Impingement can be associated with a prior single traumatic event or repetitive microtrauma, often in an adolescent with anatomical predisposition. 5. These patients include those with isolated posteromedial synovitis and no associated chondral injury or ligament instability. Furthermore, abrasion of the anterolateral talar dome articular surface and secondary chondral injury may develop [15]. Please try after some time. Associated findings include thickening of the anterior talofibular ligament. Check for errors and try again. Introduction Pain localized to the lateral subtalar region is often clinically felt to represent either subtalar joint degeneration or sinus tarsi syndrome. Pain can be caused by disruption of the cartilaginous synchondrosis between the os trigonum and the lateral talar tubercle due to repetitive microtrauma and chronic inflammation. Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. title = "Subfibular impingement: Current concepts, imaging findings and management strategies". subfibular impingement, Affiliations: Ankle impingement syndromes are important causes of persistent ankle pain after an ankle sprain. Ankle impingement, typically secondary to an ankle sprain, is classified according to its anatomic relationship to the tibiotalar joint as anterolateral [2], anterior [3], anteromedial [4], posteromedial [5], or posterior [6] impingement. Ankle impingement syndromes: an imaging review. Ultrasound-guided therapeutic injections can provide symptom relief in appropriately selected patients. Welcome to MyMichigan Health. The aim of operative treatment is to correct the hindfoot valgus and includes 4: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Please refer to our, Orthopaedic Specialty Institute, Orange, CA, Department of Orthopedics, University of Miami Miller School of Medicine, Miami, FL, Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, https://doi.org/10.1097/BCO.0000000000000702. Kaplan, J. R. M., Aiyer, A., Nguyen, D. M., Vulcano, E., Buller, L. T., Sheth, P., & Jose, J. It is classically described in ballet dancers. A scoring system based on the size and location of radiographically detected spurs is used as a prognostic factor for postoperative success [34, 35]. Current concepts, imaging findings and management strategies. Clinical presentation varies on the basis of the cause of flatfoot and hindfoot valgus. 1 Hindfoot valgus (often defined as a tibiocalcaneal angle >11) with one or both of the following 5: Treatment may be non-operative or operative. Using real-time images from X-ray, CT, ultrasound or MRI, interventional radiologists . Case Review with Dr. Donald Resnick & Dr. Rodrigo Aguiar - Part 4. Kaplan, Jonathan R.M. Please try again soon. Kaplan, Jonathan R.M. MRI of Ankle and Lateral Hindfoot Impingement Syndromes, Original Research. Lateral talocalcaneal and subfibular impingements were defined as signal and morphologic alterations or direct contact at the opposing surfaces of the lateral talus and calcaneus and at the fibula and calcaneus, respectively. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. Malicky ES, Crary JL, Houghton MJ et al. These radiographic associations should be recognized by the radiologist, and MRI may be recommended as clinically indicated. ;Aiyer, Amiethab The Achilles tendon may show contracture and tightness [72]. ;Nguyen, Duc M. The MRI features of posteromedial impingement are not specific. lateral hindfoot impingement; Arthroscopic dbridement of the impinging soft tissue has been shown to be effective in many patients [11, 18]. However, routine MRI was found to be more accurate in detecting thickened, nonenhancing scar and in the setting of a joint effusion [28]. Keywords: ankle impingement, calcaneofibular impingement, extraarticular impingement, MRI, sports medicine, talocalcaneal impingement. or neuropathic or inflammatory arthritidies. Level of Evidence: Level V. UR - http://www.scopus.com/inward/record.url?scp=85056811353&partnerID=8YFLogxK, Powered by Pure, Scopus & Elsevier Fingerprint Engine 2022 Elsevier B.V, We use cookies to help provide and enhance our service and tailor content. Finally, marked deformity associated with arthritis and fixed osseous deformity are best managed with arthrodesis. 50 (7): 1317. keywords = "CT, MRI, ankle impingement, extraarticular impingement, foot and ankle surgery, lateral hindfoot impingement, sports medicine, subfibular impingement". (2009) AJR. Get new journal Tables of Contents sent right to your email inbox, January/February 2019 - Volume 30 - Issue 1, January/February 2019 - Volume 30 - Issue 1 - p 69-76, Subfibular impingement: current concepts, imaging findings and management strategies, Articles in PubMed by Jonathan R.M. to maintaining your privacy and will not share your personal information without The diagnosis of anterior impingement is usually clinical, based on anterior ankle pain with limited and painful dorsiflexion [31]. 3 topics. Ultrasound has been shown to correlate well with arthroscopic findings in its ability to detect soft-tissue abnormalities including a synovial mass or capsular nodularity in the anterolateral gutter [19]. Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation. CT facilitates accurate assessment of osseous changes between the os trigonum and talus, such as fragmentation of the os and pressure-related erosions along the talus [49]. Pathophysiology and clinical features Posterior impingement, or so-called os trigonum syndrome, is caused by repetitive plantar flexion leading to compression of bone and soft tissues at the posterior ankle [6, 49, 50]. Donovan A, Rosenberg ZS. In a recent cadaveric study, Hayeri et al. Keywords Imaging findings that correlate well with synovitis or scarring at arthroscopy included nodular or irregular contour of the anterolateral recess. Femoroacetabular impingement is an intra-articular or internal form of impingement, where structural changes combined with dynamic factors as repetitive abnormal contact of the acetabulum and the femoral head-neck junction lead to mechanical stress and shear forces on the labrum and chondral surfaces and subsequent damage 1-4. Lateral ankle pain may develop because of lateral hindfoot impingement. Conventional axial T1 and fluid-sensitive images are optimal for detecting the intermediate- to low-signal synovial hypertrophy and scarring in the anterolateral gutter [2125] (Fig. Associated with severe hindfoot deformity, subfibular. Posteromedial abnormalities were present in all patients with a clinical diagnosis of posteromedial impingement, but posterior and posterolateral synovitis were also seen in these patients [20]. 14A, 14B). A provocative physical examination test in which a physician attempts to pinch hypertrophied synovium between the tibia and the talus has been described. Some error has occurred while processing your request. A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. 2 CT and MRI may have complementary roles in evaluating patients with posterior impingement [58]. 3: No Reference information available - sign in for access. This form of synovitis has been described as a meniscoid lesion [13]. 2. However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures A superimposed rotational mechanism and repeated microtrauma lead to anteromedial capsular thickening and synovitis in the region of the anterior tibiotalar ligament of the deltoid complex [4]. The most common MRI manifestations of talocalcaneal impingement are cystic changes, sclerosis, and edema in the posterior subtalar joint and in the lateral process of the talus and the lateral calcaneus [10] (Figs. In general, the diagnosis of ankle impingement is clinical, with supporting information provided by radiographs and more advanced imaging (CT, MRI and ultrasound), 3 - 6 which can help further elucidate the anatomic mechanism of impingement, localize pathology to guide diagnostic and therapeutic injections and assist with pre-surgical planning. Scarring, synovitis, and capsular and anterior deltoid thickening (Fig. Patients usually present with posteromedial point tenderness and pain between the medial wall of the talus and the posterior margin of the medial malleolus [5, 20]. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. Kaplan, MD, Heterotopic ossification of the hip after stroke, Acellular dermal graft augmentation in quadriceps tendon rupture repair. Thus, it is thought that impingement occurs laterally first through the sinus tarsi and then progresses to the calcaneofibular interval 3. ;Buller, Leonard T. Posterior ankle impingement (PAI) syndrome is one of the impingement syndromes involving the ankle. Contrast-enhanced fat-suppressed 3D fast gradient-recalled MR acquisition in the steady state with radiofrequency spoiling has been shown to be highly sensitive, although not very specific and accurate, for depicting enhancing vascularized synovial tissue in the anterolateral gutter [27]. (2021) Skeletal Radiology. View Record in Scopus Google Scholar. However, in the setting of a prior ankle sprain, posterolateral ankle laxity leads to anterior extrusion of the talar dome with dorsiflexion, increased pressure at the site of contact, and subsequent synovial hypertrophy and impingement between the anterolateral talus and the accessory anteroinferior tibiofibular ligament [12]. These impingements are sequelae of flatfoot deformity and hindfoot valgus from a variety of causes such as posterior tibial tendon (PTT) deficiency, rheumatologic disorders, diabetes, calcaneal fractures, and congenital flatfoot [7, 8]. Malicky, Eric S. MD; Crary, Jay L. MD; Houghton, Michael J. MD; Agel, Julie MA; Hansen, Sigvard T. Jr. MD; Sangeorzan, Bruce J. MD Talocalcaneal and Subfibular Impingement in Symptomatic Flatfoot in Adults, The Journal of Bone & Joint Surgery: November 2002 - Volume 84 - Issue 11 - p 2005-2009. Calcaneal osteotomy is often necessary to correct hindfoot valgus and lateral hindfoot impingement [7]. It is of paramount importance, however, to remember that MRI features supportive of impingement may be present in asymptomatic individuals and that accurate diagnosis requires careful correlation of imaging features with the clinical picture. Pathology. Role of imaging and imaging features Conventional radiographs with the addition of the anteromedial impingement view are helpful in the detection and characterization of spurs and in the visualization of the ankle joint space [43]. 7A, 7B) may be noted on axial, sagittal, or coronal MRI. 7 min. This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. The department of radiology provides clinical service to Michigan Medicine, which includes the physically-connected University Hospital, Taubman outpatient center, C.S. It presents as the sequela of a pathological tibialis posterior dysfunction, which can cause pes planus (flatfoot)and hindfoot valgus deformity. The anatomic boundaries of the anterolateral gutter, a triangular-shaped recess, include the tibia posteromedially; the fibula laterally; and the tibiotalar joint capsule, which is reinforced by the anteroinferior tibiofibular, anterior talofibular, and calcaneofibular ligaments, anteriorly and laterally [12] (Fig. Arthroscopy and open surgery to remove spurs or soft-tissue abnormalities are effective in patients with no underlying tibiotalar articular disease [3, 34, 36, 40, 41]. Results: Twenty-eight cases (37%) of lateral hindfoot impingement were identified, including six talocalcaneal, eight subfibular, and 14 talocalcaneal-subfibular impingements. Level of Evidence: Level V. AB - Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. 4: Extra-articular calcaneofibular impingement (EA-CFI), Extra-articular talocalcaneal impingement (EA-TCI), Extraarticular lateral hindfoot impingement syndrome, Extra-articular lateral hindfoot impingement syndrome (ELHIS), additionally, removal of any subfibular or superolateral calcaneal bone causing impingement. /. MDa; Aiyer, Amiethab MDb; Nguyen, Duc M. MDb; Vulcano, Ettore MDc; Buller, Leonard T. MDb; Sheth, Pooja MDd; Jose, Jean DOd, aOrthopaedic Specialty Institute, Orange, CA, bDepartment of Orthopedics, University of Miami Miller School of Medicine, Miami, FL, cDepartment of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, dDepartment of Radiology, University of Miami Miller School of Medicine, Miami, FL. Surgery for anterolateral impingement is reserved for patients not responding to conservative treatment such as physiotherapy or nonsteroidal antiinflammatory drugs (NSAIDs). Unlike anterolateral impingement, osteophytes are an important feature of anteromedial impingement [4]. In cases of sinus tarsi narrowing, calcaneofibular impingement is unlikely to occur without sinus tarsi impingement. Early detection of impingement using MRI may be beneficial for successful surgical results [9, 10]. Mild osteophytic lipping of the anterior portion of the posterior subtalar joint as well as of the anterior subtalar joint without established osteoarthritis. Pathophysiology and clinical features Anteromedial impingement is a relatively rare ankle impingement [45]. / Kaplan, Jonathan R.M. (2020) Foot & Ankle Orthopaedics. 2: CT is more sensitive than radiography for identifying cystic and sclerotic changes [9]. On physical examination, there is posterior ankle tenderness and occasionally there may be palpable soft-tissue thickening anterior to, but not involving, the Achilles tendon [6]. (2017) The British journal of radiology. Pathophysiology and clinical features Anterior ankle impingement syndrome is a common cause of chronic ankle pain, especially in ballet dancers and soccer players [31, 32]. 6A, 6B) and ossification (Fig. The other authors have no disclosures. Subfibular impingement is one cause of extraarticular ankle . Coronal CT images have been shown to best depict nodular thickening related to synovial impingement [30]. 13A, 13B, 13C and 14A, 14B). or extensive soft-tissue thickening between the fibula and the calcaneus. However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures described for the management of these deforming forces. MRI often is necessary to rule out other causes of ankle pain. Patients with anteromedial impingement often present with chronic anteromedial pain that is exacerbated by dorsiflexion. MRI; Suprapatellar Plica and Inferior Compartmentalized Synovitis. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. A clinical sign that is helpful in differentiating posteromedial impingement and PTT abnormalities is posteromedial tenderness on inversion with the ankle in plantar flexion, which is seen in patients with posteromedial impingement and not in those with PTT abnormalities [5]. It is thought to represent a normal variant and may be identified in 2197% of ankles [12, 1416]. 10A, 10B, 10C). 69-76(8), DOI: https://doi.org/10.1097/BCO.0000000000000702, Keywords: The radiologist must recognize, however, that MRI features supportive of impingement may not necessarily be the cause of the patient's pain and that accurate diagnosis requires careful correlation with the clinical picture and, if necessary, dynamic ultrasound for confirmation. Soft-tissue abnormalities at the posterior ankle such as posterior capsular thickening, ligament disruption, FHL tenosynovitis, and soft-tissue edema and synovitis can also be well depicted by MRI [49, 50, 60] (Figs. Delaminated Tears of the Rotator Cuff: Prevalence, Characteristics, and Diagnostic Accuracy Using Indirect MR Arthrography, Original Report. Clinical presentation The goal of conservative treatment early in the course of the disease is to prevent further disability and progressive deformity. In addition to ankle impingement sy ndromes, extraarticular soft-tissue and osseous impingements occur lateral to the ankle joint, such as talocalcaneal and calcaneofibular impingements [7]. 3 A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. Sagittal T1-weighted images may show secondary displacement of normal fat anterior to the fibula by the presence of syno vitis or scar tissue [26]. Current Orthopaedic Practice30(1):69-76, January/February 2019. 193 (3): 672-8. On physical examination, flatfoot and hindfoot valgus deformity are evaluated with the patient sitting and standing. The authors report no conflicts of interest in regard to this work. Radiology, 263 (2) (2012), pp. Subcortical cyst formation is also prominent within the mid talus and lesser so at the distal fibula with subfibular soft tissue edema. Marrow edema was seen infrequently and had no specific distribution [20]. Role of imaging and imaging features Conventional radiographs can be used to identify the os trigonum and the lateral tubercle of the talus as well as opposing cystic and sclerotic changes along the synchondrosis [57] (Fig. 8). The addition of Doppler assessment has not been shown to be helpful [19]. Pathology Etiology No studies have used weight-bearing CT scans to evaluate subfibular impingement. On ultrasound, hypoechoic nodular posteromedial soft-tissue thickening may be seen deep to the PTT, between the medial malleolus and talus. Methods:: Patients with posterior tibial tendonitis were retrospectively searched and reviewed. MRI often is necessary to rule out other causes of ankle pain. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. Talocalcaneal impingement typically occurs before subfibular or combined talocalcanealsubfibular impingements [9, 10]. In patients unresponsive to conservative therapy, arthroscopic resection of the os trigonum and any associated soft-tissue abnormality can also result in symptom relief and functional improvement [6, 55]. 90 (1070): 20160735. Role of imaging and imaging features Conventional radiographs may show periosteal new bone formation along the posteromedial wall of the talus and along the medial malleolus [5]. Compression causing subsequent hypertrophic changes and fibrosis of the posteromedial tibiotalar capsule and posterior deltoid fibersspecifically, those of the posterior tibiotalar ligament between the talus and medial malleolusis suggested as the inciting event for posteromedial impingement [5]. 1A, 1B). Kaplan, MD, Other articles in this journal by Jonathan R.M. Current Opinion in Orthopaedics (1999-2007), Clinical Orthopaedics and Related Research (1976-2007). Opposing sclerosis and cystic changes may also be seen [7]. Management focuses on limitation of symptom-provoking activity, such as correction of overpronation in ballet dancers, as well as physiotherapy [31]. An additional imaging feature, seen more commonly in patients with clinical anterolateral impingement, includes the absence of the recess between the anterolateral soft tissues and the anterior surface of the fibula despite adequate joint distention with contrast material [25]. Subfibular impingement is one cause of extraarticular ankle impingement associated with lateral ankle pain and is typically associated with pes planovalgus resulting from posterior tibial tendon dysfunction or calcaneal fracture malunion.. How do you treat ankle impingement? 10A, 10B, 10C and 11A, 11B). Interventional radiology is a fast-growing medical specialty recognized by the American Board of Medical Specialties. This accessory, or distal, fascicle is separated from the anteroinferior tibiofibular ligament by a fibrofatty septum (Fig. Furthermore, ultrasound can facilitate imaging-guided therapeutic injection of the synovial lesion [20]. In comparison, anterior osteophyte formation has been attributed to joint abnormalities related to hyperdorsiflexion, microtrauma, ankle instability, and recurrent supination [38, 39]. 3). Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. 9). Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. Department of Radiology, University of Miami Miller School of Medicine, Miami, FL. 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