Sprained Ankle: Anterior Impingement Syndrome Symptoms, Diagnosis and Treatment


Sprained Ankle Anterior Impingement Syndrome

Sprained ankle or anterior ankle pain is a widespread pain that is felt around the ankle area especially on the front side. In most cases, symptoms of this condition are nettled when the foot is forced upwards in a process known as dorsiflexion. The pain is caused by an osteophyte, which is a bone spur at the ankle joint’s front. The pain can also be felt in the soft tissues.

Apart from being strongly connected with ankle arthritis, anterior ankle pain can also occur in dancers, runners, soccer players, and those people who consistently load the ankle joint.  There are two types of treatments that can be applied to a patient in this situation: the operative and non-operative ways.

The non-operative means of treating  anterior ankle pain are limiting activities, wearing socks that have a slight heel, taping the ankle, and taking anti-inflammatory medication among other ways.  There are also other operative ways that can be used to treat this condition. They include removing the soft tissue or the bone spur.  But it is not a new thing for the bone spur to recur just after the operation to remove it. This is due to the fact that bone spur is mostly formed as a response to a certain stimulus like the ankle arthritis. The pain in the anterior part of the ankle always varies and is accompanied by other effects. In most cases, a dull or sharp pain would accompany it.

Read also about best on cloud running shoes.

Leg ankle pain, man holding sore and painful foot     Ankle pain - detail


Various symptoms joint together to cause the inflammation at the anterior ankle. It is important to note that the inflammation experienced here is as a result of trauma or a form of a chronic condition like arthritis.  The following are some of the main symptoms that usually accompany this condition.

  • A feeling of instability at the ankle
  • Pain on the outside or the front of the ankle joint
  • You may also feel a reduced ankle range of motions especially when you are stretching your toes on the location of your shin
  • You will feel some pain on your ankle’s back particularly during activities that include pointing your toes
  • You will experience tenderness at both your ankle’s back and front when touched, lowered range of motion whenever you point your toes

These are some of the symptoms that will present whenever you are suffering from anterior ankle pain.


Physiotherapy For Anterior Ankle Pain:   

How Can It Help?   Your physiotherapist will do all they can to enable you to attain your full functional goals once you have been diagnosed with anterior ankle pain.  This will allow you to resume your tasks without any pain.


The treatment of anterior ankle pain may include the following:

  • The management of pain – If you are suffering from inflammation causing pain, then your physical therapist may be forced to use electrical stimulation or ice massage. You may also be asked to lower the level of your activities for a short while. This is done to enable the inflammation in your ankle areas decreases. Muscle strengthening exercise.

To promote the right joint mechanics, it will be very imperative to strengthen all the muscles acting on the ankle, foot, and lower leg.  A strong and properly working muscles will ensure that the joint space in the area of the ankle is perfectly maintained. This, in turn, will lower the risks of the compression of bony or soft tissues.

  • The range of motions Exercises – At times, your physical therapist may want to move the affected ankle through all the range of motion.

They may also teach you the right action that can help you move through so that you can increase its decrease and mobility stiffness.  In other cases, the physical therapist may also carry out joint mobilizations and professionally move the joint in a particular direction as a means of improving its motion.

  • Balance Exercises Balance exercises are given to patients so that they can effectively challenge the way their bodies respond to foreign forces. Such exercises will also make very much aware of the place where your body is in. When your balance is improved, you will have a more stable ankle since your body is in a right position to respond to challenges.
  • Functional Training Once you have been assisted by your physical therapist to lower the inflammation and pain at the anterior ankle, you will move to tasks that are more active and specific.

Your doctor should also make sure that your ankle is in the right position to withstand various channels during sports, occupational or artistic activities.  You should get advice on the right time to begin the exercises you were doing previously. With time, you will be able to progress to other advanced exercises as the pain reduces.

Progression to more intense exercises or even addition of other exercises is allowed as part of the general rule. However, it should only be done when there are no signs of an increase in the symptoms.

You should not self-cure yourself, see a professional health care provider when you experience the symptoms of this condition. You should not also cure anterior ankle pain with a professional medical opinion. Various joint solutions can be used to lower the pain at your anterior ankle, but all are supposed to be taken with an expert medical prescription.

Anterior Impingement Syndrome

What Is It?  Anterior impingement syndrome is a condition where a person feels pain at the front of the ankle. This pain is usually caused by compression of the soft or bony tissue structures when one undertakes duties that include maximal ankle dorsiflexion motion. This condition is known with different names that include the following:

  • Anterior ankle impingement
  • Ankle impingement
  • Footballer’s ankle and
  • Anterior impingement of the ankle.

The Pertinent Anatomy For Ankle Impingement   Two bones make up the ankle joint; the talus, and the tibia. These two bones guide on each other and have articular cartilage that is used to safeguard the tibia’s collision on the talus at any activity that involves weight bearing.  During the ankle dorsiflexion movement, the shin and foot usually move towards one another, and this would mean that the tibia would always approach the talus’ front. This action puts the compressive forces present on the two structures at the ankle joint’s front. Whenever these forces go beyond the limit the ankle can be able to withstand, inflammation and damage of these structures will possibly happen.

What Happens In Anterior Ankle Impingement?  When there is a repeated compression at the anterior or the front part of the ankle joint, synovium and pinching of the joint capsule will be felt immediately. These two causes the pain that is mostly experienced in patients that undergo anterior ankle impingement.  In other instances, the repeated compression felt at the anterior ankle joint can also lead to another condition known as osteophytes or bone spurs. Osteophytes always occur on the talus or tibia’s front edge.

It is a belief that the spurs experienced here can form to assist in safeguarding the surface from the effects of continuous pulling of the joint capsule. This pulling mostly happens on the tibia’s front lips.  The spurs can also help in protecting the cumulative repetition that occurs at the point of bony contact.  Despite the fact that this process can be accelerated with continuous strains at the ankles, it does not have to be connected with arthritis that takes place at the ankle joint.


In most cases, anterior ankle impingement is caused by the following:

  • Recurrent ankle sprains
  • Ankle sprain
  • Activities and tasks that need continuous ankle dorsiflexion like deep squatting or landing.

There are some factors that can predispose you to contact this particular condition. The only person who is highly trained in identifying these conditions and correcting them at the right time is a physiotherapist. When they are rectified in the right time, you will reduce your risks of getting anterior ankle impingement.  There are also various factors that can contribute to the development of anterior ankle impingement. Some of them are listed here below.

  • Joint swelling or stiffness
  • Failing to rehabilitate properly after an injury at the ankle
  • Bony anomalies
  • Muscle tightness
  • Poor foot biomechanics. They may include high arches or flat feet
  • Too much training
  • Inappropriate training techniques – may also involve poor training surfaces or footwear
  • Poor lower limb biomechanics
  • Poor balance or proprioception
  • Poor core stability
  • Inadequate warm up
  • Inadequate recovery periods after participating in games or training sessions

Symptoms  Those who suffer from this particular condition basically present with:

  • Swelling or puffiness of the ankle joint
  • Dull ache experienced at the ankle’s front. It then develops into a sharp pain at the front part of the ankle with excessive weight bearing or dorsiflexion
  • Tenderness of the ankle joint’s front.

Patients may also experience increased symptoms as a result of specific duties and tasks, including;

  • Excessive walking or running, particularly on uneven grounds or uphill
  • Deep lunging or squatting particularly with the knee going forward over the toes
  • Doing a calf stretch while the knee is bent
  • Landing from a high jump onto an uneven ground or on an incline
  • Heavy twisting or lifting activities
  • In other instances, patients may also feel a clicking sensation especially when the ankle is moved in certain directions.


Anterior impingement syndrome can be diagnosed by a qualified physiotherapist after having analyzed your history and even the findings of your physical assessment. In some situations, the physiotherapist may ask you to produce some imaging in regards to your presentation.


X-Rays or standard ankle radiographs can be used when the anterior ankle impingement is being imaged.  There are five phases of the treatment of this condition. Here is the summary.

  • Phase One – mainly involve relieving the pain, reducing the swelling and protecting the injury
  • Phase Two – involves restoring the full range of motions
  • Phase Three – involves restoring the strength of the muscle
  • Phase Four – involves restoring power, high speed, agility, and proprioception
  • Phase Five – involves returning to normal daily activities and your favorite sport

There can also be ankle impingement surgery or specific interventions like injections.


Tibialis Anterior Tendinitis

Tibialis anterior tendinitis is a condition that happens when the muscle is put under too much stress causing degeneration and inflammation of the tendon.

  • In most cases, the condition presents itself with pain in the lower leg’s front shin, or at the foot or ankle.
  • It mainly occurs during activities like running, walking, and kicking.
  • This pain, in most cases, can be a gradual onset, in that; it begins with rest after a particular activity and increases as the activity continues.
  • The Tibialis Anterior muscle originates at the lower leg’s front at the shin bone, it then inserts at various bones of the foot through the tibialis anterior tendon.
  • It is this particular muscle that moves the ankle and foot towards the head in a process known as dorsiflexion. It then offers stability to the foot as it comes back towards the side of the floor, a process known as plantar flexion.

As the muscle contracts with dorsiflexion, it is placed under stress, and damage can occur if this motion is strained or repeated under high force.  The degeneration inflammation and the resultant pain experienced at the tendon are what are called tibialis anterior tendinitis.

What Causes Tibialis Anterior Tendinitis?   Tendinitis happens when the muscle is exerted during such movements like running or walking, particularly while moving uphill and downhill and on uneven grounds.  Large amounts of stress are also placed upon the muscle by sports that include a lot of kicking like rugby or football. This stress can as a result cause damage or inflammation at the muscles.

The repeated tension experience while doing these activities causes the tendons to degenerate over a certain amount of time. This degeneration can result in a series of discomfort and pain.  There are also other contributing risk factors to this condition, and they include poor running techniques, poor footwear, and muscle tightness or weakness in the soleus and gastrocnemius.  It can also be caused by a previous injury to the lower ankle, foot or leg that has failed to be properly rehabilitated.

Symptoms    In most cases, the pain will be very prominent at the lower leg’s front on the foot, ankle, or shin. It can happen during extreme activities like walking, running or playing your favorite sport.  It can also worsen upon rest on a given evening or the following morning.  The symptoms of pain are likely to be reproduced by too much running, walking or kicking, which can, in turn, aggravate the condition even further.  Palpating the tendon at the tibialis anterior  will also feel tender, and this is another symptom.

What Next?  It is very imperative to rest the joint and limit the movements that tend to aggravate the condition’s symptoms.

  • To help ease the pain and even any swelling that may be experienced, icing can be used.
  • Massage is also recommended to assist in relaxing the muscles as well as other strengthening exercises that an injury specialist will be able to prescribe. These strengthening exercises will assist in rebuilding the tendon or muscle and provide it with strength once again.
  • The common cause of this injury is always poor alignment of the pelvis and spine, imbalances, as well as abnormal posture. These are some of the common causes unless a direct injury has been sustained.
  • Due to the spinal-related complications experienced here, the body compensates causing significant stress in the area of the joints. This can predispose to further strains of the muscle and even other continuing distortions to other body parts.

Inferior Tibiofibular Joint Injury 

The inferior tibiofibular joint is the joint that is found between the tibia, that the shin bone, and the smaller lower leg, known as the fibula. These two meet just above the joint of the ankle. When this particular joint and the supporting structures are destroyed or damaged, an inferior tibiofibular joint injury is caused. The effective treatment of this condition is physiotherapy.

How Does The Injury Occur?   The inferior tibiofibular joint injury happens if the leg is twisted or rotated in relation to the foot. This is a common mechanism that can happen when changing the direction quickly or pivoting while sprinting.

The Symptoms Of Inferior Tibiofibular Joint Injury  One thing that the inferior tibiofibular joint injury causes is a pain at the front and just above the joint of the ankle. This pain is in most cases aggravated by activities that need the leg to be rotated. There are also a host of other symptoms of the inferior tibiofibular joint injury and they include the following:

  • Weakness
  • Stiffness
  • Reduced range of movements
  • Biomechanical complications

What You Need To Do If You Have This Condition  You can speed up your recovery over the first 24 to 48 hours by applying the following simple rule. The rule is known as the RICE regime (Rest, Ice, Compression & Elevation).

For the injury to heal, swelling might be necessary, but too much swelling can also delay the process of healing. The RICE rule will tend to lower the flow of blood to the affected area and therefore can possibly reduce the swelling in that particular area.

  • Rest – Rest, in this case, includes reducing the amount of weight that you exert on your leg. If you are experiencing many difficulties while walking, then the use of crutches may be recommended.
  • Ice – Ice should be applied on the affected area, the ankle area to be precise, for fifteen to twenty minutes. It should be done after every one to two hours. When applying the ice, you should use a bag of frozen peas, or just crash the ice and then use a damp cloth to wrap them in.
  • Compression – This technique includes the use of an elastic bandage around the area of your ankle. The bandage shouldn’t be very tight but firm.
  • Elevation – This last application involves lying while your ankle rests on a pillow or a chair that is placed above your heart’s level.

This treatment formula should go on until your physiotherapist has thoroughly assessed you. Ideally, this should be within the first 48 hours of the injury.

Things To Avoid  When you have an injury to the inferior tibiofibular joint, you should stay away from activities and duties that may increase the flow of blood. This is because such actions may lead to swelling and even bleeding in the affected areas. The activities may include the following:

  • Hot showers
  • The consumption of alcohol
  • Heat rubs and other excessive activities

The Treatment  The treatment of the inferior tibiofibular joint injury is done through a process known as physiotherapy. The first thing that your physiotherapist will do is to diagnose your injury and also studies the severity of the injury.  After the first assessment, your treating physiotherapist will then go ahead to devise for you an appropriate plan of treatment. The treatment will involve the following:

  • Electrotherapy
  • Mobilization or Manipulation
  • Range of movement exercises, and
  • Taping

Any Long-Term Effects From This Condition    If the injuries to the inferior tibiofibular joint are properly treated, they will always get better just within a short period and so do not cause any form of long-term effects.  In some cases, surgery may be the only way that can be used to stabilize the joint. But if this stabilization is not properly done in regard to serious injuries to the inferior tibiofibular joint, the patient may develop ankle joint arthritis. This is as a result of excessive tear and wears within the joint.

Posterior Impingement Syndrome

Ankle impingement can be referred to as the atomic structure’s entrapment that causes decreased range of motion of the ankle and pain. It can be classified as either osseous or soft tissue.  A posterior impingement syndrome is a group of abnormal entities that are caused by acute or repetitive forced plantar flexion of the foot. This particular condition is very common in soccer players and ballet dancers, but it can also be seen in any person that is involved in other active sports like running.

The Clinical Presentation Of Posterior Impingement Syndrome    Patients who suffer from this condition complains of chronic and strong posterior pain at the ankle that is even worsened by push-off forces or forced plantar flexion.  These are very common in activities like running downhill, jumping or ballet dancing.  In positions like that, compression always occurs at the bony structures or the soft tissues between the distal tibia posterior aspects or between the posterolateral process and the posterior tibia of the talus. The forced dorsiflexion can also be very painful in some patients.

A physical examination that is always carried out shows pain on palpation during the process of posterolateral talar. It is situated along the posterolateral ankle aspect between the peroneal tendons and the Achilles.  More pain and grinding sensation can be felt as a result of passive forced plantar flexion.  This occurs as the process of posterolateral talar is held between the calcaneus and the posterior tibia.

If the pain reduces as a result of anesthetic injection into the tibiotalar joint’s posterolateral capsule, then that would confirm the diagnosis of this condition.  It is also very important to note that the variant and normal anatomy of the ankle’s posterior aspect plays an important role when it comes to the development of this particular condition.

The Mechanisms Of Injury   The posterior impingement syndrome may complicate the event of an acute traumatic plantar hyperflexion. These may include a sprain at the ankle or maybe any other condition related to continuous low-grade trauma. Most of these traumas are connected in one way or another to plantar hyperflexion as evident with most female ballet dancers.  Posterior impingement from overuse has a much better prognosis due to other injuries that can be sustained following a severely traumatic event.

The Causes  The occurrence of the posterior impingement syndrome is mainly affected by the anatomy of the ankle’s posterior aspect.  Other common causes of this condition are naturally osseous and include the following:

  • The os trigonum
  • A downward sloping tibia’s posterior lip
  • An elongated posterolateral tubercle of the talus
  • An osteophyte resulting from the posterior distal tibia

However, in other cases, the condition can be related to soft tissues. This has been seen in cases that involve post-traumatic scar tissues, loose bodies in the posterior section of the ankle joint, posttraumatic clarifications of the capsule at the posterior joint, and thickened posterior joint capsule.  Any of the mentioned structures may be compressed during the process of plantar hyperflexion.

  • Patients may also feel the pain coming from the posterior ankle’s osseous structures impacting on each other. Pain may also be felt as a result of the compression that exists between the soft tissues that exist between the two opposing osseous structures.
  • The symptoms of all the conditions mentioned here are related to the physical impingement of the soft tissue or osseous structures, which causes painful limitations of the ankle movement’s whole range.
  • The most common cause of this condition is the availability of an os trigonum. The os triginum, in mineral form, appears between the ages of seven and thirteen years and mostly fuses within a period of one year with the talus. This forms the trigonal process.
  • The pain can also be as a result of the cartilaginous synchondrosis disruption that is between the lateral talar tubercle and the os trigonum. This disruption is caused by constant microtrauma chronic inflammation.

The MR Imaging Findings  The MRI findings are very imperative in establishing the posterior impingement syndrome diagnosis. Several MR findings that have been used in this process include the posterolateral talar process, the bone marrow edema, downward sloping of the posterior tibia, fluid around the os trigonum, and a process of posterior calcaneal process.  The marrow edema present in the posterior impingement is the cause of bone impaction and therefore represents the occult fractures or bone contusions.

The Treatment Of Posterior Impingement Syndrome   The first treatment of this condition includes rest, ice, and other non-steroidal but anti-inflammatory medications.  Another treatment procedure that is effective for reduction of swelling and symptom relief is the injection of steroids. However, it should be done under strict ultrasound guidance.

Operative treatments may be recommended if the conservative measures fail. In this process, the locations of soft tissue impingement are always debrided. The os trigonum and the bone spurs are always resected, practically in an open procedure and in light of the proximity of the tibial and sural nerves, and the halluces longus tendon.  Operative results are generally excellent since the structures that cause the impingement are usually removed.  Many runners will be ankle to resume their favorite sport 4 to 6 weeks after the surgery.

Referred Pain From The Lower Back

For anyone who might think that back pain is just back pain, they may be very wrong. Whenever you feel pain in your back, the problem at times may not actually be your back. Once you know about referred back pain, you will learn that back pain is one the last things that you should think of ignoring.  When you feel even the slightest of a back pain, you need to consult your medical professional as soon as possible.

What Is A Referred Pain?

Referred pain can be defined as pain that is felt in one particular place but is as a result of a totally different thing somewhere else.  You may also have low back pain that can be connected to a problem with your tissues. Referred pain at the lower back can be as a result of myriad of health complications that have absolutely nothing to do with your spine.  Referred pain is in most cases felt at the area of the low back and may also radiate into the groin, upper thigh and buttock. The pain moves around in most cases but does not radiate below the knee in most instances.  Do Not Ignore The Following

  • Loss of consciousness
  • Dizziness
  • Rapid rate of heart
  • Vomiting
  • Nausea
  • Clammy skin

If you experience the referred pain from the back alongside any of these symptoms, you should get checked immediately. They are just some of the things that can cause lower back pain.

Diagnosis Of Referred Pain From The Lower Back  It is unfortunate that the brain cannot actually tell the exact source of such pain. But this type of pain can be distinguished from the pain that usually radiates the leg along a particular course of a compressed spinal nerve and any type of radicular pain. This can only be possible after a keen history and physical examination carried out by a professional spine specialist.  It is very important to distinct radicular pain and the referred pain since their treatments considerably ranges.

The Treatment Of Referred Pain From The Lower Back  In general, this condition is treated with similar nonsurgical care as axial pain at the back, and as the low back problem is fixed, the pain will diminish.  The treatment of referred pain from the lower back is non-surgical and may involve either one or all of the following procedures:

  • A period of rest; a short period that ranges between one or two days
  • Physical therapy, active stretching, and exercise
  • Hot pads and ice packs
  • The right medications for the relief of pain

Additional non-surgical may be tried if the mentioned treatments fail to lower the patient’s pain to a manageable level.  Discectomy and Laminectomy surgeries can also be tried to assist the patient in managing the pain.

To Conclude

Any of the conditions that are mentioned in this article can get severe at times. Patients are therefore advised to seek medical attention at the right time before the condition worsens.

The most common ankle complication among many people is the fractures and the sprains. They are also common sports injuries but must be treated before they develop further.

Everybody should have the right access to information that can help him or her make wise health care decisions. The following sources offer certain scientific evidence related to the topics that are covered in this article. They also report the most recent research and provide an overview of how it can be solved.


  1. America Physical Therapy Association; move forward guide, Physical Therapist's Guide to Ankle Impingement, Internet
  2. Sports Injury Clinic, Anterior Ankle Pain, Internet
  3. Benedict F. DiGiovanni, MD, Anterior Ankle Impingement, Internet
  4. Scott Kaar, MD, Anterior Ankle Impingement (Athlete’s Ankle), Internet
  5. John Davis, What is the Best Treatment for Anterior Tibialis Pain?, Internet
  6. PhysioAdvisor.com, Tibialis Anterior Tendonitis, Internet
  7. KIMBERLY RIENECKE, Tibialis & Anterior Tendinitis, Internet
  8. Bridget Ellsworth, Tendinitis of the foot and ankle (non-Achilles), Internet
  9. Christman-Skieller C Merz MK Tansey JP, A Systematic Review of Tibialis Anterior Tendon Rupture Treatments and Outcomes, Internet
  10. Anne Asher, CPT, 4 Causes of Referred Back Pain, Internet
  11. Digestion relief center, Do You Have Lower back pain and Indigestion?, Internet
  12. Ari Ben-Yishay, MD, Low Back Pain with Referred Pain, Internet
  13. Dr. Cathy Fieseler, Ask the Doctor: Persistant Ankle PainWhat can I do for it?, Internet
  14. By Shine John, DPM, Robert W. Mendicino, DPM, and Alan R. Catanzariti, DPM, Mastering Ankle Impingement Syndromes, Internet
  15. Physiopedia, Ankle Impingement, Internet
  17. Marc A Molis, MD, FAAFP; Chief Editor: Craig C Young, MD , Ankle Impingement Syndrome Clinical Presentation, Internet
  18. Dr. Pribut, Q&A Resources, Internet