Soft-tissue impingement lesions in the ankle should be part of the differential diagnosis in patients with persistent symptoms following an ankle sprain. Most patients with a routine ankle sprain demonstrate considerable improvement with 6 weeks of conservative therapy.1 Patients without radiographic changes and symptoms of pain, catching, instability, swelling, stiffness, altered gait, or activity limitation should be carefully evaluated for soft-tissue impingement lesions. Soft-tissue impingement lesions can be classified based on the anatomic location. Most soft-tissue impingement lesions in the ankle occur in the antero-lateral aspect of the ankle joint. The Bassett lesion represents impingement of the anterolateral talar body on the distal fascicle of the anteroinferior tibiofibular ligament3,4 (Fig. 67-1). Patients with a Bassett lesion will have a history of an inversion ankle sprain and present with chronic anterolateral ankle pain with normal radiographs. Pain and or popping over the anterolateral ankle with forced dorsiflexion are the most consistent physical examination finding. Another type of anterolateral soft-tissue impingement can result from a tear of the anterior talofibular ligament. The torn soft-tissue becomes a mass of hyalinized connective tissue that impinges in the lateral gutter and has been termed the meniscoid lesion.5 The physical examination for anterolateral impingement is usually nonspecific, but recently a new physical sign was described to aid in the diagnosis.6 The test is performed by placing the foot in a plantarflexed position with direct pressure over the anterolateral ankle. The foot is then brought up to a maximally dorsiflexed position with continued pressure over the anterolateral ankle. Increased pain with this maneuver is caused by pinching of the hypertrophied synovium that is associated with anterolateral impingement lesions between the talus and tibia (Fig. 67-2). A positive test has been shown to be 95% sensitive and 88% specific for synovial impingement. Intra-articular injection of local anesthetic may be used as an adjunct to the physical examination to help differentiate intra-articular from extra-articular pathology. The addition of steroid to the injection may be considered for therapeutic purposes if synovial inflammation is suspected as the cause of the impingement. The diagnosis of anterolateral impingement is usually made based on the history and physical examination findings, but magnetic resonance imaging (MRI) can be considered if the diagnosis is unclear or other pathology is suspected.
Recently, a posteromedial impingement lesion was described following severe inversion ankle injury.7 It has been hypothesized
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