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:
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.
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
Research background

Posterior ankle impingement is a known cause of ankle pain which has been well described in adults but not as much in the pediatric literature.

Research motivation

The diagnosis of posterior ankle impingement syndrome (PAIS) is made based on detailed history and clinical findings. We came across patients with missed diagnosis of PAIS in clinic and realized that without adequate awareness, this diagnosis can possibly be missed in pediatric and adolescent patients.

Research objectives

The purpose of our study was to identify and characterize the delay in making the diagnosis of PAIS in the young patient population.

Research methods

We started a prospective study to enroll patients under 18 years of age who were diagnosed with PAIS and underwent arthroscopic treatment after failed conservative management. Data collection was done to try and identify any delay in making this diagnosis by the previous treating medical providers. Pre and post treatment pain and American Orthopedic Foot Ankle Society (AOFAS) scores were also noted and compared.

Research 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 to a medical provider. 25 (71%) patients had previously seen multiple medical providers. 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%). At an average follow-up of 13.1 mo after treatment, there was significant improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 93.4) (P < 0.001).

Research conclusions

The study concludes that PAIS is a misdiagnosed condition in the pediatric population.

It was shown that a variety of medical providers (pediatricians, orthopedic surgeons, sports physicians, etc.) missed this diagnosis. There needs to be increased awareness about this condition among medical providers treating young patients.

Research perspectives

The study makes us aware about the delayed diagnosis if PAIS which can be prevented by detailed history taking and examination. This research can be potentially improved in the future by collecting multi-center data to include larger cohort of patients.