Thank you to the AOSSM for inviting me to give this talk. My name is Rachel Shaked, I'm an orthopedic foot and ankle surgeon at Rothman Orthopedics affiliated with Jefferson University. Today we're going to be talking about ankle impingement syndrome and tendon injuries as part of the AOSSM Athletes Ankle Webinar. I have no disclosures related to this talk. Enter your ankle impingement syndrome can be bony or soft tissue. Soft tissue involves synovium that can get caught in the ankle mortis or hypertrophy of Bassett's ligament can occur usually after an ankle sprain. Symptoms in these patients are worse with passive ankle dorsiflexion or any activities that cause ankle dorsiflexion like going upstairs, running, jumping. Tenderness to palpation is present along the anterior ankle joint and patients have pain with ankle dorsiflexion. A lateral x-ray is useful to show an anterior spur at the distal tibia and sometimes along the tail or neck as well. I always obtain an MRI in these patients because with tenderness along the ankle joint line it's important to rule out osteochondral lesion of the talus. The MRI also shows the prominent osteophyte along the anterior aspect of the ankle. The MRI also shows the prominent osteophyte along the anterior aspect of the distal tibia and a smaller one along the tail or neck. Nonoperative treatment is always attempted first. This involves activity modification, NSAIDs, bracing, boot immobilization. A cortisone injection can sometimes be helpful but physical therapy typically is not helpful. When I place patients in a boot I always put them in an even up shoe lift on the other side to protect their hips and their back. When surgery is indicated my setup looks something like this. I place the patient supine, there's a bump under the ischial spine. I place a thigh tourniquet and then there's a leg holder under the thigh. After the leg is prepped and draped I apply external traction to help expose the joint. After the leg is prepped and draped I apply external traction to help expose the joint. Here's the view of the anterior distal tibial bone spur before it's resected. I make standard intermedial and interlateral portals and I use the 2.7 millimeter scope with typical ankle arthroscopic instruments. The bur is used to resect the distal tibial spur but one of the incisions can be extended slightly and a small osteotome can be placed to resect the spur as well. Postoperative recovery involves nonweight bearing for one to two weeks in the splint followed by weight bearing in a boot. At that point patients can gradually transition to a sneaker and start some range of motion exercises. By six weeks patients are in a sneaker and starting physical therapy as well as agility and higher impact exercise and return to sport is around 10 weeks. A meta-analysis of 20 studies showed relatively good patient satisfaction, and that almost all patients would go through the surgery again. Very low complication rate was present. This study also showed that the result after surgery is sustained for five years. This included patients with no arthritis or osteochondral lesion of the talus, but just simple ankle impingement syndrome. Interestingly, 84% of patients over the five years developed recurrence of the bone spur, and the ankle dorsiflexion range of motion was not significantly different preoperatively to postoperatively. However, patients did experience significant symptomatic improvement. That being said, this large study showed patients at two years and six years after surgery for ankle impingement syndrome, and found that initially the AOFAS score improved, but then there was some deterioration of the results. When the authors looked into it in more detail, they found that patients that had a more significant complex spur had worse outcomes, which makes sense because those are patients that had some more significant underlying arthritis to develop a complex spur like that. Next, we'll talk about posterior ankle impingement. This is almost completely seen in dancers and soccer players and other athletes that require significant plantar flexion of the ankle. It's usually due to an osteogonum or steata process and sometimes the FHL tendon is involved as well. The osteogonum is an unfused secondary ossification center posterior to the lateral plastus of the talus that's present in 15% of the population. The steata process is a fused ossification center but elongated and also can cause posterior impingement symptoms. The FHL tendon runs in a fibro-osseous tunnel between the posterior medial and posterior lateral processes of the talus. Patients have tenderness posterior lateral or posterior medial along the ankle. A lateral x-ray is helpful to evaluate for the osteogonum or prominent steata process. I always obtain an MRI in these patients as well which shows bone marrow edema at the osteogonum and occasionally shows FHL tenosynovitis as well. When surgery is performed, this can be done through an open posterolateral or posteromedial approach, or it can be done endoscopically. This MRI shows a really nice example of the anatomy of the posterior ankle. The blue circle is the FHL tendon. The red circle is the neurovascular bundle. And the orange circle is the osteogonum. You can see how that, how everything is in such close proximity. So the approach for posterior ankle impingement endoscopically is two portals hugging the Achilles tendon at the level of the distal tip of the fibula. Initially, the trocar is placed in the posterolateral portal, aiming towards the first web space, towards the posterior process of the talus. Then another instrument is placed in the other poster, in the posteromedial portal, and it's triangulated towards the trocar to the level of the posterior process talus. At this point, you use a small shaver to create a working space and identify the FHL tendon. You're always staying lateral to the FHL to avoid affecting the neurovascular bundle. Then you can identify the osteogonum. In this picture on the right side, you can see that the osteogonum is lateral to the FHL. In the view on the left side, you can really see the osteogonum nicely, and then the picture on the bottom shows it after it's been removed. Interoperative fluoroscopy can also be used to confirm that the osteogonum is completely excised once the surgery is completed. Generally, patients do well after this operation as well. This study showed 24 patients after endoscopic osteogonum excision. Patients were at full activity at six weeks, and by eight months, they had no limitations at all. Only one out of 24 had a neuropraxia. When comparing open versus endoscopic posterior ankle impingement operations, the results are not significantly different. There may be slightly fewer complications with endoscopic procedures, but certainly both operations are acceptable. Next, we'll talk about Achilles tendon ruptures. This is a clinical diagnosis. I evaluate patients and look for three things, palpable gap, diminished tension on prone exam which is shown in the picture here, and a positive Thompson test. I do get an MRI if there's any question about the diagnosis or if the rupture seems to be more proximal near the musculotendinous junction. When identified with an Achilles rupture, I have a conversation with the patient about the pros and cons of the different treatment options and then we come to a conclusion on what to do. In general, we talk about operative treatment resulting in a higher likelihood of regaining full calf strength. The recovery is a little bit easier in the sense that the patients don't have to sleep in the boot for two months, but there are risks of surgery, there's risks of wound healing issues, and there's risks of infection. With non-operative treatment, patients avoid the surgical risks, but they may have up to a 20% strength deficit and they do have to sleep in the boot for eight weeks which many patients don't like. There's also a possibility of an increased risk of re-rupture up to about 10%. Achilles rupture has risks and there are certain patients that I really avoid surgery in such as smokers, diabetics, and patients who use chronic steroids. I take great caution in patients with skin compromise like a laceration. And to me, age is not really a factor. It depends more on the patient's activity goals and so we have that conversation about pros and cons. It's also very important to set expectations with the patients. I always tell patients it's a one-year recovery. It takes three months to lose the muscle and then triple the time to gain it back. I tell patients the tendon will heal very thickened and that they are at risk of rupturing the other side up to about 5 or 6%, especially if the patient is in their 30s when the initial rupture occurs. There are some surgical pearls that I'll share in order to have successful outcomes. It's very important to keep the incision small, whether that's a percutaneous approach or an open approach. It seems like both options have pros and cons and studies have shown benefits and disadvantages of both options. So the take-home point really is to keep the incision as small as possible. I position the incision slightly proximally because you can plantar flex the foot to deliver the distal tendon end through the incision. I also use a percutaneous jig to pass one stitch distally through the tendon and pull and pass that stitch up in a Bunnell-style fashion to pass another stitch through the tendon in addition to the Krakow sutures. I also aim to set the tension tight. If you set it too tight, it will stretch out over the six months after surgery. But if you set it too loose, the patient will have permanent weakness. I always try to close the paratenon so that the tendon does not stick to the surface of the skin. And almost most importantly is the accelerated rehab program. There's physiologic benefits to early weight-bearing. So the accelerated rehab program I use is from the Willett et al study in JBJS in 2010 that shows that the patient is in a split at first and then a boot for 10 weeks, gradually reducing the wedges in the boot, starting PT at two weeks. By three months, the patients are in a sneaker. They're starting jogging at four months. And they may return to sports between five and six months. So we're always trying to accelerate the rehab program even more. And how can we accomplish this? One thing, there are some limiting factors such as wound healing, which is why a mini, open, or percutaneous repair is really important. We also worry if the repair is strong enough. So we use multiple strands across the stitch and locking stitches. There's also a newer technique that involves putting anchors in the calcaneus. Although the studies have not shown that there's any significant benefit at this point, there's probably still more studies to go to see if there's any strength benefit to allow earlier rehab. Finally, we're going to talk about peroneal tendon pathology. I put this picture of people playing pickleball because I have seen a significant increase in peroneal tendon injuries related to pickleball. So peroneal tendon applied anatomy. The tendons pass through posterior to the fibula in a fibroosteus tunnel that's made up of the fibular groove and the superior peroneal retinaculum. The groove in most patients is concave to accommodate the tendons, but in 20% to 30% of patients, it's convex or flat, which can make the tendons unstable. The muscle of the peroneus brevis tendon is lower and sometimes can overcrowd the tunnel. The tendons are important for eversion and plantarflexion, but they also are secondary stabilizers to the ankle ligament complex so that if the ankle is unstable, they tend to be overworked. On exam, patients have pain with passive plantarflexion and inversion of the ankle and pain with active, resisted dorsiflexion and eversion of the foot. Circumduction of the ankle needs to be performed to evaluate for subluxation or dislocation of the tendons, and there should be an evaluation for hindfoot varus alignments. Ankle instability should also be assessed to determine if peroneal tenosynovitis has an etiology underlying. Imaging studies. X-rays are not usually that helpful unless there's an avulsion fracture due to superior peroneal retinacular avulsion. MRI is often performed and can show peroneal tendon pathology. However, in 35% of MRIs, there are false positive findings because of the magic angle. Really, the best test is a dynamic musculoskeletal ultrasound, which I almost always send patients for. If surgery is indicated, I perform an open approach using a curvilinear incision along the course of the perineal tendons and just posterior to the fibula. The superior perineal retinaculum often needs to be incised off the posterior border of the fibula. And this is tagged and then repaired later through drill holes along the back of the fibula using 2-0 fiber wire suture. It's really important not to over-tighten the tunnel and constrict the tendons that are running through it. In surgery, an unhealthy tendon is evaluated and debrided, including the tendon and the teen synovium. If more than 50% of the tendon appears intact and viable, the tendon can be tubularized. I use 0-fiber wire suture, but there's really no consensus on what type of suture to use. If less than 50% of the tendon is viable, then the damaged portion of the tendon is resected and the stumps are sewn and tenodesed in side-to-side fashion to the intact tendon while holding the ankle in a neutral position. If peroneal tendon subluxation or dislocation is present, nonsurgical treatment has a very low success rate and these patients almost always need surgery. The surgery involves repair of the superior peroneal retinaculum and peroneal groove deepening, which I do using a burr. Hindfoot varus looks something like this. A Coleman block test can be performed to determine if this is a flexible or a rigid deformity. Flexible deformities can be improved with orthotics like the arch rival or a custom orthotic, or a dorsal closing wedge osteotomy of the first metatarsal base, because the etiology of the hindfoot varus is because of plantar flexion of the first right. If this is a rigid deformity, then a calcanea osteotomy should be performed at the time of surgery in order to offload the lateral aspect of the ankle and the peroneal tendons. The rehab for peroneal tendon, as long as an osteotomy is not performed, involves two weeks non-weight bearing in a splint, followed by another four weeks weight bearing in a boot, and then gradual transition to a brace, physical therapy. At three months, I allow higher impact exercise. Sports can begin as early as four months with the brace, and I usually maintain the brace for at least six to nine months after surgery. So how did these patients do after surgery? In this series, with long-term follow-up at 6.5 years, isolated peroneus brevis tendon repair, almost all the patients returned to sports. A similar study with four and a half year follow-up and peroneus brevis tendon repair showed about 83% return to sports. Peroneal tendoscopy is also an option. Right now, its applications are somewhat limited, but it's certainly useful for evaluation of the tendons and debridement of tenosynovium. Most peroneal tendon operations are done open at this point, and an evaluation of the current evidence showed poor evidence supporting peroneal tendoscopy for now. However, certainly there will be applications for it in the future. So in conclusion, arthroscopic approaches for ankle impingement syndromes are associated with a high rate of return to sport. Successful treatment of athletes with Achilles rupture depends on attention to keeping the incision small, the repair tight, and an accelerated rehab program. And peroneal tendon pathology is still primarily treated open, but hopefully there will be more applications to more endoscopic options in the future. Thank you so much for your time, and this concludes this portion of the webinar.

ankle impingement syndrome

tendon injuries

soft tissue impingement

arthroscopic approach

Achilles tendon ruptures