Donovan A, Rosenberg ZS. Current Orthopaedic Practice30(1):69-76, January/February 2019. Pathophysiology and clinical features Posteromedial impingement is the least recognized ankle impingement syndrome and is thought to be a sequela of severe inversion injury [47, 48]. 7 min. 10A, 10B, 10C and 11A, 11B). Lateral ankle pain may develop because of lateral hindfoot impingement. FEATURED PROVIDER. subfibular impingement, Affiliations: MDa; Aiyer, Amiethab MDb; Nguyen, Duc M. MDb; Vulcano, Ettore MDc; Buller, Leonard T. MDb; Sheth, Pooja MDd; Jose, Jean DOd, aOrthopaedic Specialty Institute, Orange, CA, bDepartment of Orthopedics, University of Miami Miller School of Medicine, Miami, FL, cDepartment of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, dDepartment of Radiology, University of Miami Miller School of Medicine, Miami, FL. Posterior impingement, also termed os trigonum syndrome, typically occurs due to a large os trigonum or Stieda process . Patients usually present with posteromedial point tenderness and pain between the medial wall of the talus and the posterior margin of the medial malleolus [5, 20]. Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY 2). 4A, 4B). Malicky, Eric S. MD; Crary, Jay L. MD; Houghton, Michael J. MD; Agel, Julie MA; Hansen, Sigvard T. Jr. MD; Sangeorzan, Bruce J. MD Talocalcaneal and Subfibular Impingement in Symptomatic Flatfoot in Adults, The Journal of Bone & Joint Surgery: November 2002 - Volume 84 - Issue 11 - p 2005-2009. It remains unclear whether this is primarily due to bony or soft-tissue impingement. Dive into the research topics of 'Subfibular impingement: Current concepts, imaging findings and management strategies'. Severe flatfoot and hindfoot valgus deformity may present with lateral ankle pain in the region bounded by the anterior fibula and the sinus tarsi [7]. The MRI features of posteromedial impingement are not specific. With progressive deformity, secondary osteoarthrosis of the subtalar, talonavicular, and calcaneocuboid articulations contribute to pain symptoms [62]. In cases of trauma and calcaneal fractures that have malunited, there may be lateral calcaneal wall blow-out with widening of the heel 4. MRI has been used to evaluate both the subacute stage (i.e., within 4 weeks of the participating injury) and the chronic stage (i.e., 1452 weeks after injury) of posteromedial impingement [20, 48] (Fig. Patients usually present after the development of significant soft-tissue abnormality such as synovial thickening along the posterior capsule or thickening of the posterior intermalleolar or talofibular ligaments [52, 54]. In patients with PTT dysfunction, medial ankle pain is the presenting symptom during the early stages of PTT dysfunction, whereas lateral ankle pain related to hindfoot valgus and lateral impingement predominates in long-standing PTT dysfunction [7]. 14A, 14B). ankle impingement , subfibular impingement , extraarticular impingement , lateral hindfoot impingement , MRI , CT , foot and ankle surgery , sports medicine. Acute synovitis is treated with rest and NSAIDs to reduce inflammation. Jonathan R.M. Relief of symptoms after therapeutic injection helps confirm the diagnosis [49]. 2: Posteromedial abnormalities were present in all patients with a clinical diagnosis of posteromedial impingement, but posterior and posterolateral synovitis were also seen in these patients [20]. View Record in Scopus Google Scholar. Hindfoot valgus (often defined as a tibiocalcaneal angle >11) with one or both of the following 5: Treatment may be non-operative or operative. A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. keywords = "CT, MRI, ankle impingement, extraarticular impingement, foot and ankle surgery, lateral hindfoot impingement, sports medicine, subfibular impingement". Ankle impingement syndromes: an imaging review. This can include talocalcaneal, calcaneofibular (subfibular)or combined talocalcaneal-subfibular impingements. Operative treatment is reserved for patients that fail non-operative treatment. 50 (7): 1317. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. The diagnosis of anterior impingement is usually clinical, based on anterior ankle pain with limited and painful dorsiflexion [31]. This accessory, or distal, fascicle is separated from the anteroinferior tibiofibular ligament by a fibrofatty septum (Fig. modify the keyword list to augment your search. What causes Subfibular impingement? A superimposed rotational mechanism and repeated microtrauma lead to anteromedial capsular thickening and synovitis in the region of the anterior tibiotalar ligament of the deltoid complex [4]. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. The treatment for anterior impingement in the ankle can include physical therapy to . sports medicine; Imaging features of subfibular impingement often include extensive lateral soft-tissue thickening between the fibula and the calcaneus (Fig. Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. In addition to ankle impingement sy ndromes, extraarticular soft-tissue and osseous impingements occur lateral to the ankle joint, such as talocalcaneal and calcaneofibular impingements [7]. Physical therapy and orthotics relieve stress and pain in the ankle. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, Early detection of impingement using MRI may be beneficial for successful surgical results [9, 10]. MRI often is necessary to rule out other causes of ankle pain, and advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-Tissue thickening between the Fibula and the calcaneu. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-62238, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":62238,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/extra-articular-lateral-hindfoot-impingement-syndrome-1/questions/2118?lang=us"}. However, in the setting of a prior ankle sprain, posterolateral ankle laxity leads to anterior extrusion of the talar dome with dorsiflexion, increased pressure at the site of contact, and subsequent synovial hypertrophy and impingement between the anterolateral talus and the accessory anteroinferior tibiofibular ligament [12]. Financial Disclosure: Dr. Aiyer discloses a financial relationshp outside this work with Paragon 28, Medline, and Medshape. For more information, please refer to our Privacy Policy. 1A, 1B). The extent of arthro desis should be limited to minimize the stress transfer to proximal and distal joints [72]. The main differential diagnosis for postero medial ankle pain includes PTT abnormalities. 3). Conservative management is usually successful in most patients with anterior ankle impingement syndrome. Kaplan, MD, Articles in Google Scholar by Jonathan R.M. Surgical Technique for Management of Severe Calcaneofibular Impingement: Case Series:. Introduction Pain localized to the lateral subtalar region is often clinically felt to represent either subtalar joint degeneration or sinus tarsi syndrome. On MR arthrography, anteromedial capsular thickening and abnormal soft tissue anterior to the tibiotalar ligament and medial malleolus are best seen on axial images, whereas both the axial and sagittal planes are helpful in assessing anteromedial osteophytes [4]. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment Coronal CT images have been shown to best depict nodular thickening related to synovial impingement [30]. Advanced Radiology Services hires the nation's best and brightest board-certified radiologists. or extensive soft-tissue thickening between the fibula and the calcaneus. Soft-tissue abnormalities at the posterior ankle such as posterior capsular thickening, ligament disruption, FHL tenosynovitis, and soft-tissue edema and synovitis can also be well depicted by MRI [49, 50, 60] (Figs. Impingement syndrome of left shoulder. It is classically described in ballet dancers. ;Vulcano, Ettore On this page: Article: Clinical presentation Pathology Radiographic features Treatment and prognosis References Images: Cases and figures CT may be helpful for further characterizing the location and size of the spurs but is rarely indicated [36] (Fig. Advanced imaging findings are related to abutment between the fibula and calcaneus and . Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. MRI can also aid in assessing other causes for lateral pain in valgus foot such as lateral malleolar bursitis and distal fibular stress fracture. MRI may be useful in examining patients in whom coexistent abnormalities are suspected clinically [29]. MRI often is necessary to rule out other causes of ankle pain. Pressing the buy now button more than once may result in multiple purchases. As more healthcare continues to . It is of paramount importance, however, to remember that MRI features supportive of impingement may be present in asymptomatic individuals and that accurate diagnosis requires careful correlation of imaging features with the clinical picture. author = "Kaplan, {Jonathan R.M.} Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. ankle impingement; N2 - Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. Kaplan JRM, Aiyer A, Nguyen DM, Vulcano E, Buller LT, Sheth P et al. Anterolateral Impingement (Ankle) 6 min. On physical examination, flatfoot and hindfoot valgus deformity are evaluated with the patient sitting and standing. Up to 14% of the asymptomatic population may have an os trigonum [49]. Additionally, MRI is valuable in the detection of extraarticular, lateral hindfoot impingements in patients with hindfoot valgus deformity. Get new journal Tables of Contents sent right to your email inbox, January/February 2019 - Volume 30 - Issue 1, January/February 2019 - Volume 30 - Issue 1 - p 69-76, Subfibular impingement: current concepts, imaging findings and management strategies, Articles in PubMed by Jonathan R.M. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. 1 Department of Radiology, Musculoskeletal Division, NYU Langone Orthopedic Hospital, NYU Langone Health, 301 E 17th St, 6th Fl, New York, NY 10003. . Correspondence to Duc M. Nguyen, MD, Orthopedic Surgery Resident, University of Miami Miller School of Medicine, Department of Orthopedics, Jackson Memorial Hospital, 1611 NW 12th Ave, Miami, FL 33136 Tel: +305-585-1315; fax: +305-324-7658; e-mail: [emailprotected]. and Amiethab Aiyer and Nguyen, {Duc M.} and Ettore Vulcano and Buller, {Leonard T.} and Pooja Sheth and Jean Jose". 7A, 7B) may be noted on axial, sagittal, or coronal MRI. Current Opinion in Orthopaedics (1999-2007), Clinical Orthopaedics and Related Research (1976-2007). Please refer to our, Orthopaedic Specialty Institute, Orange, CA, Department of Orthopedics, University of Miami Miller School of Medicine, Miami, FL, Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, https://doi.org/10.1097/BCO.0000000000000702. The other authors have no disclosures. The department of radiology provides clinical service to Michigan Medicine, which includes the physically-connected University Hospital, Taubman outpatient center, C.S. Role of imaging and imaging features Conventional radiographs can be used to identify the os trigonum and the lateral tubercle of the talus as well as opposing cystic and sclerotic changes along the synchondrosis [57] (Fig. Ankle impingement, typically secondary to an ankle sprain, is classified according to its anatomic relationship to the tibiotalar joint as anterolateral [2], anterior [3], anteromedial [4], posteromedial [5], or posterior [6] impingement. This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. Methods:: Patients with posterior tibial tendonitis were retrospectively searched and reviewed. Mott Children's Hospital, the von Voigtlander Women's Hospital, Frankel Cardiovascular Center, and Rogel Cancer Center on the main campus. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. 5. CT; Osseous correction of hindfoot deformity is required and consists of calcaneal osteotomy, either at the body (medial calcaneal displacement osteotomy) or at the anterior calcaneus (lateral column lengthening). doi = "10.1097/BCO.0000000000000702". Delaminated Tears of the Rotator Cuff: Prevalence, Characteristics, and Diagnostic Accuracy Using Indirect MR Arthrography, Original Report. Epidemiology It is usually a unilateral phenomenon. 3. Production or aggravation of pain during this maneuver, or so-called positive impingement sign, has been shown to be highly sensitive and specific (94.8% and 88%, respectively) for identifying anterolateral impingement [17]. Level of Evidence: Level V. AB - Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. MRI often is necessary to rule out other causes of ankle pain. [37] noted that medially situated anterior talar osseous outgrowths occur intraarticularly, consistent with osteophytes, whereas lateral outgrowths develop extraarticularly, representing enthesophytes from capsular or ligamentous traction [37]. Article copyright remains with the publisher, society or author(s) as specified within the article. Although the initial injury is usually minor and does not result in clinical ankle instability [2], repetitive microtrauma and subclinical microinstability may lead to soft-tissue abnormalities in the anterolateral gutter. Role of imaging and imaging features Conventional radiographs with the addition of the anteromedial impingement view are helpful in the detection and characterization of spurs and in the visualization of the ankle joint space [43]. Results: Twenty-eight cases (37%) of lateral hindfoot impingement were identified, including six talocalcaneal, eight subfibular, and 14 talocalcaneal-subfibular impingements. MRI of Ankle and Lateral Hindfoot Impingement Syndromes, Original Research. Pathology Etiology Marrow edema was seen infrequently and had no specific distribution [20]. It presents as the sequela of a pathological tibialis posterior dysfunction, which can cause pes planus (flatfoot)and hindfoot valgus deformity. Associated with severe hindfoot deformity, subfibular. A clinical sign that is helpful in differentiating posteromedial impingement and PTT abnormalities is posteromedial tenderness on inversion with the ankle in plantar flexion, which is seen in patients with posteromedial impingement and not in those with PTT abnormalities [5]. Kaplan, MD, Other articles in this journal by Jonathan R.M. Subfibular impingement is one cause of extraarticular ankle impingement associated with lateral ankle pain and is typically associated with pes planovalgus resulting from posterior tibial tendon dysfunction or calcaneal fracture malunion.. How do you treat ankle impingement? 4 Pathophysiology and clinical features Anteromedial impingement is a relatively rare ankle impingement [45]. The responsibility for the publication content rests with the publishers providing the material. Patients with anterolateral impingement present with chronic ankle pain, swelling along the anterolateral aspect of the ankle, and limited dorsiflexion. Address correspondence to A. Donovan ([emailprotected]). CT facilitates accurate assessment of osseous changes between the os trigonum and talus, such as fragmentation of the os and pressure-related erosions along the talus [49]. In a recent cadaveric study, Hayeri et al. These radiographic associations should be recognized by the radiologist, and MRI may be recommended as clinically indicated. Malicky ES, Crary JL, Houghton MJ et al. This is the American ICD-10-CM version of M75.42 - other international versions of ICD-10 M75.42 may differ. Together they form a unique fingerprint. Marrow edema is uncommonly seen with anterior ankle impingement [29, 44]. MRI of Ankle and Lateral Hindfoot Impingement Syndromes. 2 A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. Furthermore, mild posteromedial synovitis was present in two control subjects [20]. MRI; 1. Keywords ;Aiyer, Amiethab Journal of Bone and Joint Surgery (Am) 2002 November 84-A: 2005-2009. . Authors: Kaplan, Jonathan R.M. This website uses cookies. American Journal of Radiology, September 2010, Vol. Clinical presentation varies on the basis of the cause of flatfoot and hindfoot valgus. Conventional arthrography may confirm disruption at the synchondrosis, evident by contrast material collecting within the synchondrosis, and is an excellent tool for performing a diagnostic or therapeutic injection. ; Aiyer, Amiethab ; Nguyen, Duc M. et al. In general, the diagnosis of ankle impingement is clinical, with supporting information provided by radiographs and more advanced imaging (CT, MRI and ultrasound), 3 - 6 which can help further elucidate the anatomic mechanism of impingement, localize pathology to guide diagnostic and therapeutic injections and assist with pre-surgical planning. 195: 595-604 . Calcaneal osteotomy is often necessary to correct hindfoot valgus and lateral hindfoot impingement [7]. The main role of ultrasound is to assist with therapeutic injection of the synchondrosis [56]. Calcaneotalar Coalition and Subfibular Impingement. Kaplan, Amiethab Aiyer, Duc M. Nguyen, Ettore Vulcano, Leonard T. Buller, Pooja Sheth, Jean Jose, Research output: Contribution to journal Review article peer-review. lateral hindfoot impingement; You may be trying to access this site from a secured browser on the server. Regardless of the initial cause of flatfoot, patients with rigid flatfoot deformity experience decreased range of motion at the midfoot and hindfoot and decreased ankle dorsiflexion [72]. In patients with anterolateral impingement, indirect MR arthrography did not offer additional information compared with conventional MRI [29]. On physical examination, there is focal anteromedial ankle tenderness and swelling with limited dorsiflexion and supination [4, 46]. Lateral hindfoot impingement is believed to be secondary to a lateral shift of weight-bearing forces from the talar dome to the lateral talus and fibula [65] and to talocalcaneal joint subluxation [66]. The most common MRI manifestations of talocalcaneal impingement are cystic changes, sclerosis, and edema in the posterior subtalar joint and in the lateral process of the talus and the lateral calcaneus [10] (Figs. A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. Indirect MR arthrography is a noninvasive alternative to direct MR arthrography, which requires IV administration of contrast material followed by 20 minutes of joint exercise. The role of MRI in detecting anteromedial impingement has not yet been established [45] (Fig. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Furthermore, ultrasound can facilitate imaging-guided therapeutic injection of the synovial lesion [20]. 2. 9). (2021) Skeletal Radiology. Impingement is a clinical syndrome of chronic pain and restricted range of movement caused by compression of abnormal bone or soft tissue within the ankle joint. Most patients with posterior impingement respond to conservative management including physiotherapy. MRI often is necessary to rule out other causes of ankle pain. Icahn School of Medicine at Mount Sinai Home, Subfibular impingement: Current concepts, imaging findings and management strategies, https://doi.org/10.1097/BCO.0000000000000702. Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. /. Repetitive kicking in plantar flexion has been postulated to lead to traction on the anterior capsule and enthesophyte formation [37]. Contrast-enhanced fat-suppressed 3D fast gradient-recalled MR acquisition in the steady state with radiofrequency spoiling has been shown to be highly sensitive, although not very specific and accurate, for depicting enhancing vascularized synovial tissue in the anterolateral gutter [27]. 672-678. Several normal osseous and soft-tissue anatomic variants predispose individuals to posterior impingement including a prominent os trigonum, a prominent lateral talar process (Stieda process), a shelflike superior prominence of the calcaneal tuberosity, and a posterior intermalleolar ligament [49, 52]. Search for Similar Articles Glenoid Dysplasia: Incidence and Association with Posterior Labral Tears as Evaluated on MRI, Original Research. ARS offers Prostate Artery Embolization, a procedure performed by an Interventional Radiologist and designed to shrink an enlarged prostate thereby improving urinary tract symptoms. Conventional MRI may play a role in excluding other abnormalities contributing to a patient's symptoms, such as talar osteochondral injuries, but may not be sensitive in detecting subtle capsular changes. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Weerakkody Y, Knipe H, Knipe H, et al. ;Jose, Jean 13A, 13B, 13C and 14A, 14B). your express consent. Peroneal tendon subluxation (Fig. Department of Orthopedics, University of Miami Miller School of Medicine, Miami, FL The accessory anteroinferior tibiofibular ligament may normally contact the anterolateral corner of the talus. MRI may be advantageous compared with ultrasound in differentiating between anterolateral impingement and other potential osseous and intraarticular causes for persistent ankle pain after an ankle sprain such as marrow contusions, chondral defects, osteochondral talar lesions, intraarticular bodies, and sinus tarsi syndrome. Clinical presentation It presen. Imaging findings that correlate well with synovitis or scarring at arthroscopy included nodular or irregular contour of the anterolateral recess. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. title = "Subfibular impingement: Current concepts, imaging findings and management strategies". Data is temporarily unavailable. Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. Impingement results from abnormal contact laterally as the valgus deformity results in sinus tarsi narrowing, which it does normally during eversion (although to a lesser degree in normal individuals)3. (2009) AJR. 13A, 13B, 13C). These include talonavicular arthrodesis, double arthrodesis at Chopart joints, a subtalar arthrodesis, and a triple arthrodesis. Department of Radiology, University of Miami Miller School of Medicine, Miami, FL. Interventional radiology is a fast-growing medical specialty recognized by the American Board of Medical Specialties. Interobserver agreement and accuracy, sensitivity, and specificity in the detection of fibular periostitis, peroneal . Website 2022 Ingenta. Level of Evidence: Level V. Subfibular impingement : Current concepts, imaging findings and management strategies. 4. Thus, it is thought that impingement occurs laterally first through the sinus tarsi and then progresses to the calcaneofibular interval 3. Surgical strategies for the treatment of posteromedial impingement include dbride ment of abnormal soft tissue from the postero medial corner. However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures described for the management of these deforming forces. Subfibular impingement is one cause of extraarticular ankle . On physical examination, there is posterior ankle tenderness and occasionally there may be palpable soft-tissue thickening anterior to, but not involving, the Achilles tendon [6]. @article{573babf591204f73998be74cfa79bf3d. Lateral hindfoot impingement, with extra-articular talocalcaneal impingement and subfibular (calcaneofibular) impingement. Glenohumeral Joint, Wrist and Ankle Plica. In most patients, ultrasound will show hypoechoic, nodular capsular thickening localized to the lateral aspect of the lateral talar process or the os trigonum. A scoring system based on the size and location of radiographically detected spurs is used as a prognostic factor for postoperative success [34, 35]. Similar to other types of ankle impingement, Doppler evaluation does not show increased flow within the abnormal soft tissues. These impingements are sequelae of flatfoot deformity and hindfoot valgus from a variety of causes such as posterior tibial tendon (PTT) deficiency, rheumatologic disorders, diabetes, calcaneal fractures, and congenital flatfoot [7, 8]. Cross-sectional imaging, ultrasound or MRI, is useful for assessing ankle impingement. Finally, marked deformity associated with arthritis and fixed osseous deformity are best managed with arthrodesis. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. Conventional MRI can accurately detect abnormalities at the synchondrosis including opposing marrow edema or fluid signal at the synchondrosis related to motion [49, 50, 59] (Fig. You may search for similar articles that contain these same keywords or you may MRI often is necessary to rule out other causes of ankle pain. On examination, there may be soft-tissue swelling or a palpable spur over the anterior ankle joint [31]. These patients include those with isolated posteromedial synovitis and no associated chondral injury or ligament instability. A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. Role of imaging and imaging featuresIn most cases, conventional, preferably weight-bearing, radiography is the imaging study of choice because anterior impingement is typically related to osseous abnormalities [3, 42]. Unilateral Sacroiliitis: Differential Diagnosis Between Infectious Sacroiliitis and Spondyloarthritis Based on MRI Findings, Clinical Observations. ;Nguyen, Duc M. Compression causing subsequent hypertrophic changes and fibrosis of the posteromedial tibiotalar capsule and posterior deltoid fibersspecifically, those of the posterior tibiotalar ligament between the talus and medial malleolusis suggested as the inciting event for posteromedial impingement [5]. Copyright 2019 Wolters Kluwer Health, Inc. All rights reserved. Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. It is thought to represent a normal variant and may be identified in 2197% of ankles [12, 1416]. 3 Orthopaedic Specialty Institute, Orange, CA 4A, 4B). 1A, 1B). (2017) The British journal of radiology. A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. (2019). Therefore, detection of impingement with MRI at an early stage may be beneficial [10, 74]. MRI often is necessary to rule out other causes of ankle pain. Keywords: ankle impingement, calcaneofibular impingement, extraarticular impingement, MRI, sports medicine, talocalcaneal impingement. This condition is most commonly seen in ballet dancers [51] and soccer players [39]. No Citation information available - sign in for access. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. Calcaneocuboid joint effusion. publisher = "Lippincott Williams and Wilkins Ltd.", Kaplan, JRM, Aiyer, A, Nguyen, DM, Vulcano, E, Buller, LT, Sheth, P & Jose, J 2019, '. However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures described for the management of these deforming forces. Sagittal T1-weighted images may show secondary displacement of normal fat anterior to the fibula by the presence of syno vitis or scar tissue [26]. presence of subfibular impingement, and hindfoot valgus angle measurements. MRI is useful in confirming the diagnosis, evaluating patients with an uncertain clinical diagnosis, and planning surgery. Pathophysiology and clinical features Anterior ankle impingement syndrome is a common cause of chronic ankle pain, especially in ballet dancers and soccer players [31, 32]. Berman Z, Tafur M, Ahmed SS, Huang BK, Chang EY. or neuropathic or inflammatory arthritidies. Ligaments of the Transverse Tarsal Joint Complex: MRIAnatomic Correlation in Cadavers. The most common symptoms include pain and tenderness along the posterior ankle that is exacerbated on plantar flexion or dorsiflexion [6, 55]. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 1A, 1B). Unable to process the form. 6A, 6B). This lateral ankle pain has been attributed to extraarticular lateral hindfoot impingement including talocalcaneal impingement (between the lateral talus and calcaneus) [61] and subfibular impingement (between the calcaneus and fibula) [6264] (Fig. Lateral talocalcaneal and subfibular impingements were defined as signal and morphologic alterations or direct contact at the opposing surfaces of the lateral talus and calcaneus and at the fibula and calcaneus, respectively. There are several causes of lateral hindfoot impingement including PTT dysfunction [67, 68], healed intraarticular calcaneal fractures [69], neuropathic arthropathy [70], and inflammatory arthritides [71]. Clinical presentation MRI features of lateral hindfoot impingement are more commonly seen in patients with advanced PTT tears and with greater MR hindfoot valgus angle [10]. However, there is no associated ligamentous ankle instability. Furthermore, abrasion of the anterolateral talar dome articular surface and secondary chondral injury may develop [15]. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. Kaplan, J. R. M., Aiyer, A., Nguyen, D. M., Vulcano, E., Buller, L. T., Sheth, P., & Jose, J. Impingement can be associated with a prior single traumatic event or repetitive microtrauma, often in an adolescent with anatomical predisposition. Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. The goal of conservative treatment early in the course of the disease is to prevent further disability and progressive deformity. In this review, we describe the pathophysiology, clinical presentation, and imaging features of ankle impingement syndromes and extraarticular impingement syndromes with a focus on MRI findings. Welcome to MyMichigan Health. Anterolateral impingement has also been described in a subset of patients with an accessory fascicle of the anteroinferior tibiofibular ligament [12]. 2 69-76(8), DOI: https://doi.org/10.1097/BCO.0000000000000702, Keywords: Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation. However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures described for the management of these deforming forces. Os subfibulare is an accessory ossicle that lies at the tip of the lateral malleolus of the ankle and is rarely reported 1. MRI can aid in the management of posteromedial impingement by excluding significant concomitant injuries and by identifying patients who may benefit from ultrasoundguided therapeutic injection. 2 In patients with advanced synovitis, the synovial tissue may become molded to the triangular shape of the anterolateral gutter. However, the severity of symptoms is not associated with the presence or size of either of these two structures [6]. Opposing sclerosis and cystic changes may also be seen [7]. MRI Appearance of Wrisberg Variant of Discoid Lateral Meniscus, MRI Findings Associated with Distal Tibiofibular Syndesmosis Injury, Original Research. For patients unable to undergo an MRI examination, CT arthrography may be useful. Less frequent findings include fibular tip marrow edema and contact between the fibula and calcaneus, occasionally with the formation of a neocalcaneal facet (Fig. Statistical analyses were performed using Cochran-Armitage, Fisher's exact, and Mann-Whitney tests. Radiology, 263 (2) (2012), pp. Clinical presentation Os subfibulare are usually asymptomatic although they may eventually cause painful syndromes or degenerative change in response to overuse and trauma. However, routine MRI was found to be more accurate in detecting thickened, nonenhancing scar and in the setting of a joint effusion [28]. 3 topics. However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures described for the management of these deforming forces. 12A, 12B, 12C). Suprapatellar Plica and Inferior Compartmentalized Synovitis. In patients with impingement that is resistant to conservative therapy, imaging-guided therapeutic injection with a mixture of local anesthetic and steroids offers a rapid return to athletic activity and long-lasting symptom relief [56]. Ultrasound is helpful in guiding therapeutic injection of the posteromedial synovial mass in select patients with no associated osteochondral abnormality or joint instability [20]. Conventional weight-bearing ankle radiographs are useful to assess the plantar arch and hindfoot valgus. Arthroscopy and open surgery to remove spurs or soft-tissue abnormalities are effective in patients with no underlying tibiotalar articular disease [3, 34, 36, 40, 41]. The radiologist must recognize, however, that MRI features supportive of impingement may not necessarily be the cause of the patient's pain and that accurate diagnosis requires careful correlation with the clinical picture and, if necessary, dynamic ultrasound for confirmation. By continuing to use this website you are giving consent to cookies being used. Level of Evidence: Level V.". Current concepts, imaging findings and management strategies. The addition of Doppler assessment has not been shown to be helpful [19]. Anteromedial tibial and talar osteophytes are not always detected on lateral radiographs, and additional oblique anteromedial impingement radiographs may be required [43]. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. Radiographs enable evaluation of the spurs and the tibiotalar joint space, both of which are important for diagnosis and preoperative planning (Fig. This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. Furthermore, overall clinical postsurgical outcome depends on the degree of articular cartilage loss and subchondral marrow abnormality along the remainder of the tibiotalar joint [36]. ;Sheth, Pooja Syed Ehtasham Junaid, Anil Haldar, Raul Colta, Karan Malhotra, Kar Ho Brian Lee, Matthew Welck, Asif Saifuddin. Femoroacetabular impingement is an intra-articular or internal form of impingement, where structural changes combined with dynamic factors as repetitive abnormal contact of the acetabulum and the femoral head-neck junction lead to mechanical stress and shear forces on the labrum and chondral surfaces and subsequent damage 1-4. Kaplan, Jonathan R.M. Associated injuries including articular cartilage and ligamentous tears need to be assessed and potentially may need to be repaired during surgery. Pathology. The efficacy of conventional nonarthrographic MRI to detect anterolateral gutter soft-tissue abnormalities remains controversial, with a wide range of sensitivities (39100%) and specificities (50100%) [2123], and has been shown to be accurate in detecting only substantial joint effusions [24]. Case Review with Dr. Donald Resnick & Dr. Rodrigo Aguiar - Part 4. / Kaplan, Jonathan R.M. Advanced lateral hindfoot osseous impingement may show direct contact between the talus and calcaneus or between the lateral calcaneus and fibula. Surgical correction of osseous lateral hindfoot impingement related to hindfoot valgus is increasingly being performed [7]. Pathophysiology and clinical features Anterolateral impingement is thought to be secondary to an inversion injury resulting in disruption of the syndesmotic and/or lateral collateral ligaments and capsule and is typically seen in young athletic patients [11]. In patients with advanced PTT dysfunction, soft-tissue balancing procedures alone are inadequate for restoring the longitudinal arch [73]. foot and ankle surgery; journal = "Current Orthopaedic Practice". Several mechanisms have been proposed for spur formation along the anterior margin of the joint. Surgery for anterolateral impingement is reserved for patients not responding to conservative treatment such as physiotherapy or nonsteroidal antiinflammatory drugs (NSAIDs). Pathophysiology and clinical features Posterior impingement, or so-called os trigonum syndrome, is caused by repetitive plantar flexion leading to compression of bone and soft tissues at the posterior ankle [6, 49, 50]. Check for errors and try again. Assessment of Bony Subfibular Impingement in Flatfoot Patients Using Weight-Bearing CT Scans - Clifford L. Jeng, Tyler Rutherford, Michael G. Hull, Rebecca A. Cerrato, John T. Campbell, 2019 MENU Browse Resources Authors Librarians Editors Societies Reviewers Advanced Search IN THIS JOURNAL Journal Home Browse Journal Current Issue OnlineFirst Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. Kaplan, Jonathan R.M. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. MRI often is necessary to rule out other causes of ankle pain. Pain can be caused by disruption of the cartilaginous synchondrosis between the os trigonum and the lateral talar tubercle due to repetitive microtrauma and chronic inflammation. Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. Administration of IV gadolinium may improve detection of small focal areas of synovitis surrounding the posterior ligaments [60]. The predominant abnormality detected on MRI is spur formation along the anterior tibial rim, medial lateral malleolus, or talar neck and is often accompanied by synovitis and soft-tissue thickening in the anterior recess (Fig. Role of imaging and imaging features Conventional radiographs may show periosteal new bone formation along the posteromedial wall of the talus and along the medial malleolus [5]. ; Source: Current Orthopaedic Practice, Volume 30,Number 1, January/February 2019, pp. No Reference information available - sign in for access. However, the clinical challenge is to exclude other causes of persistent anterolateral ankle pain such as stress fractures, chondral damage, osteochondral lesions of the talus, intraarticular bodies, ankle instability, sinus tarsi syndrome, and peroneal tendon dysfunction. Ingenta is not the publisher of the publication content on this website. Ligamentous and capsular tearing and the resultant microinstability and hemorrhage after an ankle sprain may lead to reactive synovial hyperplasia and scarring in the anterolateral gutter [2] (Fig. Please try again soon. The objective of this article is to review the pathophysiology and clinical presentation of impingement syndromes at the ankle joint (anterolateral, anterior, anteromedial, posteromedial, and posterior) and the role of MRI in evaluating impingement at the ankle joint and at extraarticular locations, lateral to the ankle joint (talocalcaneal and calcaneofibular). Scarring, synovitis, and capsular and anterior deltoid thickening (Fig. Talocalcaneal impingement typically occurs before subfibular or combined talocalcanealsubfibular impingements [9, 10]. More than 8,800 employees, volunteers, health care providers and other personnel working together to create healthy communities and provide award-winning high-quality care for the 938,000 residents in our 25-county service area. 6A, 6B) and ossification (Fig. Some of these abnormalities may coexist with anterolateral impingement and may lead to persistent pain despite surgical resection of the tissues causing impingement. 3: The mechanism is not well understood but is likely a rare complication of a supination (inversion) injury [4, 46] rather than a pronation (eversion) injury as initially hypothesized [45]. Please try after some time. In patients unresponsive to conservative therapy, arthroscopic resection of the os trigonum and any associated soft-tissue abnormality can also result in symptom relief and functional improvement [6, 55]. Although some patients present after an acute injury such as avulsion of the posterior talofibular ligament, disruption of the synchondrosis, or a talar fracture, most patients report insidious development of symptoms related to repetitive athletic activity that requires plantar flexion [6]. Patients with anteromedial impingement often present with chronic anteromedial pain that is exacerbated by dorsiflexion. Wolters Kluwer Health 14A, 14B) may be seen more commonly in patients with moderate or severe hindfoot valgus and in those with combined talocalcanealsubfibular impingement. The authors report no conflicts of interest in regard to this work. MRI is valuable in assessing both osseous and soft-tissue abnormalities associated with impingement syndromes. Unlike anterolateral impingement, osteophytes are an important feature of anteromedial impingement [4]. Associated findings include thickening of the anterior talofibular ligament. Mild osteophytic lipping of the anterior portion of the posterior subtalar joint as well as of the anterior subtalar joint without established osteoarthritis. In cases of sinus tarsi narrowing, calcaneofibular impingement is unlikely to occur without sinus tarsi impingement. Wolters Kluwer Health, Inc. and/or its subsidiaries. The anatomic boundaries of the anterolateral gutter, a triangular-shaped recess, include the tibia posteromedially; the fibula laterally; and the tibiotalar joint capsule, which is reinforced by the anteroinferior tibiofibular, anterior talofibular, and calcaneofibular ligaments, anteriorly and laterally [12] (Fig. 8). N1 - Publisher Copyright: However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures described for the management of these deforming forces. 3 min. No studies have used weight-bearing CT scans to evaluate subfibular impingement. This accessory, or distal, fascicle is separated from the anteroinferior tibiofibular ligament by a fibrofatty septum (Fig. A provocative physical examination test in which a physician attempts to pinch hypertrophied synovium between the tibia and the talus has been described. 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