summary Tibiotalar Impingement is a source of anterior ankle pain that is most often caused by osteophyte impingement in the anterior tibiotalar joint. Diagnosis is made clinically with anterior ankle pain that worsens with forced dorsiflexion. Radiographs often show spurs in the anterior distal tibia or dorsal aspect of the talus. Treatment is a trial of activity modifications, NSAIDs and corticosteroid injections. Surgical management is indicated in patients with progressive symptoms who fail nonoperative management. Epidemiology Demographics common in athletes who play on turf or on grass including rugby football dancers soccer Etiology Mechanism repetitive overuse injuries trauma degenerative sequelae can also be caused by excessive anterolateral soft tissues or posterior soft tissue or osseous abnormalities Presentation 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 Imaging 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 Treatment Nonoperative therapy, lifestyle modifications, NSAIDS indications first line of treatment corticosteroid injections help with soft tissue impingement and synovitis-related pain Operative arthroscopic excision indications nonoperative modalities fail Techniques 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 Complications Superficial peroneal nerve injury during anterolateral portal creation Saphenous vein injury during anteromedial portal creation Dorsal neurovascular bundle injury during tibiotalar spur removal
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next (OBQ17.168) A 27-year-old rugby player returns to clinic noting persistent ankle pain. He endorses a history of vague ankle issues but none that required missed competition time. His pain is located anteriorly and worsens when in a crouched position. Exam shows point tenderness at the anterior joint line, and passive dorsiflexion to 10° reproduces his pain. Which structure is unlikely to be a potential source of pain in this condition? QID: 210255 Type & Select Correct Answer 1 Anterior inferior tibiofibular ligament 11% (218/1950) 2 Tibial osteophyte 20% (385/1950) 3 Accessory ossification near the posterolateral talar process 54% (1059/1950) 4 Inflamed synovium and capsular tissues 7% (128/1950) 5 Talar neck exostosis 7% (145/1950) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4554 FIGURES: A Type & Select Correct Answer 1 Ankle arthropscopy with synovial debridement 53% (1783/3337) 2 Open Brostrom ligament repair with Gould modification 20% (665/3337) 3 Chrisman-Snook tendon transfer 5% (175/3337) 4 Syndesmosis reduction and screw fixation 8% (270/3337) 5 Ankle arthroscopy with loose body removal 12% (415/3337) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ08.198) The current body of available evidence supports the use of ankle arthroscopy for all of the following indications EXCEPT: QID: 584 Type & Select Correct Answer 1 Ankle arthrodesis 29% (718/2498) 2 Debridement of diffuse degenerative ankle cartilage 67% (1683/2498) 3 Osteochondral lesions 1% (21/2498) 4 Anterior ankle impingement 2% (60/2498) 5 Loose body removal 0% (9/2498) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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 operative treatment? QID: 1012 FIGURES: A Type & Select Correct Answer 1 Arthroscopic chondral drilling 2% (70/3856) 2 Arthroscopic tibial debridement 88% (3394/3856) 3 Modified Brostrom procedure 2% (60/3856) 4 Arthroscopic os trigonum excision 7% (286/3856) 5 Arthroscopic tibiotalar arthrodesis 1% (30/3856) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (2) Podcasts (1) Orthopaedic Summit Evolving Techniques 2021 Evolving Technique Update: Making The Diagnosis Of Posterior Impingement Of The Ankle - A. Holly Johnson Foot & Ankle - Tibiotalar Impingement 17 hours ago 9 views 0.0 (0) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques Posterior Ankle Impingement - Phinit Phisitkul, MD (OSET 2018) Phinit Phisitkul Foot & Ankle - Tibiotalar Impingement A 9/12/2019 320 views 4.0 (3) Foot & Ankle⎪Tibiotalar Impingement Foot & Ankle - Tibiotalar Impingement Listen Now 10:11 min 11/5/2020 158 plays 3.0 (2)