Prospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Oct 18, 2019; 10(10): 364-370
Published online Oct 18, 2019. doi: 10.5312/wjo.v10.i10.364
Posterior ankle impingement–an underdiagnosed cause of ankle pain in pediatric patients
Indranil Kushare, Kristen Kastan, Sachin Allahabadi
Indranil Kushare, Kristen Kastan, Department of Orthopaedics, Texas Children’s hospital, The Woodlands, TX 77384, United States
Sachin Allahabadi, Department of Orthopaedics, University of California, San Francisco, CA 94143, United States
Author contributions: Kushare I designed and performed the research; Kastan K and Allahabadi S contributed to data acquisition; Kushare I, Allahabadi S analyzed the data and wrote the article; Kushare I, Kastan K and Allahabadi S contributed to editing, reviewing and final approval of article.
Institutional review board statement: The study was reviewed and approved by Baylor College of Medicine Institutional Review Board.
Clinical trial registration statement: Since this is a descriptive study and not a clinical trial, it was not registered.
Informed consent statement: The legal guardians of all the study participants provided written, informed consent about personal and medical data collection prior to enrollment in the study.
Conflict-of-interest statement: There is no conflict of interest associated with the senior author or other coauthors who contributed their efforts in this manuscript. All the authors have no conflict of interest related to the manuscript.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript (even though it was not a randomized control trial) was prepared and revised according to the CONSORT 2010 Statement as applicable.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Indranil Kushare, DNB, MBBS, Assistant Professor, Pediatric Orthopaedic Surgeon, Orthopedic Surgery, Texas Children's Hospital, 17850 I-45 South, Woodlands, TX 77384, United States. ikushare@texaschildrens.org
Telephone: +1-617-6029365 Fax: +1-936-267-7914
Received: June 3, 2019
Peer-review started: June 4, 2019
First decision: July 31, 2019
Revised: August 8, 2019
Accepted: September 15, 2019
Article in press: September 15, 2019
Published online: October 18, 2019
Abstract
BACKGROUND

Posterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population.

AIM

To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.

METHODS

This descriptive prospective study at a tertiary children’s hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up.

RESULTS

35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94).

CONCLUSION

This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.

Keywords: Ankle impingement, Ankle pain, Os trigonum, Delayed diagnosis, Ankle arthroscopy, Pediatric

Core tip: Our prospective study included 35 patients under 18 years of age diagnosed with posterior ankle impingement syndrome (PAIS) who underwent arthroscopic treatment for failed conservative management. We found that there was an average of 19 mo delay in diagnosis from initial presentation to a medical provider. All patients had posterior ankle tenderness which was used to make the clinical diagnosis. The pain relief with arthroscopic debridement, as evidenced by improvement of Visual Analogue Scale and American Orthopedic Foot Ankle Society scores was used to confirm our clinical diagnosis of PAIS. Our study shows that there needs to be an increased awareness about PAIS is needed amongst providers treating young patients.