Posterior ankle impingement syndrome: A systematic four-stage approach

Abstract

Posterior ankle impingement syndrome (PAIS) is a common injury in athletes engaging in repetitive plantarflexion, particularly ballet dancers and soccer players. Despite the increase in popularity of the posterior two-portal hindfoot approach, concerns with the technique remain, including; the technical difficulty, relatively steep learning curve, and difficulty performing simultaneous anterior ankle arthroscopy. The purpose of the current literature review is to provide comprehensive knowledge about PAIS, and to describe a systematic four-stage approach of the posterior two-portal arthroscopy. The etiology, clinical presentation, diagnostic strategies are first introduced followed by options in conservative and surgical management. A detailed systematic approach to posterior hindfoot arthroscopy is then described. This technique allows for systematic review of the anatomic structures and treatment of the bony and/or soft tissue lesions in four regions of interest in the hindfoot (superolateral, superomedial, inferomedial, and inferolateral). The review then discusses biological adjuncts and postoperative rehabilitation and ends with a discussion on the most recent clinical outcomes after posterior hindfoot arthroscopy for PAIS. Although clinical evidence suggests high success rates following posterior hindfoot arthroscopy in the short- and mid-term it may be limited in the pathology that can be addressed due to the technical skills required, but the systematic four-stage approach of the posterior two-portal arthroscopy may improve upon this problem.

Keywords: Posterior ankle impingement syndrome, Arthroscopy, Endoscopy, Review, Os trigonum

Core tip: A systematic four-stage approach was developed to standardize technical variety of posterior two-portal hindfoot arthroscopy for the treatment of posterior ankle impingement syndrome (PAIS). After making two-portals using the “nick and spread” technique, hindfoot strictures are divided into 4 regions of interest (superolateral, superomedial, inferomedial, and inferolateral) based on the intermalleolar ligament. In each region, anatomical structures are systematically reviewed and treated in regards to the presence of mechanical impingement and inflammation. Clinical evidence suggests high success rates following arthroscopic approach in short- and mid- term follow-up. This technique can help the surgeons optimize the outcomes following two-portal hindfoot arthroscopy for PAIS.