No relevant disclosures, I'm going to talk about three specific topics, anterolateral soft tissue impingement, anterior bony impingement and then posterior ankle impingement. These are all in the athlete. So anterolateral ankle pain with anterolateral impingement, fairly common, usually post-previous ankle sprain type history, is secondary to soft tissue impingement from synovitis, scar or a hypertrophied AITFL inferior bundle. Impingement test is generally positive, I've found. Impingement test is actually a little more delicate. Don't push too hard. If you push too hard, they're all tender right on that corner. So just push just enough, bring the ankle and dorsiflexion and see if they get the impingement. Initial treatment is conservative. I find a local cortisone injection to be both diagnostic and therapeutic. The key is primary symptom is pain, not instability. An arthroscopic debridement in this situation with appropriate rehab carries good to excellent results in 75-95% of your cases. The difficulty is when it's an associated symptom. So when you have macro instability with secondary impingement, you can take care of the impingement at the time of doing your ligament reconstruction. The ones that I struggle with are the ones that you go in thinking you have isolated anterolateral impingement and you need to look for evidence of micro instability. The micro instability is going to come in two forms. First can be on the medial side. You can have kind of a grade 2 injury to the tibia navicular portion of your superficial deltoid or in two-thirds of the case you'll have an anterior bundle to your deep deltoid and that can have an injury. What that does is that allows the talus to externally rotate a couple extra degrees when you go into dorsiflexion and then you're going to get impingement on the contralateral side. The second situation is lateral. Your ATFL can have two bundles also in about two-thirds of the cases and that superior bundle is intraarticular. You can see that arthroscopically. If you need to start looking for it when you do your impingement debridement and look for that anterior, that superior bundle, the ATFL, you see in the left image there, you see a high grade 2, 3 injury to this and it creates what I call a comma sign. So instead of the ligament being taut, it's going to be more relaxed in that C shape and that allows for even some macro instability. You see the chondromalacia of the fibula here which is showing signs of instability. Now, can you get by with just debridement and rehab or do we need to start taking care of some of these micro instabilities arthroscopically at the time? And that I don't have an answer for you just yet. But you need to start looking for it. If you're not looking for it, you're not going to find it. Angiobony impingement in the athlete is generally this middle type, the more wide type. The complex types you're going to see in your post-traumatics and they don't do as well. But your focal or your wide types are what we see in the athlete. You can do an intermedial impingement view, externally rotate the foot 30 degrees for your lateral and that will bring that intermedial talus and intermedial corner of your tibia into view. Arthroscopic treatment yields good to excellent results. In most cases, minor complications, about 4%, major complications and 1%. Most of your complications are minor nerve irritation. So here's one of my wide receivers. This is after his sophomore year. He played the sophomore year. He wasn't even getting his ankle up to neutral dorsiflexion. All of his clinical symptoms were anterior. And I think that's important. Radiographically you can see signs of potential impingement posterior in this case and also at the talonevicular joint. And you have to decide preoperatively how much of that you're going to need to address with your surgery. In this case he didn't have any posterior symptoms. I do like to get a weight-bearing lateral. I think it gives me a good visualization of the impinging lesions, in this case potentially also some impinging in the lateral gutter. Do you get a CT scan or an MRI? I find that the MRI gives me a little more useful information because it's going to better evaluate the other potential sources of pain. And I think it gives me adequate bony anatomy for what I need to go take care of intraoperatively. But if you're concerned, a CT scan or even a 3D, and if you're concerned about lateral subtalar impingement, I think a weight-bearing CT may benefit as well. So in this case you can see all across his anterior distal tibia, he's a very wide, pushing even complex type of anterior impingement. And so your technique is I do it supine. I do start with a distractor because that's what I'm comfortable with. I do remove the distractor for my debridement, especially as I get to the extra-articular portion. Standard portal placement, your debridement can start on the articular side or the non-articular side and work down. And I think either way works equally well. I generally start on the articular side. I'm just comfortable doing that. But it's whichever way you like. And then I do like to do a layered portal closure because you're in and out of that portal a little bit more times. And I think you want a very good closure. In this case, post-operative rehab, pretty straightforward. Generally these are off-season type surgeries, so you've got about four months to work with, which gives you adequate time to recover the athlete. He went on to a good career for us that next year, second round draft pick, and then he's had three solid years in the NFL. So he's now approaching year five. And so I think that's where you're going to start to see some potential, you know, second surgeries as you get into that five to seven intermediate time frame. Posterior ankle impingement, you see in your plantar flexion athletes, your ballet and soccer. So for me, this is my soccer athletes, both men's and women's. It's repetitive posterior ankle trauma associated with that maximum plantar hyperflexion as they strike a long ball or from that position standpoint. This is different than what I call the posterior impaction syndrome. Posterior impaction is very common. This is after ankle sprain where the foot was in plantar flexion and you can have inflammation in the posterior sinovitis, PITFL injury with syndesmosis sprain. Also you can have inflammation in a PTFL. And so I find that that's a reason for prolonged posterior ankle pain in recovery, and you see that in all sports, but that's different than your impingement. Your pain generators with posterior ankle impingement is a multitude. You have sinovitis, you have FHL sinovitis, cartilage synchondrosis, an elongated posterior process, even a fracture of the posterior process, and I think you have to look at all those entities to get when you're treating them. This is present in almost every single case I have, FHL tenosinovitis, and the best test for it is this FHL stress test. Put the foot in plantar flexion and check MTP joint dorsiflexion, and then put it up in a dorsiflexion and check your range of motion. And what happens is because of that tenosinovitis and thickening of your FHL, it binds in that retro-Taylor pulley right there and it limits range of motion. And that can be very symptomatic, and you have to address that with your surgery. So here's one of my men's soccer players, central defender, which is very, very common because they strike a lot of long balls to the wings as they go down. Generally they're going to have greater than six months of chronic posterior ankle pain. They can generally get through that season, but you're addressing it at the end of the season. He did have significant FHL tenosinovitis as well. And so there on the left, you see this tenosine tenosinovitis. His osteophyte actually extended medial to this, which is going into the tarsal canal, which is a little bit unusual, and so I used a probe to protect the FHL as I took my debridement further medial than you normally do. But you want to adequately decompress this as you see on the right. And when you range the ankle during there, you can see that the FHL will move very nicely. Standard post-op protocol, they do take a little bit longer than the anterior ones. For me they take about four months, and I'm not sure if it is, they just have a little more prolonged pain, a little longer recovery. Technique is prone. I do use a tourniquet. I want to really make sure I have the ankle in very neutral. You don't want the ankle rotating out or in just a little bit, so you can think of your angle when you're going in. Your portals are right at the tip of the lateral malleolus, it's a 30-degree angle, very safe from that standpoint, just on either side of the Achilles tendon. And you have these goal posts that you're working with. On one side you have the FHL, and on the other side you have your perineal tendons, and you're working between those two goal posts. The base of the goal post is usually right at that intermalleolar ligament. So the endoscopic technique shows a lower complication rate and accelerated rehab in a number of studies in the literature, so I think it's more eloquent, but it's also to me, I see the anatomy much better endoscopically than I would do open at all. And so here's a final case, another one of my soccer players, post-triangle pain, unresponsive for conservative modalities, he's a left-foot central defender, very similar to the last one. Pain was striking the long ball, FHL tenosynovitis, but he also had intermittent sharp pain over his perineals. And if you look at his MRI here, you see both the FHL and the perineus brevis with a tear there. And in the middle video, this is endoscopically, this ostragonum had a lot more mobility than normal, but after removing that, you can see the FHL moving nicely, you can even see the area of thickening of the FHL causing that stenosis there. And so what you're doing is you're re-sculpting the posterior talus. So that includes the posterior process, ostragonum, and you're getting it back to right at that articular margin, and then you're cleaning out all the way down to that retrotalar pulley. And so he also had a tear in his perineus brevis, which you can see endoscopically very nicely. You can actually go fairly far up the perineal tendons endoscopically from the posterior approach. So if you have a low-lying perineus brevis, or in this case, a very low partial longitudinal tear that underwent local debridement endoscopically, he went on to play for our national championship team and was the first pick in the MLS Super Draft in 2022. And so in summary, I think you need an accurate diagnosis. Anterolateral soft tissue impingement, is it a primary problem or is it a secondary problem or do you have an associated secondary micro-instability, which you really can't decide preoperatively. And so I think you need to be prepared, number one, to look for it, and number two, to address it at the time of surgery. For me, first-line treatment is always conservative, but most athletes do present with chronic pain, usually of about a full season duration, about six months, and arthroscopic or endoscopic management lowers complication rate and accelerates recovery. Thank you.

ankle impingement

anterolateral impingement

anterior bony impingement

posterior ankle impingement

micro-instability