquisition in the steady state with radio-frequency-spoiling [CE 3D-FSPGR]") for detection of post-traumatic ankle impingement. (81) The results of their technique were a sensitivity of 92%, a specificity of 84%, and an accuracy of 88%. They suggested that MRI assessment is appropriate for patients who fail non-operative treatment for at least 3 months, and they recommend this type of MR imaging as a preferable diagnostic tool because its intravenous contrast induction is less invasive compared to MR arthrography.

Other studies have recommended that a decision for surgical debridement of ankle soft tissue be made primarily on clinical grounds because they found conventional MRI to be relatively insensitive. (87,88) One series consisted of syndesmosis pathology (anterior, posterior, and interosseous tibiofibular ligaments) in athletes resulting from supination and external rotation trauma. (88) This was a retrospective study, so the investigators' imaging procedures could not be controlled or customized. They did find, however, that MRI was useful in confirming or ruling out pathologies not related to syndesmotic ligament impingement. A similar conclusion was drawn by Farooki and coworkers in their study of conventional MRI for anterolateral ankle impingement. (87) These investigators suggested that MRI studies using contrast techniques, though more invasive, may be more reliable than the conventional MR imaging they employed. Finally, in a study that clearly opposes the use of MRI, Liu and associates stated that pre-operative MRI of ankles with suspected anterolateral impingement is neither beneficial nor cost-effective, and it may delay definitive treatment. (31)

Conclusions and Clinical Relevance

The intention of this review article is to elucidate sources of anterior ankle impingement that can occur in dancers. The repetitive ankle dorsiflexion required by dance, especially in demi-plie and grand-plie, may lead to symptoms of chronic anterior impingement. Given this necessity to routinely force the ankle into maximum dorsiflexion, the incidence of any of the differential diagnoses--stemming from osseous or soft tissue sources, or both--can create serious repercussions for the dancer. Moreover, based on the literature consulted, it seems clear that the very common lateral ankle sprain may precipitate soft tissue impingement syndrome on both the anterolateral and anteromedial aspects of the ankle.

Healthcare professionals must become familiar with the extraordinary demands of dance in order to provide effective care, as dancers who suffer an impingement syndrome cannot perform at full capacity unless the pathology is accurately identified. Anterior ankle impingement may be more prevalent in dancers than previously thought, and awareness of its pathoanatomical etiologies will facilitate the clinical assessment and treatment of these artistic athletes.

Caption: Figure 1 Anterior view of a right ankle. The heavier lines indicate the box-like mortise--formed by the distal tibia (Tib) and fibula (Fib)--that contains the talus (Tal).

Caption: Figure 2 Lateral view of the right ankle, with identification of significant ligaments: 1. Calcaneofibular ligament; 2. Anterior talofibular ligament; 3. Anterior inferior tibiofibular ligament; 3 a. Distal fascicle of the anterior inferior tibiofibular ligament. Tib: Tibia. Fib: Fibula. Tal: Talus. Cal: Calcaneus. Nav: Navicular. Cub: Cuboid.

Caption: Figure 3 Anterior view of the right ankle, with identification of significant ligaments that sit in the anterior arc and that may be involved in anterior impingement. 2. Anterior talofibular ligament; 3. Anterior inferior tibiofibular ligament; 3a. Distal fascicle of the anterior inferior tibiofibular ligament; 4. Tibiotalar portion of the deltoid ligament. Note the dotted line representing the anterolateral corner of the talus that can be impinged by the distal portion of the anterior inferior tibiofibular ligament that lies over it. Tib: Tibia. Fib: Fibula. Tal: Talus.

Caption: Figure 4 Two radiographs of the same patient with anteromedial ankle impingement secondary to development of exostoses. A: Directly lateral view does not reveal exostoses. B: Exostoses are clearly seen on this oblique x-ray view, as indicated by the arrows. (With kind permission from Springer Science+Business Media: van Dijk CN, Wessel RN, Tol JL, et al. Oblique radiograph for the detection of bone spurs in anterior ankle impingement. Skeletal Radiology. 2002; 31(4):214-21, Figure 5, page 218.)

Caption: Figure 5 Technique for measuring calcaneal inclination angle (CIA) and lateral talocalcaneal angle (LTCA) on x-ray. (68,69) The arrows indicate the landmarks where the tangential lines are drawn. This is a normally arched foot. With pes cavus, CIA exceeds 40[degrees] (68) and anterior bony impingement is more likely. When LTCA exceeds 50[degrees], pes planus is present (68) and anterior bony impingement is less likely. PS: Plane of support. CIAx: Calcaneal inclination axis. CTA: Collum tali axis.


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Jeffrey A. Russell, Ph.D., A.T., is in the School of Applied Health Sciences and Wellness, Ohio University, Athens, Ohio. David W. Kruse, M.D., is at the Orthopaedic Specialty Institute, Orange, California. Yiannis Koutedakis, Ph.D., is in the Department of Exercise Sciences, University of Thessaly, Trikala, Greece, and the School of Sport, Performing Arts and Leisure, University of Wolverhampton, Walsall, United Kingdom. Matthew A. Wyon, Ph.D., is in the School of Sport, Performing Arts and Leisure, University of Wolverhampton, Walsall, United Kingdom.

Correspondence: Jeffrey A. Russell, Ph.D., A.T., Ohio University, School of Applied Health Sciences and Wellness, Grover Center E335, Athens, Ohio 45701; jeffr@
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Author:Russell, Jeffrey A.; Kruse, David W.; Koutedakis, Yiannis; Wyon, Matthew A.
Publication:Journal of Dance Medicine & Science
Date:Jul 1, 2012
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