Physical Therapy for Ankle Impingement

Ankle impingement can occur when either soft or bony tissues are compressed within the ankle joint at the extreme end of a motion, such as pointing the foot sharply downward. This condition commonly affects gymnasts, dancers, runners, and football, soccer, and volleyball players as these activities require either a repetitive kicking motion or repeated extremes of ankle motion in dorsiflexion or plantarflexion. Physical therapy can reduce ankle impingement pain, heal and strengthen the ankle complex, improve overall balance, and help athletes and dancers return to sport and dance safely.

Anatomy of the Ankle

The ankle joint is comprised of three bones that glide and pivot on one another: the tibia (shin bone), the fibula (the thin bone that runs next to the shin bone), and the talus (foot bone that sits above the heel bone). The ankle joint allows up-and-down movement of the foot, while the subtalar joint sits below the ankle joint and allows for side-to-side motion of the foot.

There are numerous ligaments that surround the ankle and subtalar joints, which bind the bones of the legs to each other and those of the foot. There is also a thick covering that surrounds the entire ankle joint (the joint capsule) that keeps the synovial fluid within the joint. The synovial fluid and the smooth cartilage that lines the ends of each bone within the joint allow the ankle joint to move with very low friction.  

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What is Ankle Impingement?

Ankle impingement can occur when either soft or bony tissues are compressed within the ankle joint at the extreme end of a motion, such as pointing the foot sharply downward. Ankle impingement generally affects gymnasts, ballet dancers, runners, and soccer, football, and volleyball players whose athletics require either a repetitive kicking motion or repeated extremes of ankle motion in dorsiflexion (moving ankle up) or in plantarflexion (moving ankle downward).

There are two types of ankle impingement:

1. Anterior ankle impingement: pain is felt at the front of the ankle during ankle motion, squatting, sprinting, stair climbing, or hill climbing. Inflammation and swelling can result due to repetitive stresses at end-range dorsiflexion positions that can lead to the development of bone spurs in the ankle joint space that can compress tissue in the ankle joint.

   Anterior ankle impingement can also be caused by chronic ankle instability, which involves looseness in the ankle joint that develops after repeated ankle sprains and causes damage to the ligaments in the ankle. The ligaments can become scarred and thicken, taking up more joint space and compressing tissue in the ankle during dorsiflexion (stretching toes toward the shin).

2. Posterior ankle impingement: pain is felt on the back side of the ankle, especially when pointing toes. Pain is caused by compression of soft or bony tissue between the shin bone and heel bone. It often occurs due to repeated or forced plantarflexion of the ankle.

Common symptoms of ankle impingement can be broken down into anterior vs. posterior ankle impingement symptoms:

• Anterior ankle impingement symptoms: pain at the front or outside of the ankle joint, ankle instability, decreased ankle range of motion when stretching toes toward the shin, pain at end-range when stretching toes toward the shin, tenderness at front of the ankle when touched.

• Posterior ankle impingement symptoms: pain at the back of the ankle, particularly during activities that require pointing of toes, decreased range of motion when pointing toes, and tenderness at the back of the ankle when touched.

Physical Therapy for Ankle Impingement

Physical therapy can reduce ankle impingement pain, heal and strengthen the ankle complex, improve overall balance, and help athletes and dancers return to sport and dance safely. The physical therapist can also address any lower extremity motion or mechanical factors that are contributing to ankle impingement.

Physical therapy is commonly prescribed for conservative treatment of ankle impingement and is effective in mitigating pain and improving ankle movement, stability, and strength. At the start of rehabilitative treatment, the physical therapist conducts a thorough evaluation, reviewing medical history and assessing ankle strength, range of motion, sensation, balance, and structural stability.

Physical therapy treatment for ankle impingement can include:

• Pain and swelling management using ice, electrical stimulation, and massage

• Manual therapy soft tissue and joint mobilizations to improve the movement of the joint

• Range of motion exercises involving moving the ankle through its available range of motion as well as teaching proper movements to move through to increase ankle mobility and decrease stiffness

• Muscle strengthening of the muscles of the foot, ankle, and lower leg to promote correct joint mechanics as well as stretching of the gastrocnemius and soleus muscles of the calf

• Targeted strengthening of the knee and hip to ensure proper movement and gait mechanics to take stress off the ankle joint

• Balance training to enhance ankle stability and improve spatial awareness and proprioception

• Functional training for sport-and-dance-specific tasks

Research has shown that non-operative physical therapy treatment is effective in treating ankle impingement, demonstrating that a personalized strengthening program in conjunction with proprioception and balance exercises that progressively increase in intensity helps improve static and dynamic stabilization of the ankle and prevent the recurrence of injury.

Are you experiencing persistent ankle pain? Work with a physical therapist to improve your ankle stability, reduce pain, and return to the activities you love!