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Clinical Observations |
1 Leeds Teaching Hospitals, St. James University Hospital, Chancellor Wing,
Beckett St., Leeds LS9 7TF, UK.
2 Department of Orthopedic Surgery, Bradford Royal Infirmary, Bradford,
UK.
Received April 8, 2005;
accepted after revision June 7, 2005.
Address correspondence to P. Robinson
(p.robinson{at}leedsth.nhs.uk).
Abstract
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CONCLUSION. The results show a role for sonographically guided steroid and anesthetic injection into a posterolateral capsule abnormality in athletes with clinical posterior impingement. The procedure was well tolerated and allowed a rapid return to athletic activity in all patients.
Keywords: ankle • MRI • musculoskeletal imaging • sonography • sports medicine • trauma
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As the ankle starts to plantar flex, the restraint to inversion is increasingly provided by the ligaments, which explains why most ligament injuries in soccer players occur during takeoff or landing—that is, when the ankle is naturally in a plantar-flexed position.
The anterior talofibular ligament is the primary restraint to inversion, anterior translation, and internal rotation of the talus and is the most commonly injured. The calcaneofibular ligament comes under greatest strain as inversion is applied and the ankle moves into dorsiflexion. If the ankle is inverted in neutral position, the calcaneofibular ligament and posterior talofibular ligament are most at risk [4].
Inversion injury of the ankle in the neutral position is not rare in soccer players and generally occurs during tackling [1]. When injury to the posterior talofibular ligament has occurred, as the initial anterolateral symptoms, bruising, and swelling settle, the player can develop symptoms of posterior ankle pain that prevent return to competition and training. These symptoms are generally noticed as the player starts to try and sprint, push off on changing direction, or strike through the ball, which all result in forcible plantar flexion of the ankle.
The aim of this report is to describe the use of MRI and to evaluate the efficacy of sonographically guided injection of steroid and anesthetic in the management of 10 professional soccer players who sustained an inversion injury of the ankle in the neutral position and subsequently developed posterior impingement.
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Clinical Assessment
All players were referred to an experienced foot and ankle sports
orthopedic surgeon by team clinicians after initially experiencing an acute
inversion injury in the neutral position during a tackle. The mechanism of
injury was obtained from history and videotape data
(Fig. 1). Despite
rehabilitation with resolution of anterior and lateral symptoms, all players
developed posterior pain that was resistant to conservative therapy 3-4 weeks
after the initial injury. The pain limited sprinting and striking through the
ball and prevented the players from returning to competition. All the players
denied any previous posterior ankle pain.
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MRI Evaluation
All players underwent MRI of the ankle after clinical examination by a foot
and ankle surgeon (mean, 2 days after injury; range, 1-5 days after injury).
All MRI examinations were performed on a 1.5-T system (Intera, Philips Medical
Systems). For each examination, axial proton density-weighted (TR/TE,
2,903/15; echo-train length, 8); sagittal T1-weighted conventional spin-echo
(400/13); and axial (2,000/90; echo-train length, 14), sagittal, and coronal
T2-weighted fast spin-echo fat-suppressed (3,242/90; echo-train length, 9)
images were obtained. In the last five players, additional axial and sagittal
T1-weighted spin-echo fat-suppressed (456/12) contrast-enhanced (Magnevist
[gadopentetate dimeglumine], Schering-Plough) images were also obtained. These
sequences were added to the routine imaging protocol to highlight enhancement
within the capsular and pericapsular soft tissues
[5,
6]. A formal comparison of
imaging sequences was not performed.
All images were obtained using a head coil (Synergy, Philips), with a slice thickness of 3 mm, field of view of 127-160 mm, and matrix of 256 x 256. MR images were evaluated by a musculoskeletal radiologist for the presence and distribution of capsular synovitis, bone marrow edema, os trigonum, and—if present for synchondrosis disruption—collateral ligament, osteochondral, and tendon and tendon sheath abnormalities (Figs. 2A, 2B, 2C, 3A, 3B, 3C, 4A, and 4B).
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Sonographically guided injection was then performed into the posterior capsule abnormality and, if present, around the os trigonum. The median time between MRI and sonography was 2 days (range, 1-7 days). After choosing a probe position to visualize the posterolateral tissues and using aseptic technique, the operator guided a 20- or 23-gauge needle directly to the abnormal area of the posterior capsule. Dry needling (i.e., multiple passes without injection) throughout the abnormal tissues and then subsequent infiltration of the abnormal tissues with 40 mg of triamcinolone acetonide (Kenalog, Bristol-Myers Squibb) and 3 mL of 0.5% bupivacaine hydrochloride (Marcain, AstraZeneca) were performed (Figs. 2A, 2B, 2C, 3A, 3B, and 3C). If an os trigonum was present, the needle was advanced onto the ossicle with injection of the superficial and deep aspects.
Follow-Up
Thirty minutes after receiving an injection, the player could leave the
department; he was instructed to rest for 48-72 hours and commence light
training with gradually increasing intensity over the next 10-14 days. Players
were followed up by telephone interview at 4 weeks and again at 6-month
intervals. Any further interventions or surgical procedures were recorded.
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Sonographically Guided Injection
Posterolateral hypoechoic capsule thickening that was nodular and localized
to the lateral aspect of the lateral talar process or os trigonum was seen in
all patients (n = 10) (Figs.
2A,
2B,
2C,
3A,
3B, and
3C). Doppler interrogation did
not show flow within the abnormal tissues. The os trigonum was identified in
both patients as well as the associated fragment in one of these patients.
Although the synchondrosis could not be visualized directly because of
acoustic shadowing from the ossicles, the needle could easily be directed to
the deep aspect of the fragment and os trigonum (Figs.
3A,
3B, and
3C).
All patients tolerated the injection procedure with no immediate or delayed complications. All patients noted a marked decrease in symptoms and stiffness immediately after the injection of bupivacaine.
Clinical Follow-Up
The median follow-up for all players was 26 months (range, 6-42 months).
All players had returned to their previous level of playing within 3 weeks of
injection.
The players who originally had posterolateral synovitis and no os trigonum (n = 8) did not experience any residual or recurrent symptoms on follow-up (median, 31 months; range, 18-42 months).
The two players with posterolateral synovitis and an os trigonum on imaging had recurrence of symptoms at 4 and 6 months after the injection, respectively. These players underwent repeat sonographically guided injection, and both players again returned to professional play within 3 weeks. One player subsequently underwent endoscopic resection of the os trigonum and synovitis during the off season (4 months after the second injection). The second player is still playing and remains pain free (5 months after the second injection).
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Posterior impingement has been classically described in ballet performers but is also common in professional soccer players [7, 11, 12]. Posterior soft-tissue injury occurs during compression between the posterior process of the calcaneus and the posterior tibia. The lateral posterior process of the talus is also important because if it is prominent or an os trigonum is present, additional bone impingement with these structures can occur [7]. In soccer, repeated plantar flexion occurs during sprinting, cutting in, and striking the ball, all of which constitute the majority of soccer-playing activity [1, 2]. Studies have shown that the degree of plantar flexion produced on ball strike exceeds that which can be reproduced on passive clinical examination [2]. These features suggest that there is constant stress on the posterior tibiotalar capsule structures that causes subclinical posterior capsule damage in professional soccer players.
The soft tissues potentially involved in the setting of posterior ankle impingement include the capsule and posterior talofibular, intermalleolar, and tibiofibular ligaments. All of these structures have been described either individually or in combination as contributing to posterior impingement in both surgical and imaging series [13-15]. The imaging abnormalities in the current study consisted of marked posterolateral synovitis involving an intact but thickened posterior talofibular ligament in all cases (Figs. 2A, 2B, 2C, 3A, 3B, 3C, 4A, and 4B). Although the posterior intermalleolar ligament was thickened in seven of the 10 patients, this was not the major imaging abnormality (Figs. 2A, 2B, and 2C).
Stenosing tenosynovitis of the flexor hallucis longus tendon can be the predominant process in ballet dancers who frequently perform "en pointe" but was not clinically evident in this group of soccer players. MRI and sonography also confirmed a normal appearance of the tendon with tenosynovial fluid but no tendon sheath synovitis [7].
The majority of the previous articles about ankle impingement have described posterior impingement developing insidiously over many months with diagnosis and treatment often being delayed [7, 14, 16, 17]. The authors of some articles have also described subgroups of athletes developing posterior impingement immediately after an acute injury [7, 17, 18]. Most athletes described had a symptomatic os trigonum that was presumed to have fractured during an acute inversion injury in plantar flexion [18].
The soccer players in the current study all experienced inversion injuries in the neutral position during tackling, and an os trigonum was present in only two patients. None of the players had acute posterior symptoms but presented with insidious onset after 3-4 weeks as rehabilitation progressed. Professional soccer players can present with chronic posterior impingement; however, we believe this particular mechanism of injury produced a strain and hemorrhage of the posterior talofibular ligament and capsule tissues that, superimposed on a presumed background level of capsule damage, was sufficient to precipitate posterior impingement as the tissues attempted repair.
Injection therapy for posterior impingement has been described but mainly in the form of anesthetic injection to temporarily reduce symptoms and confirm diagnosis [7, 14, 19]. A number of surgical series describe ineffective results with steroid injection, but most of the procedures were not imaging-guided and additional bias occurred because only the athletes who proceeded to surgery were presented [7, 14, 17]. Another series of 19 recreational and professional athletes with presumed symptomatic os trigonum underwent fluoroscopically guided steroid injection into the synchondrosis [18]. Ten athletes required no further treatment, whereas six athletes required a second injection with the remaining three athletes requiring excision surgery. The authors state the synchondrosis appeared intact in all patients, but they did not give details about the proportion of professional athletes returning to previous activity levels [18].
In the current series, all injections were sonographically guided with needle placement directly into the abnormal posterolateral synovitis providing therapeutic effect in all eight players without an os trigonum. Initial injection in the two players with os trigonum produced relief for 4 and 6 months, respectively, with similar periods of relief reproduced after a second injection. The reason for a shorter duration of effect with these two players compared with the previous os trigonum series [18] may relate to the complete disruption of the synchondrosis and a higher level of athletic activity.
Limitations of this study include its retrospective nature and relatively low case numbers compared with some other series due to the evaluation of a specific subgroup of athletes. The outcome measure used in this study was return to the previous level of professional play rather than response on a hindfoot scoring system. However, the hindfoot scores commonly used were developed for the general population and allow elite athletes to attain excellent scores regarding pain and function but still not be able to return to full athletic activity. There was no control for injection technique to determine if dry needling, soft-tissue disruption, or steroid injection was the most effective component of the procedure. Dry needling and injection are thought to mechanically disrupt tissues, stimulating bleeding and also diluting local inflammatory mediators, but there have been no definitive studies to determine the exact mechanism of therapeutic action [20]. In the two patients with an os trigonum, the second injection performed around the ossicles was intraarticular, which may have been the reason for pain relief; however, as we already stated, previous clinical studies of intraarticular injection have not shown a clear benefit in patients with posterior impingement [7].
A number of effective surgical procedures have been described involving arthroscopic resection of ossicles and synovitis in athletes with posterior impingement resistant to conservative treatment [7, 14, 17]. We present a series of 10 professional soccer players who developed subacute posterior impingement after sustaining an initial inversion injury. Our results show a role for sonographically guided steroid and anesthetic injection into the posterolateral capsule abnormality. The procedure was well tolerated with no complications and allowed a rapid return to previous athletic activity in all patients.
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