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I. Posterior ankle impingement-compression of the talus and surrounding soft tissues between the tibia and calcaneus
- Cause-forced or repetitive plantar flexion of the foot
- Occurs in dancers and athletes
- Presentation-pain in the medial or lateral aspect of the ankle posteriorly with activities, especially plantar flexion
- Physical examination-tenderness medial or lateral to the Achilles tendon
- Diagnosis is difficult to make and often missed because of the following:
- Symptoms are reproduced by plantar flexion of the ankle
- Injections can be performed to see if the injection relieves the symptoms
II. Causes of posterior impingement
- Os trigonum
- Enlarged lateral process of the talus
- Enlarged posterior process of the calcaneus
- Posterior intermalleolar ligament
- Soft tissue impingement
- Loose bodies
- Low lying flexor hallucis longus muscle body
- Anomalous muscle bodies
III. Anomalous muscles about the ankle
- Most common is the peroneus quartus (prevalence of the muscle between 7% and 22%)
- Arises from peroneus brevis and inserts into retrotrochlear eminence of the calcaneus
- Peroneocalcaneus internus (1%)
- Arises from the fibula and inserts into under surface of sustentaculum tali
- Long accessory to the long flexors or quadratus plantae (1%-8%)
- Tibiocalcaneus internus
- Accessory soleus
IV. Recent report-three elite athletes with four symptomatic ankles, mean age was 21 years with a mean of 16 months of symptoms
- Magnetic resonance imaging (MRI) showed the anomalous muscles and there was fluid in the tendon sheath of each
- For each patient, the anomalous muscle was resected and the patients had excellent pain relief
V. Take home Message:
- These anomalous muscles may cause ankle pain and should be considered in athletes with chronic ankle pain.
- These muscles may be hard to detect on MRI and one should review MRIs with an experienced musculoskeletal radiologist when one is uncertain of the diagnosis.
- Release of excision of these muscles may resolve an athlete's pain.
- Best A, Giza E, Linklater J, Sullivan M. Posterior impingement of the ankle caused by anomalous muscles: A report of four cases. J Bone Joint Surg Am. 2005; 87:2075-2079.
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