Tibiotalar Impingement

Topic updated on 02/22/15 3:08pm
  • Most often caused by osteophyte impingement in anterior tibiotalar joint
  • can also be caused by excessive anterolateral soft tissues  or posterior soft tissue or osseous abnormalities
  • Epidemiology
    • common in athletes who play on turf or on grass including
      • rugby
      • football
      • dancers
      • soccer
  • Mechanism
    • repetitive overuse injuries
    • trauma
    • degenerative sequelae
  • Symptoms
    • pain in anterior ankle
  • Physical exam
    • pain with forced dorsiflexion
    • limited dorsiflexion
    • soft tissue swelling and effusion may be evident
    • subtalar joint is pain free
  • Radiographs
    • recommended views
      • AP, lateral, and oblique
    • findings
      • spurs seen in anterior distal tibia or dorsal aspect of the talus
      • oblique views are beneficial in revealing anteromedial talar spurs
  • CT
    • delineates extent of bony osteophytes
  • MRI
    • shows spurring and fluid in joint 
  • Nonoperative
    • therapy, lifestyle modifications, NSAIDS
      • indications
        • first line of treatment
  • Operative
    • arthroscopic excision   
      • indications
        • nonoperative modalities fail
  • Arthroscopic excision
    • supine position with external traction device and leg over a padded bump
    • use knife to only cut the skin and use hemostat to spread to avoid neurovascular injury while making portals
    • ensure adequate field of view prior to burring or shaving anterior distal tibia to avoid iatrogenic dorsal NV bundle injury
  • Superficial peroneal nerve injury during anterolateral portal creation
  • Saphenous vein injury during anteromedial portal creation
  • Dorsal neurovascular bundle injury during tibiotalar spur removal


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Qbank (3 Questions)

(OBQ12.194) A 34-year-old active duty military officer has lateral right ankle pain with running during physical training that is worsening over the past 6 months. He recalls sustaining an ankle sprain 3 years ago that resolved with physical therapy. On examination the skin is intact and the talar drawer test is normal. He has pain anterolaterally with end-arc passive dorsiflexion and no pain posteriorly with passive plantarflexion. He has no tenderness on palpation at the distal fibula, anterior talofibular ligament, calcaneofibular ligament. An axial MR arthrogram of the ankle is shown in Figure A. What is the next most appropriate step in management following recalcitrant pain despite conservative management? Topic Review Topic
FIGURES: A          

1. Ankle arthropscopy with synovial debridement
2. Open Brostrom ligament repair with Gould modification
3. Chrisman-Snook tendon transfer
4. Syndesmosis reduction and screw fixation
5. Ankle arthroscopy with loose body removal

(OBQ08.198) The current body of available evidence supports the use of ankle arthroscopy for all of the following indications EXCEPT: Topic Review Topic

1. Ankle arthrodesis
2. Debridement of diffuse degenerative ankle cartilage
3. Osteochondral lesions
4. Anterior ankle impingement
5. Loose body removal

(OBQ05.126) A 28-year-old rugby player has had anterior ankle pain for several years. On physical exam he has painful and limited dorsiflexion of the ankle. Based on a dorsiflexed ankle radiograph shown in figure A, what is the most appropriate treatment? Topic Review Topic
FIGURES: A          

1. Arthroscopic chondral drilling
2. Arthroscopic tibial debridement
3. Modified Brostrom procedure
4. Arthroscopic os trigonum excision
5. Arthroscopic tibiotalar arthrodesis



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