Os trigonum: a discussion of its role in posterior ankle impingement syndrome and a meta-analysis of its prevalence.

PURPOSE: the os trigonum is a supernumerary bone that may lead to posterior ankle impingement syndrome. The present study aims to assess the prevalence of this bone. METHODS: A meta-analysis regarding the presence of the os trigonum was performed. For this, the MEDLINE and SciElo databases were searched using "os trigonum" as the keyword. Only original articles, theses, books, dissertations, and monographs were included. Papers with a sample size of < 50 individuals were excluded. The data extracted from the articles were: the total sample size, the prevalence of the trigonum, the method of analysis, the region of the sample, and data regarding sex and side (left or right). Statistical analysis was performed using MedCalc Statistical Software version 14.8.1 (MedCalc Software bvba, Ostend, Belgium). The heterogeneity between the studies was assessed using the I² estimation and the Cochran Q test. For all analyses, a random effect was used and a value of p < 0.05 was considered significant. RESULTS: 249 papers were found, while 18 were included in the meta-analysis. A total of 17,626 ankles were included. The pooled prevalence of the os trigonum was 10.3% (95% CI 7-14.1%) in the present study. There was no significant difference regarding sex or side, while studies conducted in imaging exams showed a higher prevalence in comparison to cadaveric studies. CONCLUSION: Our results suggest that the os trigonum is relatively common. Knowledge of the prevalence of the os trigonum may help surgeons and clinicians diagnose posterior ankle impingement syndrome.

Síndrome del impacto posterior del tobillo secundario a proceso de Stieda / Posterior Ankle Impingement secondary to a Stieda process

Introducción: El síndrome de impacto posterior es una condición que resulta de la compresión de tejidos blandos entre la cara posterior del astrágalo y el área posteroinferior de la tibia durante el movimiento de flexión plantar del tobillo y provoca inflamación de los tejidos blandos circundantes. Objetivo: Presentar un caso de síndrome de impacto posterior secundario a proceso de Stieda. Presentación de caso: Se presenta el caso de un varón de 53 años, cocinero de profesión que se quejaba de dolor en la región posterior del tobillo derecho, que se exacerbaba con la flexión plantar del tobillo sin traumatismo previo. Se descartaron lesiones de tipo tendinosas y ligamentosas al examen físico, por lo que se indica radiografía convencional. A través de la radiografía de tobillo se define proceso de Stieda el cual justifica la clínica. Por esto no se realizaron otros estudios. Conclusiones: La radiografía convencional en el contexto clínico de un síndrome de impacto posterior del tobillo permite establecer el diagnóstico sin requerir estudios de imagen de mayor complejidad(AU)

Introduction: The posterior impingement syndrome is a condition resulted of compressed posterior soft tissues, between the posterior talus and the calcaneus. Classically, this is seen at activities that cause extreme plantar flexion. Objective: To describe a posterior Ankle Impingement case secondary to a Stieda process. Case report: We report a 53 years old male, cook profession, with a chronic pain history within the posterior ankle, previous trauma was denied. At clinical examination tendon and ligament injuries were not found. Initial evaluation with conventional radiography showed the presence of a Stieda's process as cause of clinical manifestations. No further imaging studies were required. Conclusion: Conventional radiograph allows to clarify diagnosis in the posterior impingement syndrome(AU)

Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement: A Meta-analysis.

BACKGROUND: Surgical treatment of symptomatic posterior ankle impingement consists of resection of the bony impediment and/or debridement of soft tissue. Historically, open techniques were used to perform surgery with good results. However, since the introduction of endoscopic techniques, advantages attributed to these techniques are shorter recovery time, fewer complications, and less pain. PURPOSE: The primary purpose was to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcome (American Orthopaedic Foot & Ankle Society [AOFAS] score). The secondary aim was to determine differences in return to full activity, patient satisfaction, and complications. STUDY DESIGN: Systematic review and meta-analysis. METHODS: MEDLINE, EMBASE (Classic), and CINAHL databases were searched. Publication characteristics, patient characteristics, surgical techniques, AOFAS scores, time to return to full activity, patient satisfaction, and complication rates were extracted. The AOFAS score was the primary outcome measure. Data were synthesized, and continuous outcome measures (postoperative AOFAS score and time to return to full activity) were pooled using a random-effects inverse variance method. Random-effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients who were satisfied and who experienced complications. RESULTS: A total of 32 studies were included in this review. No statistically significant difference was found in postoperative AOFAS scores between open surgery (88.0; 95% CI, 82.1-94.4) and endoscopic surgery (94.4; 95% CI, 93.1-95.7). There was no difference in the proportion of patients who rated their satisfaction as good or excellent, 0.91 (95% CI, 0.86-0.96) versus 0.86 (95% CI, 0.79-0.94), respectively. No significant difference in time to return to activity was found, 10.8 weeks (95% CI, 7.4-15.9 weeks) versus 8.9 weeks (95% CI, 7.6-10.4 weeks), respectively. Pooled proportions of patients with postoperative complications were 0.15 (95% CI, 0.11-0.19) for open surgery versus 0.08 (95% CI, 0.05-0.14) for endoscopic surgery. Without the poor-quality studies, this difference was statistically significant for both total and minor complications, 0.24 (95% CI, 0.14-0.35) versus 0.02 (95% CI, 0.00-0.06) and 0.14 (95% CI, 0.09-0.20) versus 0.03 (95% CI, 0.01-0.05), respectively. CONCLUSION: We found no statistically significant difference in postoperative AOFAS scores, patient satisfaction, and return to preinjury level of activity between open and endoscopic techniques. The proportion of patients who experienced a minor complication was significantly lower with endoscopic treatment when studies of poor methodological quality were excluded.

Pediatric elbow arthroscopy: clinical outcomes and complications after long-term follow-up.

BACKGROUND: Elbow arthroscopy is becoming increasingly important for the treatment of a wide range of acute and chronic elbow pathologies. Even if elbow arthroscopy is technically demanding, in the pediatric population this minimally invasive technique is preferred by many surgeons for the treatment of pathologies such as osteochondritis dissecans (OCD), posttraumatic stiffness (PTS), or elbow posterior impingement (PI). The aim of this study is to evaluate outcomes and safety of elbow arthroscopy in the pediatric and adolescent population after long-term follow-up. MATERIALS AND METHODS: In this retrospective study, 26 patients younger than 18 years old undergoing elbow arthroscopy were evaluated. All surgeries were performed by a single senior surgeon. Patients were divided into three subgroups based on preoperative diagnosis: OCD, PTS, and PI. After at least 60 months follow-up, several outcome measures, including range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) were evaluated in relation to preoperative values. The level of patient satisfaction on a five-level Likert scale, any limitation or change in sport activity, and the onset of any possible complications were also evaluated. RESULTS: In the study population, we found an improvement in ROM (flexion of 14.4 ± 13.6°, extension of 19.5 ± 13.9°, pronation of 5.8 ± 5.7°, and supination of 8.5 ± 11.6°) and in validated outcome measures (MEPS of 21.0 ± 13.5 points and VAS of 3.8 ± 2.2 points). The satisfaction rate was 4.5, with no dissatisfaction. Eighty-seven percent of patients fully recovered their performance levels, 9% changed sport, and 4% were unable to return to sport. We identified one major and one minor complication, with an overall complication rate of 7.7%. No neurovascular injuries were detected. CONCLUSIONS: Elbow arthroscopy in a pediatric population can be considered an effective and safe procedure for selected pathologies when performed by an experienced surgeon. At long-term follow-up, we reported excellent clinical outcomes (both objective and subjective), with a relatively low complication rate without permanent injuries. LEVEL OF EVIDENCE: Level IV-case series.

Anterior and Posterior Ankle Impingement Syndromes: Arthroscopic and Endoscopic Anatomy and Approaches to Treatment.

Ankle impingement refers to a chronic painful mechanical limitation of ankle motion caused by soft tissue or osseous abnormality affecting the anterior or posterior tibiotalar joint. Impingement can be associated with a single traumatic event or repetitive microtrauma. These syndromes are a possible etiology of persistent ankle pain. An arthroscopic approach to this pathology, when indicated, is considered as ideal treatment with its high safety and low complication rate. We describe the clinical and potential imaging features, and the arthroscopic/endoscopic management strategies, for the 4 main impingement syndromes of the ankle: anterolateral, anterior, antero-medial, and posterior.

Combined anterior and posterior ankle impingement syndrome with nonunion of Cedell fracture in a 58-year-old female: a case report.

BACKGROUND: Combined anterior and posterior ankle impingement has seldom been reported. Cedell fracture, fracture of posteromedial tubercle of talus, is an uncommon and easily missed injury which may elicit posteromedial ankle impingement. The injury mechanisms and management strategies of these two lesions have been reported individually. But the concurrent lesion of both of them has not been reported. CASE PRESENTATION: We reported a 58-year-old female with combined anterior and posterior ankle impingement syndrome with nonunion of Cedell fracture in whom open osteophytes debridement, fracture internal fixation and posterior talotibial ligament reconstruction were performed. The AOFAS hindfoot score was 90 at 1 year follow-up. To our knowledge, this was the first reported case with anterior, posterior and posteromedial impingement which was treated operatively with an excellent short-term outcome. CONCLUSIONS: To fully recognize this occult lesion and avoid missing is imperative for reducing the morbidities. We suggest CT and MRI as excellent imaging modalities that can help the timely diagnosis and appropriate treatment for this combined impingement with circumferential lesions.

Morphological features of the deep component of the posterior inferior tibiofibular ligament.

PURPOSE: The deep component of the posterior inferior tibiofibular ligament (PITFL) was classified by type in this large-scale cadaveric study to provide basic information that will help elucidate the mechanisms underlying ankle joint posterior impingement syndrome. METHODS: This investigation examined 100 legs from 49 Japanese cadavers (mean age at death, 79 ± 11 years; 58 sides from men, 42 from women). In classification, absence of an independent fiber of the deep component of the PITFL were classified as Type I, an independent fiber of the deep component of the PITFL was classified as Type II-a, an independent fiber of the deep component of the PITFL with bundles of fibers connected to the posterior intermalleolar ligament (PIML) was classified as Type II-b, and an independent fiber of the deep component of PITFL with a band shape connected to the PIML was classified as Type III. RESULTS: A deep component of the PITFL was present in all specimens. An independent fiber of the deep component of the PITFL was present in 37 legs (37%), connecting to the deep component of the PITFL and PIML in 26 (70.3%). Several types of deep component of the PITFL were identified: Type I in 63 legs (63%); Type II-a in 11 (11%); Type IIb in 12 (12%); and Type III in 14 (14%). No significant differences were seen between the right and left legs. Type I male were significantly more than Type I female (p < 0.05). Type III female were significantly more than Type III male (p < 0.05). CONCLUSIONS: Strong relationships exist between the PITFL and PIML.

Endoscopic Treatment of Posterior Ankle Impingement Secondary to Os Trigonum in Recreational Athletes.

BACKGROUND: The os trigonum (OT)-the most common accessory bone of the foot-although usually asymptomatic, may cause posterior ankle impingement syndrome (PAIS), which may be a severely debilitating problem for recreational or competitive athletes. The aim of the present study was to evaluate effectiveness of posterior ankle arthroscopy and to assess the outcome in the treatment of PAIS secondary to OT impingement or OT fractures within a group of young athletes and their return to previous sports level. METHODS: From 2011 to 2018, a retrospective review of 81 recreational athletes of mean age 27.8 years was performed. All patients were diagnosed with PAIS due to OT pathology and were operated on endoscopically with resection of the OT. Pre- and postoperative clinical evaluation were performed at 3 months, 1 year, and 2 years based on visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the Foot & Ankle Disability Index (FADI) scores, in a follow-up of at least 2 years. RESULTS: VAS score was significantly improved from an average of 7.5 (5-9) preoperatively to 1.9 (1-3) at 3 months postoperatively and to 0.6 (0-2) and 0.3 (0 -1) at 1 and 2 years postoperatively. Ankle ROM was significantly improved from an average of 24.8 (10-35) preoperatively to 58.0 (50-65) at 3 months postoperatively and to 64.0 (50-65) at 1 year and 64.7 (60-65) at 2 years postoperatively. AOFAS and FADI scores were significantly improved from 39.4 (18-55) and 49.7 (42.3-62.5) preoperatively to 85.2 (74-89) and 87.3 (81.7-88.5) postoperatively at 3 months to 97.7 (85-100) and 97.9 (93.3-100) postoperatively at 1 year, respectively (P < .001). Only 5 patients dropped to a lower activity level. There were 5 complications (4 transient). CONCLUSION: Endoscopic treatment of PAIS due to OT pathology demonstrated excellent results. Posterior ankle arthroscopy was an effective treatment and allowed for a prompt return to a high activity level of their athletic performance. LEVEL OF EVIDENCE: Level IV, therapeutic study / retrospective case series.

Incidence of symptomatic os trigonum among nonathletic patients with ankle sprain.

PURPOSE: Os trigonum syndrome is a rare condition, often affecting athletes. A paucity of data exists on the incidence of os trigonum syndrome in nonathletic population. The study aimed to determine the incidence and clinical characteristics of os trigonum syndrome in nonathletic patients with sprained ankles. METHODS: The sample consisted of 798 adolescent and adult patients that attended the emergency department or Foot and Ankle Clinic with acute ankle sprain. Lateral and/or oblique lateral radiographs of the feet were screened for the presence of os trigonum in relation to age and gender. A cohort of 163 patients with os trigonum was followed up prospectively over a 48-month period to correlate the presence of the os trigonum with patient symptomatology. RESULTS: Os trigonum was found in 20.4% (163/798) of sprained ankles. Patients aged 18-35 exhibited most os trigonum [42.3% (69/163)], with higher incidence in females. 5.5% (9/163) of the os trigonum patients developed an os trigonum syndrome after a standard treatment of an ankle sprain [3.8% (3/78) of males and 7.1% (6/85) of females]. Females aged between 18 and 35 years had higher incidence of os trigonum syndrome compared to males of a similar age. CONCLUSION: Os trigonum syndrome should be suspected in nonathletic patients with an ankle sprain unresponsive to standard treatment. About 1.1% of acute ankle sprain patients develop an os trigonum syndrome. This finding can help identify the source of a patient's symptoms, leading to an accurate diagnosis, appropriate treatment and reducing the potential chronic symptoms.

Morphological features of the posterior intermalleolar ligament.

PURPOSE: In the present study, the posterior intermalleolar ligament (PIML) was classified by type using large-scale cadavers to provide basic information to help elucidate the mechanism of ankle joint posterior impingement syndrome. METHODS: This investigation examined 100 legs from 49 Japanese cadavers (mean age at death, 79 ± 11 years; 58 sides from men, 42 from women). In the classification method, an absent PIML was classified as Type I, a PIML with one fiber bundle (attachment to one place) was Type II, a PIML with two fiber bundles (attachment to two places) was Type III, and a PIML with three fiber bundles (attachment to three or more places) was Type IV. Furthermore, according to other adhering tissues, they were further subdivided and classified by type. RESULTS: There were various types of PIML: 19 (19%) Type I; 24 (24%) Type II; 23 (23%) Type III; and 34 (34%) Type IV. A PIML was present in 81 legs (81%). There were no significant differences between men and women and between left and right sides. CONCLUSIONS: The complex relationships of the PIML with the surrounding ligaments and tissues are considered to be among the factors that make interpretation of imaging findings difficult.

Chronic lateral ankle instability increases the likelihood for surgery in athletes with os trigonum syndrome.

PURPOSE: The etiology and incidence of os trigonum syndrome in professional athletes is highly variable. There is a paucity of data to ascertain why some athletes evolve towards surgery whilst others remain asymptomatic. We hypothesized that a lateral ligament ankle injury would increase the likelihood for surgery in those athletes with os trigonum syndrome. METHODS: Eighty professional athletes with clinical and radiological signs of os trigonum syndrome were identified to ascertain the incidence of injury to the lateral ligamentous ankle complex (acute and chronic) by magnetic resonance imaging (MRI). This cohort was subdivided into 2 groups; a surgical (n = 40) and a non-surgical (n = 40) cohort. Surgical division was decided if (1) the clinical hyper-plantar flexion test was positive, (2) a positive diagnostic ultrasound-guided injection and (3) no improvement was observed after 6 weeks of conservative rehabilitation. RESULTS: From the surgical cohort, 37 players (94.1%) had a chronic lateral ankle ligament injury on MRI, whilst 3 players (5.9%) had an acute lateral ankle ligament injury. Binary logistic linear modelling revealed that having a chronic lateral ligament injury increases the likelihood of os trigonum syndrome surgery by ten times compared to those with an acute lateral ligament injury. CONCLUSION: Professional athletes with chronic lateral ligament ankle injury have an approximate ten times greater risk for os trigonum syndrome surgery compared to athletes with acute lateral ligament ankle injury. LEVEL OF EVIDENCE: IV.

Imaging Manifestations of Ankle Impingement Syndromes.

Ankle impingement syndromes encompass various pathologic entities that contribute to ankle pain with limited range of motion. Although classically described in athletes, these changes can occur in individuals of all ages, often with a history of prior ankle trauma. Ankle impingement is broadly categorized as anterolateral, anterior, posterior, anteromedial, and posteromedial, depending on the area of the ankle affected. Both osseous and soft tissue abnormalities can contribute to impingement symptoms, and a combination of these is often present. Multiple imaging modalities have been evaluated in the work-up of suspected impingement, including radiography, CT, MR imaging, and ultrasound.

Painful stress reaction in the posterior subtalar joint after resection of os trigonum or posterior talar process.

INTRODUCTION: The resection of os trigonum or posterior talar process as treatment for posterior ankle impingement is an established operation. However, the authors encountered several painful stress reactions in the posterior subtalar joint during follow-up resulting in persisting incapacity to do sports. METHODS: From March 2011 to July 2015, 29 patients with 30 feet were operated (22 endoscopic, 8 open resections). Average follow-up time was 43 ± 13 months. Complications were grouped into "none", "temporary disadvantage" and "permanent damage". The following radiographic parameters were measured: (1) length of posterior talar process or os trigonum, (2) length of the uncovered calcaneal joint surface after resection, (3) amount of resection. RESULTS: The rate of permanent damage was 13.3% (4 of 30 feet), and all four of these patients developed a painful stress reaction in the posterior subtalar joint. One temporary disadvantage (persistent pain for three months) was found. All patients with major complications showed retrospectively what we call the "risk configuration" -the radius of the talus ending within the subtalar joint. The length of the uncovered calcaneal joint surface was therefore significantly larger (6.4 mm ± 3.33) in feet with permanent damage than in feet without (1.06 mm ± 2.15, P < 0.001). CONCLUSION: The resection of os trigonum or posterior talar process has a complication rate of 13.3% with persisting inability to do sports due to painful stress reaction in the posterior subtalar joint. The only risk factor found was the "risk configuration". In such cases, the resection has to be made not anterior into the subtalar joint and patients have to be informed about this possible complication. STUDY DESIGN: Retrospective case series; Evidence Level 4.

Posterior ankle labral changes at MRI: A preliminary study.

INTRODUCTION: The transverse ligament in the ankle joint has been described as a labrum-like structure in a previous cadaveric study. The purpose of this study is to assess the spectrum of abnormal changes related to this structure on imaging/MRI, and correlate these findings with other ankle joint findings and patient symptoms. METHOD: A retrospective observational review of 172 ankle MRI scans was carried out independently by two fellowship trained musculoskeletal Radiologists. Correlation between abnormal labral changes, other ankle joint findings and patient symptomatology was performed. RESULTS: Abnormal labral changes were seen in 26% of the MRI scans (n = 44/172) and included signal change, contour abnormality with heterogeneous signal change, linear fluid filled clefts, multidirectional fluid filled clefts, and a macerated labrum. There was a statistically significant association between abnormal labral changes and the presence of Stieda process/os trigonum (P = 0.001), talocrural joint osteoarthritis (P = 0.0003), paralabral cysts (P = 0.0001), imaging features of posterior impingement (P = 0.01), and both medial (P = 0.005) and lateral (P = 0.01) ankle ligament injuries. However, there was no statistically significant association between abnormal labral changes and patient symptoms. CONCLUSION: The posterior ankle labrum can develop a spectrum of abnormal MRI appearances in patients with other ankle joint abnormalities. Although this study showed no correlation between patients' symptoms and posterior ankle labral changes, larger studies are needed to examine the biomechanical alterations that may arise from these labral changes.

Conservative management of posterior ankle impingement: a case report.

OBJECTIVE: To describe the pain and functional improvements of a patient with posterior ankle impingement following a treatment plan incorporating soft tissue therapy, chiropractic adjustment and a progressive rehabilitation program. CLINICAL FEATURES: A 37-year- old male presented with posterolateral ankle pain exacerbated by plantar flexion two weeks after sustaining an inversion ankle sprain. Oedema was present and the patient was describing a sensation of instability while walking. The initial diagnosis of lateral ankle sprain was found to be complicated by a posterior ankle impingement caused by a tenosynovitis of the flexor hallucis longus sheath suspected during the physical examination and confirmed by MRI. INTERVENTION AND OUTCOME: The patient was treated over a 14-week period. Soft tissue therapy, a rehabilitation program and cortisone injection were used to treat this condition. A precise description of the rehabilitation program that contains open kinetic chain, closed kinetic chain, proprioception, and conditioning exercises prescribed to the patient is given. After the treatment plan, the patient returned to play pain free and had no daily living restrictions. SUMMARY: A protocol including rest, soft tissue therapy, open and closed kinetic chain exercises, sport-specific exercises and cortisone injection appeared to facilitate complete recovery of this patient's posterior ankle impingement.

OBJECTIF: Présenter l'histoire de cas, notamment la progression de la douleur et le retour aux activités fonctionnelles, chez un patient présentant un accrochage postérieur de la cheville. L'article présente ces données en lien avec un plan de traitement incorporant le traitement des tissus mous, l'ajustement chiropratique et un programme de réadaptation progressive. CARACTÉRISTIQUES CLINIQUES: Un homme âgé de 37 ans présentant une douleur à la cheville postéro-latérale exacerbée par une flexion plantaire deux semaines après avoir subi une entorse de la cheville en inversion. Le patient souffrait d'un œdème et se plaignait d'une sensation d'instabilité lorsqu'il marchait. Le diagnostic initial d'une entorse de la cheville en inversion a été modifié suite à l'examen physique. L'entorse est compliquée par un accrochage postérieur de la cheville relié à une ténosynovite de la gaine du muscle long fléchisseur de l'hallux. Cette trouvaille mise en évidence à l'examen physique fut confirmée par une IRM. INTERVENTION ET RÉSULTATS: Le patient a été traité pendant une période de 14 semaines. Le traitement des tissus mous, un programme de réadaptation et l'injection de cortisone ont été utilisés pour traiter cette condition. Une description précise du programme de réadaptation (exercices cinétiques en chaîne ouverte et fermée, exercices proprioceptifs ainsi que de conditionnement physique), est présentée. Après le traitement, le patient est retourné au jeu sans douleur et sans aucune contrainte dans ses activités quotidiennes. RÉSUMÉ: Un protocole comprenant du repos, le traitement des tissus mous, des exercices cinétiques en chaîne ouverte et fermée, des exercices particuliers pour la discipline sportive et l'injection de cortisone semble avoir facilité une guérison complète de l'accrochage postérieur de la cheville de ce patient.

Outcome of Arthroscopic Treatment of Posterior Impingement of the Ankle.

BACKGROUND: Open and arthroscopic techniques have been utilized in the treatment of posterior impingement of the ankle and hindfoot. Because posterior impingement occurs more frequently in patients who repetitively plantarflex the ankle, this population may especially benefit from a procedure that reduces pain and results in maximal range of motion (ROM). The purpose of this study was to assess the outcome of hindfoot endoscopy in patients with posterior ankle impingement through a higher level of function outcome measures and physical examination parameters, focused on analysis of ROM. METHODS: Twenty patients were followed prospectively at a minimum 1-year follow-up (mean 38.2 months). Nineteen of 20 patients were competitive athletes. Patients completed a minimum of 3 months of nonoperative treatment. Diagnoses included os trigonum, tibial exostosis, talar exostosis, loose body or fracture nonunion, and ganglion cyst removal. Patients underwent arthroscopic treatment utilizing a posterior approach; all relevant pathology was addressed. RESULTS: At the most recent follow-up, visual analog scale pain and American Orthopaedic Foot & Ankle Society hindfoot scores showed significant improvement (P < .01) pre- to postoperatively; Tegner score remained unchanged (P = .888). Three patients were professional athletes; all returned to their previous level of professional activity. ROM variables between affected and unaffected sides reached statistical similarity at the most recent follow-up. Only ankle plantarflexion reached statistical significance when compared pre- to postoperatively. Fifteen percent of patients reported postoperative neuritis. CONCLUSIONS: Posterior ankle arthroscopy allowed for maintenance or restoration of anatomic ROM of the ankle and hindfoot, ability to return to at least previous level of activity, and improvement in objective assessment of pain relief and higher level of function parameters. Complications associated with this procedure were minimal. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Shoulder posterior internal impingement in the overhead athlete.

UNLABELLED: Posterior internal impingement (PII) of the glenohumeral joint is a common cause of shoulder complex pain in the overhead athlete. This impingement is very different from standard outlet impingement seen in shoulder patients. Internal impingement is characterized by posterior shoulder pain when the athlete places the humerus in extreme external rotation and abduction as in the cocking phase of pitching or throwing. Impingement in this position occurs between the supraspinatus and or infraspinatus and the glenoid rim. Understanding regarding this pathology continues to evolve. Definitive understanding of precipitating factors, causes, presentation and methods of treatment have yet to be determined. A high index of suspicion should be used when attempting to make this diagnosis. This current concepts review presents the current thinking regarding pathophysiology, evaluation, and treatment of this condition. LEVEL OF EVIDENCE: 5.

Arthroscopic Olecranon Osteophyte Resection in the Baseball Players with Elbow Valgus Extension Overload Syndrome / 대한스포츠의학회지

We evaluated the clinical outcome after arthroscopic olecranon osteophyte resection without ligament operation in the elite baseball players who had valgus extension overload syndrome without moderate or severe medial collateral ligament injury. From January 2007 to December 2011, twelve patients underwent arthroscopic osteophyte resection without ligament operation and they were followed for more than 12 months. The mean age was 19.2 years and mean follow-up period was 26 months. The clinical results were evaluated using range of motion, visual analogue scale (VAS) and Mayo elbow performance score (MEPS). After checking osteophyte size and location through 3-dimensional computed tomography, arthroscopic osteophyte resection was performed. Average preoperative extension, flexion, pronation and supination were 2.3degrees, 138.2degrees, 76.4degrees, and 69.1degrees. Average postoperative extension, flexion, pronation and supination had been changed into 0.7degrees, 137.3degrees, 79.1degrees, and 77.3degrees. Average preoperative pain VAS and MEPS were 5.5 and 67.5. Average postoperative pain VAS and MEPS had been changed into 0.4 (p<0.001) and 97.5 (p<0.001). Eleven patients returned to play. Ten cases returned to their own position. No patients were performed other operation for elbow pain. The arthroscopic osteophyte resection in valgus extension overload syndrome with low grade medial ulnar collateral ligament (MUCL) injury or without MUCL injury was a one of the ideal treatment option for early return to pre-injury levels and relief of pain.

Posterior Impingement Syndrome of the Ankle Joint in Classical Ballet Dancer / 대한정형외과학회잡지

In the classical ballet dancers, ankle joints are frequently overused. Especially the Pointe and the Releve are the two basic steps of ballet dance which cause the narrowing of the posterior aspect of the ankle joint. Posterior impingement syndrome of the ankle joint is defined as impingement occuring at the anatomical interval between the posterior tibial articular surface and os calcis. The purpose of this study is to describe the anatomy and etiology of this injury and to review the non-operative and operative treatments. Sixteen cases of posterior impingment syndrome had been treated between March 1994 and March 1995. Ten dancers were professional and six were students. The patients was divided 3groups by etiologic factor. Group 1 is anatomical problem factor, Group 2 is overuse factor and Group 3 is ankle sprain factor. Thirteen dancers (81.2%) improved with conservative treatment including local steroid injection. Among the other three dancers, operation was performed in one case. The other two cases stopped dancing. The result was good in one dancer after operation. In the classic ballet dancers, posrerior impingement syndrome was frequent disorder and major etiologic factors are anatomical problem and overuse. Operation was necessary in only group l. It is good result in conservative treatment and operation.

Differential diagnosis and treatment of posterior ankle pain in dancers and equinus athletes.

Posterior ankle pain in dancers and equinus athletes is often caused by the extreme plantarflexion requirements of their activity. Differentiation between true posterior ankle pain and Achilles tendon pain is discussed. Signs and symptoms of posterior ankle pain are specific to the flexor hallicus tendon on the medial side or impingement when on the lateral side. Surgical exploration as well as conservative treatment is discussed.