1. Anterior Ankle Impingement in Gymnasts
Jon Fravel, MS, ATC/L

2. Overview Clinical Interest Anatomical Descriptions Etiology
Gymnastics Overview
Conservative Treatment
Surgical Summary

3. Clinical Interest Ankle injuries are very common in sport
As an outsider a few years ago it seemed there were quite a few gymnasts with ankle “issues”
First case I was involved with at the Univ of Iowa

4. Defining Anterior Ankle Impingement
Footballers Ankle
Morris & McMurray
Chronic anterior ankle pain is commonly caused by talotibial osteophytes at the anterior portion of the ankle joint.
In general, osteophytes are the secondary manifestation of osteoarthritic changes. However, repetitive minor trauma in the ankle, as seen in athletes, can induce spur formation, with radiographic characteristics similar to osteophytes. – van Dijk

5. Exostoses Diagram Hopper & Robinson 2008

6. Tol and van Dijk Classification of Osteoarthritic Changes

7. Etiology Footballers Ankle (Traction Spurs)
The anterior joint capsule attaches on the tibia at an average of 6 mm proximal to the joint level
On the talar side, the capsule attaches approximately 3 mm from the distal cartilage border
The distance of capsular attachment to the most frequent location of bony spurs is thus relatively large
Traction spurs from recurrent traction to the joint capsule is not plausible
On top of this during arthroscopy the spurs are found within the capsule
van Dijk Tol JL, van Dijk CN. Etiology of the anterior ankle impingement syndrome: a descriptive anatomical study. Foot Ankle Int 2004;25:382–6.
van Dijk CN, Tol JL, Verheyen CC.Aprospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement.Am J Sports Med 1997;25: 737–45.
Tol JL, Verheyen CP, van Dijk CN. Arthroscopic treatment of anterior impingement in the ankle. J Bone Joint Surg Br 2001;83:9–13.

8. Footballer’s Ankle
Examination of video showing only a minority of individuals actually reached full plantarflexion during kicking.
Likely bones response to the trauma of the ball contacting the tibia and the talus.
Tol 2002

9. Etiology
O’Donohue (1957) considered the osteophytes to be related to direct mechanical trauma associated with the impingement of the anterior articular border of the tibia and the talar neck during forced dorsiflexion of the ankle.
Bone formation is considered to be a response of the skeletal system to intermittent stress and injury
Wolff’s law of bone remodeling
O’Donoghue DH. Impingement exostoses of the talus and tibia. J Bone Joint SurgAm1957; 39-A:835–52.

10. Etiology
In cadavers a triangle of soft tissue- synovial fold, synovial fat, and collage tissue were found along the anterior jt line.
Repetitive trauma may cause hypertrophy of the synovial layer and and create subsynovial fibrotic tissue also causing infiltration of inflammatory cells.
These osteophytes decrease anterior space and compression of this tissue is more likely to occur.
Berberian WS, Hecht PJ, Wapner KL, et al. Morphology of tibiotalar osteophytes in anterior ankle impingement. Foot Ankle Int 2001;22:313–7.
Ferkel RD, Karzel RP, Del Pizzo W, et al. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med 1991;19:440–6.

11. Anteromedial and Anterolateral Impingement
Murawski 2010

12. Posterior Ankle Impingement
Chronic posterior ankle pain is commonly caused by an os trigonum or other bony impediment
hypertrophic posterior process of the talus.
Hyperplantar flexion (with dancers en pointe or demi pointe but with research does not seem to be the case)
Traumatic event plus this hyperdorsiflexion to cause post ankle impingement
(hard floors, ankle sprains, supination trauma)
Posterior talar prominence becomes compressed between the tibia and the calcaneus during forced plantarflexion. In the presence of an os trigonum, this can lead to micromotion of the os trigonum, and pain.

13. Who
Typically, patients with an anterior ankle impingement are relatively young athletes with recurrent inversion injuries of the ankle
St Pierre RK, Velazco A, Fleming LL. Impingement exostoses of the talus and fibula secondary to an inversion sprain. A case report. Foot Ankle 1983;3:282–5.
Pt present with anterior ankle pain, swelling after activity, and (slightly) limited dorsiflexion. The diagnosis of anterior impingement is clinical, based on physical examination. Recognizable local pain on palpation is present anteriorly, and the osteophytes may be palpable with the ankle joint in slightplantarflexion.
Van Dijk 2001
If pain is anterormedial with palpation it is consiered anteromedial impingement. If pain is anterolateral with palpation it is considered anterolateral impingement
Forced dorsiflexion can often provoke pain but sometimes false negatives.

14. Gymnastics Quite a few injuries in gymnastics
Each gymnast reported an average of 3.64 injuries per 12 month period
4.19 for the elite gymnasts and 3.30 for the subelite gymnasts
In relation to training hours: the elite gymnasts reported 2.63 injuries per 1000 training hours while their subelite counterparts reported 4.11 injuries per 1000 hours
Kolt and Kirby 1999

15. Univ of Iowa Gymnastics
Over the past 1 yr we’ve had 3 surgical cases on the men’s and women’s gymnastics teams.
Most bilateral but not all.
2 more likely scheduled for the end of this year.
1/5 male

16. Univ of Iowa
As I work mostly with the women’s team I reviewed the hx of all of the women’s team over the past 3 yrs.
For that population 10/26 have been diagnosed with these anterior impingement.
38.5%

17. How does this compare? How do you define injury? 1 NCAA
Result from participation in practice
AND Require attn from ATC or MD
AND Restricted participation for 1 or more days
2 Kolt and Kirby (18 mos prospective survey)
Also reviewed injury studies
Snook- Bring attn to a doctor
Sands- Damaged body part that affected training

18. How does this compare? Actual answer is we don’t know.
When asked gymnasts say it is not uncommon.
Kolt and Kirby say 30.7% of the injuries are foot and ankle.
NCAA ISS thru 03-04
23.0% foot and ankle at competition
18.2% foot and ankle at practice

19. When do we see these injuries?
Unscientific and not a lot of evidence to base this on
Women/girls earlier than men/boys
Why? Two thoughts.
Age at peak
Training
Intertwined....

20. Age at Peak Females in the US peak elite at 15.7 yrs
Must be 16 for Olympics by December of that year.
(US levels) USA Gymnastics
1-3 (not often done)
4-10 (belt system in karate) accomplish certain skills or certain scores
Elite
International elite FIG (Federation Internationale Gymnastique)
Most College gymnasts are Level 10, Elite, or International Elite.
Very few international elites at Univ of Iowa.

21. Training and Misc
Problem with men as well, but is more frequently seen with women (in my experience)
Men have 6 events
FX, PH, SR, V, PB, HB (Olympic Order)
Women have 4 events
V, UB, BB, FX (Olympic Order)
Both w/ 2 most LE events
Men spend a different ratio of time dedicated to UE events
Ring strength, pommel strength.
Years to be able to swing pommels.

22. Training and Misc Unfortunately no longer have an NCAA ISS for MGM
@ Iowa 294 Injuries over the past 5 yrs.
29 ankle, 6 foot (for 35 injuries)
22 knee
12, elbow 36 shoulder 34 wrist (82 UE)
13 hand, and 7 clavicle

23. Training and Misc WGM Self Fulfilling
Even before this many elite coaches predict age 16 as peak.
Men no stats for peak, but most agree it is in the late 20’s.
Time to push and push hard.
We now have foam pits in the world of gymnastics but this means more reps.
Safe reps?

24. Triple Double

25. How do we see these injuries
Landing in a hyperdorsiflexed position.
FX 31.1% of the injuries in NCAA ISS
V 27.3% for a combined total of 58.4%.
Warm up, cool down, S&C, other, UB, Beam
Skills
Mostly large skills...
Mostly backwards skills.
Double backflip (tucked, piked, laid out)
Full-in, full-out, double-double, triple double.

26. Gymnastics Explained
Need large skills for points (to reach a 10.0 for WGM or to increase D Score for MGM)
A-E skills
Do backwards because it is easier to spot landings and more consistent.
Women have to do one forward skill and that’s all they usually do.
Men can do 1/2’s so you end up rolling out.
Unfortunately lots of power to rotate twice and lots of force c landing 5.0x body weight at take-offs and 17.5x BW at landings
McNitt-Gray J
Same goes for vaulting

27. Landing Short

28. Backwards Over Rotation Video

29. Fwd Under Rotation Video

30. Fwd Over Rotation

31. Other Problem Events Vault! Dismounts on Men’s Pbars
All other dismounting events
Not so much for twisting activities even for back twisting

32. Treatment Acute Treatment Follow impingement tx’s of shoulder
Bring down during inflammatory phase
RICE and protect from activity.
ROM Wall stretches, kneeling stretches,
Toes under, toes out.
Strengthening.

33. Chronic Treatment Bring down during the inflamm phase Strengthening
Assist in plantarflexion anything
SL Squats
B Heel raise
Step up plus
Weighted bounces
Toe Walks
Eccentric heel raises
Intrinsics to take up the load
Marbles
J’s
Towel Scrunches
Arch-ups
Knee and Hip
Candle stick jumps ups
lunge jump
Box jumps
Fails SL
Larry Nassar Big Green Book

34. Rehab
All conservative rehab is stretching and strengthening –Jackie Alvis
We haven’t mentioned any stretching. Mechanical problem

35. Textbook Orthopaedic Recommendations
Orthopaedic recommendations are “appropriately placed injections or heel lifts”
Dry needling with injection of steroid and local anesthetic can be performed under ultrasound guidance allowing a return to previous levels of activity even in elite athletes, but this technique has not been evaluated in the literature

36. Goals Avoid Landing Short! Extra power at take off
extra absorption of forces at landing
Landing technique
rolling fails
twisting fails
fwd landing/backwards landing

37. Gymnastics Tricks of the Trade
Appearance must be uniform
30 seconds for injury or blood
beam and bars
Taping no rules
Appearance should be uniform
Cover c coflex
Posterior track straps
place in plantar flexion
Elastikon
theraband
Anterior limits
Fx and vault events tennis ball in the front of the ankle.
UCLA team NCAA champs 2010

38. Tennis Ball

39. Tennis Ball Tape

40. Surgery Do they all need them? No. Fwd skills Some do.
no pain c ADL’s
modify gym to avoid over rotation c forward skills
Some do.
limited function out of the gym
failed conservative treatment
Surgical treatment for more resistant cases has a low complication rate and a high level of success.
The previously unsuccessful results of nonoperative treatment for impingement are well recognized in the literature.
Van Dijk reported 62 patients with anterior ankle impingement who did not respond to nonoperative treatment and thus underwent surgery.
Ferkel also reported symptoms of impingement as unresponsive to nonoperative treatment

41. UI Sports Medicine Rehab Protocol
WEIGHT BEARING
ROM
THERAPEUTIC EXERCISES
Initial post-op
1-14 days
Wt.bear as tolerated with crutches. Expect to d/c crutches as able to walk without a limp (approx. 7 days).
0° dorsiflexion, 0-20° plantarflexion.
AROM/AARPOM, Alphabet exercises, Towel stretches, towel scrunches,
Progressive Rehabilitation
(2-4 weeks)
Full weight bearing without pain or limp.
10° dorsiflexion, 35° plantarflexion.
Progress with AROM/AAROM, Progress with strengthening, elastic band exercises along with previous exercises.
Increased Weight bearing activities
(4-6 weeks)
Full ROM
Toe (heel) raises, BAPS board, balancing exercises, biking/ stairmaster/pool. Begin jogging.
Sport Related Activities
(6-8 weeks)
Gradual return to sports specific training and exercises if all symptoms have resolved and full, functional ROM obtained.

42. Surgery Bilateral scopes for the last three cases on the gym teams
Walking right away
4-6 wks of conservative rehab.
8-10 wks before return to sport
from ROM, open chain, closed chain, NM/perturbation, plyos, return to sport.

43. Rehab Protocols
Postoperative management involves a compression bandage and partial weight bearing for 3 to 5 days. Patients are instructed to actively dorsiflex.
After surgery the patient was asked to be non-weightbearing for 2 days to prevent fistula formation through the portal incisions and to allow the soft tissues to settle.
Ankle pumps were encouraged the day after surgery for 20 minutes daily.
After 2 days, instruction was given to increase weight bearing as tolerated.
A postoperative AMI view radiograph was obtained at suture removal to once again assess the removal of the osseous impingement. The soft tissue aspect of AMI was evaluated clinically by pressing in the medial soft spot and dorsiflexing the ankle joint at final follow-up.
Physical therapy was commenced 1 week to 10 days after surgery once the sutures were removed.

44. Rehab Protocols
Patients discharged from hospital same day with a posterior splint. Non-weightbearing for 5 days. Treated w/ anti-inflammatory meds for 6 wks and postoperative physiotherapy consisting of early passive and active ROM and strengthening exercises, proprioceptive training, and functional exercises specific to dance technique.
Nihal

45. Surgical Results Diagnosis Procedure Overall Result VAS (mean ± SD)
From the late 1980s, several authors have published retrospective studies on management of anterior ankle impingement. Good/excellent results varied between 57% and 67%, with an overall complication rate from 10% to 15%.
90% of those without joint space narrowing had good or excellent results
van Dijk 1997
15 soft tissue impingement and 14 anterior bony impingement cases out of a 79 ankle series.
Amendola 1996
Diagnosis
Procedure Overall Result VAS (mean ± SD)
2-yr Follow Up Overall Result VAS (mean ± SD) p
Soft tissue impingement
4.3 ± 3.7
8.3 ± 3.4
.02
Anterior bony
impingement
3.1 ± 3.7
7.7 ± 3.2
.008

46. Recurrence?
Coull and colleagues reported recurrence of osteophytes in all their 27 patients who underwent open debridement.
Coull 2003
At follow-up, most ankles in which osteophytes had recurred were asymptomatic. It is not the osteophyte itself that is painful but the compression of the synovial fold or fibrotic (scar) tissue causes pain.
van Dijk 2001
1/11 Reccurence in elite dancers. 9 years following initial surgery.
Nihal 2005.
Patients who had osteophytes without joint space narrowing (grade I, 82% good/excellent results) showed significantly better results than did patients who had joint space narrowing (grade II, 50% good/excellent results;
20/30 Recurrent exostoses in 5-8 years
Tol 2006

47. Surgery
This has allowed grade B recommendations for the use of ankle arthroscopy for the treatment of ankle impingement
Grading and Assigning a Category of Recommendation for Summaries or Reviews of Orthopaedic Studies
A Good evidence (Level I studies with consistent findings) for or against recommending intervention
B Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention
C Poor-quality evidence (Level IV or V studies with consistent findings) for or against recommending intervention
I Insufficient or conflicting evidence not allowing
Glazebrook 2009
Evidence based indications for ankle surgery.
Level I High-quality randomized trials with
statistically significant difference or no
statistically significant difference but narrow
confidence intervals. Systematic reviews of
Level I RCT (and study results were
homogeneous).
Level II Lesser-quality RCT (e.g., 80% follow-up, no
blinding, or improper randomization).
Prospective comparative studies. Systematic
reviews of Level II studies or Level I
studies with inconsistent results.
Level III Case-control studies. Retrospective
comparative studies. Systematic reviews of
Level III studies.
Level IV Case series
Level V Expert opinion

48. Summary Anterior ankle impingement is relatively common in gymnasts
There are some conservative treatments that can be used
Surgery is effective in treating this condition
Rehabilitation is relatively straight forward

49. Perfect Tumbling

50. Questions
Questions?
Comments?
Concerns?