Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role?

  • Indranil Kushare
  • Matthew G. Ditzler
  • Siddharth P. JadhavEmail author
Original Article



Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.


To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.

Materials and methods

Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.


Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager’s fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).


PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.


Ankle Children Impingement Magnetic resonance imaging Os trigonum Posterior ankle impingement Stieda process 


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Bojanic I, Janjic T, Dimnjakovic D et al (2015) Posterior ankle impingement syndrome. Lijec Vjesn 137:109–115PubMedGoogle Scholar
  2. 2.
    Giannini S, Buda R, Mosca M et al (2013) Posterior ankle impingement. Foot Ankle Int 34:459–465CrossRefGoogle Scholar
  3. 3.
    Hayashi D, Roemer FW, D'Hooghe P, Guermazi A (2015) Posterior ankle impingement in athletes: Pathogenesis, imaging features and differential diagnoses. Eur J Radiol 84:2231–2241CrossRefGoogle Scholar
  4. 4.
    Kudaş S, Dönmez G, Işık Ç et al (2016) Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes. Acta Orthop Traumatol Turc 50:649–654CrossRefGoogle Scholar
  5. 5.
    Maquirriain J (2005) Posterior ankle impingement syndrome. J Am Acad Orthop Surg 13:365–371CrossRefGoogle Scholar
  6. 6.
    Nault ML, Kocher MS, Micheli LJ (2014) Os trigonum syndrome. J Am Acad Orthop Surg 22:545–553CrossRefGoogle Scholar
  7. 7.
    Roche AJ, Calder JD, Lloyd Williams R (2013) Posterior ankle impingement in dancers and athletes. Foot Ankle Clin 18:301–318CrossRefGoogle Scholar
  8. 8.
    Rungprai C, Tennant JN, Phisitkul P (2015) Disorders of the flexor hallucis longus and os trigonum. Clin Sports Med 34:741–759CrossRefGoogle Scholar
  9. 9.
    Russell JA, Kruse DW, Koutedakis Y et al (2010) Pathoanatomy of posterior ankle impingement in ballet dancers. Clin Anat 23:613–621CrossRefGoogle Scholar
  10. 10.
    Peace KA, Hillier JC, Hulme A, Healy JC (2004) MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. Clin Radiol 59:1025–1033CrossRefGoogle Scholar
  11. 11.
    Smyth NA, Zwiers R, Wiegerinck JI et al (2014) Posterior hindfoot arthroscopy: a review. Am J Sports Med 42:225–234CrossRefGoogle Scholar
  12. 12.
    Hopper MA, Robinson P (2008) Ankle impingement syndromes. Radiol Clin North Am 46:957–971, vCrossRefGoogle Scholar
  13. 13.
    Toolan BC, Wright Quinones VJ, Cunningham BJ, Brage ME (2001) An evaluation of the use of retrospectively acquired preoperative AOFAS clinical rating scores to assess surgical outcome after elective foot and ankle surgery. Foot Ankle Int 22:775–778CrossRefGoogle Scholar
  14. 14.
    Coetzee JC, Seybold JD, Moser BR, Stone RM (2015) Management of posterior impingement in the ankle in athletes and dancers. Foot Ankle Int 36:988–994CrossRefGoogle Scholar
  15. 15.
    Yasui Y, Hannon CP, Hurley E, Kennedy JG (2016) Posterior ankle impingement syndrome: A systematic four-stage approach. World J Orthop 7:657–663CrossRefGoogle Scholar
  16. 16.
    Luk P, Thordarson D, Charlton T (2013) Evaluation and management of posterior ankle pain in dancers. J Dance Med Sci 17:79–83CrossRefGoogle Scholar
  17. 17.
    Lopez Valerio V, Seijas R, Alvarez P et al (2015) Endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players. Foot Ankle Int 36:70–74CrossRefGoogle Scholar
  18. 18.
    Theodoulou MH, Bohman L (2016) Arthroscopic approach to posterior ankle impingement. Clin Podiatr Med Surg 33:531–543CrossRefGoogle Scholar
  19. 19.
    Miyamoto W, Takao M, Matsushita T (2015) Hindfoot endoscopy for posterior ankle impingement syndrome and flexor hallucis longus tendon disorders. Foot Ankle Clin 20:139–147CrossRefGoogle Scholar
  20. 20.
    Russo A, Zappia M, Reginelli A et al (2013) Ankle impingement: a review of multimodality imaging approach. Musculoskelet Surg 97(Suppl 2):S161–S168CrossRefGoogle Scholar
  21. 21.
    Wiegerinck JI, Vroemen JC, van Dongen TH et al (2014) The posterior impingement view: an alternative conventional projection to detect bony posterior ankle impingement. Arthroscopy 30:1311–1316CrossRefGoogle Scholar
  22. 22.
    Chokkappan K, Srinivasan S, Subramanian M, Kannivelu A (2015) Os trigonum - sheer incidental or quite significant? Single photon emission computed tomography/computed tomography's role in a case of ankle impingement. World J Nucl Med 14:205–208CrossRefGoogle Scholar
  23. 23.
    Ribbans WJ, Ribbans HA, Cruickshank JA, Wood EV (2015) The management of posterior ankle impingement syndrome in sport: a review. Foot Ankle Surg 21:1–10CrossRefGoogle Scholar
  24. 24.
    Lavery KP, McHale KJ, Rossy WH, Theodore G (2016) Ankle impingement. J Orthop Surg Res 11:97CrossRefGoogle Scholar
  25. 25.
    Vasukutty NV, Akrawi H, Theruvil B, Uglow M (2011) Ankle arthroscopy in children. Ann R Coll Surg Engl 93:232–235CrossRefGoogle Scholar
  26. 26.
    Wong GNL, Tan TJ (2016) MR imaging as a problem solving tool in posterior ankle pain: a review. Eur J Radiol 85:2238–2256CrossRefGoogle Scholar
  27. 27.
    Al-Riyami AM, Tan HK, Peh WCG (2017) Imaging of ankle impingement syndromes. Can Assoc Radiol J 68:431–437CrossRefGoogle Scholar
  28. 28.
    Sellon E, Robinson P (2017) MR imaging of impingement and entrapment syndromes of the foot and ankle. Magn Reson Imaging Clin North Am 25:145–158CrossRefGoogle Scholar
  29. 29.
    Ogut T, Yontar NS (2017) Treatment of hindfoot and ankle pathologies with posterior arthroscopic techniques. EFORT Open Rev 2:230–240CrossRefGoogle Scholar
  30. 30.
    Smyth NA, Murawski CD, Levine DS, Kennedy JG (2013) Hindfoot arthroscopic surgery for posterior ankle impingement: a systematic surgical approach and case series. Am J Sports Med 41:1869–1876CrossRefGoogle Scholar
  31. 31.
    Sundararajan PP (2012) Combined arthroscopic and fluoroscopic guidance in the atraumatic treatment of posterior ankle impingement syndrome. J Foot Ankle Surg 51:687–689CrossRefGoogle Scholar
  32. 32.
    Ahn JH, Kim YC, Kim HY (2013) Arthroscopic versus posterior endoscopic excision of a symptomatic os trigonum: a retrospective cohort study. Am J Sports Med 41:1082–1089CrossRefGoogle Scholar
  33. 33.
    Carreira DS, Vora AM, Hearne KL, Kozy J (2016) Outcome of arthroscopic treatment of posterior impingement of the ankle. Foot Ankle Int 37:394–400CrossRefGoogle Scholar
  34. 34.
    Galla M, Lobenhoffer P (2011) Technique and results of arthroscopic treatment of posterior ankle impingement. Foot Ankle Surg 17:79–84CrossRefGoogle Scholar
  35. 35.
    Gasparetto F, Collo G, Pisanu G et al (2012) Posterior ankle and subtalar arthroscopy: indications, technique, and results. Curr Rev Musculoskelet Med 5:164–170CrossRefGoogle Scholar
  36. 36.
    Georgiannos D, Bisbinas I (2017) Endoscopic versus open excision of os trigonum for the treatment of posterior ankle impingement syndrome in an athletic population: a randomized controlled study with 5-year follow-up. Am J Sports Med 45:1388–1394CrossRefGoogle Scholar
  37. 37.
    Guo QW, Hu YL, Jiao C et al (2010) Open versus endoscopic excision of a symptomatic os trigonum: a comparative study of 41 cases. Arthroscopy 26:384–390CrossRefGoogle Scholar
  38. 38.
    Best A, Giza E, Linklater J, Sullivan M (2005) Posterior impingement of the ankle caused by anomalous muscles: a report of four cases. J Bone Joint Surg 87:2075–2079CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of OrthopedicsTexas Children’s HospitalHoustonUSA
  2. 2.E. B. Singleton Department of Pediatric RadiologyTexas Children’s HospitalHoustonUSA

Personalised recommendations