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Anterior inferior tibiofibular ligament
11%
241/2258
Tibial osteophyte
19%
435/2258
Accessory ossification near the posterolateral talar process
55%
1239/2258
Inflamed synovium and capsular tissues
7%
149/2258
Talar neck exostosis
8%
177/2258
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This patient has anterior tibiotalar impingement which can be caused by a number of different structures, but an os trigonum is not a source of pain in anterior impingement. Anterior tibiotalar impingement was first described as "footballer's ankle" given the high incidence seen in soccer players. It is also common among ballet dancers, rugby players, and wrestlers. Anterior impingement can be further subdivided into anterolateral and anteromedial impingement. Anteromedial impingement is often due to intraarticular exostoses of the anterior tibia and talar neck that impinge the interposed synovium and capsular tissues, leading to chronic inflammatory changes. Anterolateral impingement may result from the anterior inferior tibiofibular ligament (AITFL) catching on the talus, or may follow an anterior talofibular ligament (ATFL) sprain with fibrotic tissue in the anterolateral gutter. Physical therapy and anti-inflammatory medications are the mainstay of conservative treatment; however, if these fail, arthroscopic debridement is an effective alternative to open procedures. Tol and van Dijk outlined management and treatment of anterior impingement. They report that the diagnosis can be made with meticulous physical exam and that the addition of oblique radiographs may better demonstrate osteophytes than a standard series. They advocate for arthroscopic debridement of underlying bony abnormalities and the inflamed synovial tissues. Murawski and Kennedy reported a series of 41 patients who underwent arthroscopic debridement for anteromedial impingement. All patient-reported outcome measures showed clinically significant improvements with 97% returning to prior sporting level. This highlights the efficacy of minimally-invasive arthroscopic debridement in returning athletes to sports. Illustration A is a lateral radiograph demonstrating anterior tibial and talar exostoses. Incorrect Answers: Answers 1, 2, 4, 5: All of these structures have been shown to play a role in anterior ankle impingement.
1.1
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