A posterior ankle ‘impingement’ is a painful condition which is prevalent in the athletic dancing population. Ballet dancers in particular will commonly suffer from this condition, due to the demands of their performance movements. This injury will typically present without trauma, and is classified as pain at the back of the ankle when performing a heel rise. When the ankle is taken into large ranges of plantarflexion (pointing toes and foot down to lift heel) the pain of this condition is often sharp and debilitating.

There are many structures that are located at the back of the ankle complex and run through the foot, as such the diagnosis of the exact tissue irritated is difficult to determine. Historically, an accessory bone in the ankle was blamed for causing this painful condition. This little accessory bone known as an ‘Os Trigonum’ is actually quite common in the population, and therefore is probably not the reason for the painful symptoms. An Os Trigonum represents the failed fusion of the posterolateral tubercle of the talus bone. The age that this typically forms is between the ages of 8-13 years of age.

With the theory that this little accessory bone was causing the painful condition, surgeons started removing it to eliminate symptoms. However, surgery as always has complications and does not always guarantee complete symptomatic relief. What does often result from Os Trigonum resection surgery is a painful stress reaction of the talus into the subtalar joint! Furthermore, the surgical procedure rarely increases plantarflexion range of motion. The surgery has also been linked to increasing the risk of developing subtalar joint osteoarthritis in the long term.

Posterior ankle impingement is now understood to be due to synovitis. Synovitis is inflammation to the connective tissue synovium, which lines the inside of our joint capsules. A synovium connective tissue also encases our tendons and when inflammation occurs here it is known as a tenosynovitis. With inflammation there is typically local swelling. This would likely reduce the space for the tendons to glide over joints, and lead to the ‘impingement’ like symptoms. How we manage these conditions comes down to appropriate guidance through exercise rehabilitation. Like a pure tendinopathy reaction injury, we need to build appropriate load capacity in the structures affected.

One muscle and its tendon that are known to influence symptoms and potentially cause the symptoms, is the Flexor Hallucis Longus. This muscle functions to flex the big toe and also assists in plantarflexion of the ankle. Its tendon travels down the back and inside of the ankle, where it can be compressed and become irritated with overload. Ballet dancers commonly get a flexor hallucis longus tenosynovitis from repetitive positioning to en pointe. This is a position where a great range of plantarflexion is needed. Factors that contribute to the overload of flexor hallucis longus include; a weak gastrocnemius muscle (superficial calf muscle) and joint stiffness or even hypermobility of the foot/ankle. With osteopathy at The Reform Lab Osteopathy, we will provide a comprehensive assessment and management plan to reduce the eccentric friction overload through the large range of motion of plantarflexion.