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Does the Back of Your Ankle Hurt? It Could Be Posterior Ankle Impingement

Have you ever felt pain in the back of your ankle while pointing your foot or rising onto relevé? This could be a sign of an injury common in dancers, especially those working on pointe, called posterior ankle impingement. Don't ignore this pain. Early treatment could mean the difference between healing and needing surgery down the line.


The Anatomy

The ankle joint involves three bones: the two of the lower leg, the tibia and fibula, and a bone that sits on top of the heel bone, the talus. A small part of the talus, called the posterior process, sticks out toward the back of the ankle. In some people, it is short and stubby, but in others, it's long and pointy. Sometimes the back part of the talus doesn't fuse, and it is called an os trigonum.

"This is a normal variant. It's present in about 10 percent of the population," says Dr. Selina Shah, a dance and sports medicine physician in the San Francisco Bay Area. When you point your foot, the soft tissues in the back of the ankle can get pinched, especially if you have a prominent posterior process or an os trigonum.

Getting a Proper Diagnosis

It's ideal to see a dance specialist who will evaluate and diagnose you based on your symptoms, not based on an X-ray or MRI alone. "Usually, the way we test for this is by having the dancer point their foot. Then we firmly push farther. If the person is symptomatic, they'll say, 'Oh, that's it,' " says Dr. David Weiss, associate director of the Harkness Center for Dance Injuries in New York City.

"Ninety-nine percent of the time, dancers think it's their Achilles tendon," says Shah. A doctor unfamiliar with dancers may even make this mistake. If there are no dance physicians in your area, says Weiss, try seeing a physical therapist or an athletic trainer familiar with dancers.

Treatment and Prevention

As it gets worse, dancers may start to feel posterior ankle impingement while jumping or even walking. Continuing to dance while ignoring the pain can cause more damage, which can lead to a stress fracture, so early treatment is key.

"You want to attack the inflammation, so I usually have dancers put the ankle in a bucket of ice water three times a day. Typically, they need to avoid relevé, though they can keep doing things on flat if that's not causing pain," says Shah.

Dancing on full pointe causes even more impingement, says Weiss, so some dancers' symptoms may resolve with a break from pointe work. Physical therapy can address any technique issues that may have contributed to the injury and build strength for a stable, supported relevé. This is especially useful for hypermobile dancers. "I call it the 'too-good foot,' where some dancers can just kind of sit on relevé," says Weiss. "They need to build more control, and should only be working in what feels to them like seven-eighths relevé."

When Rest Isn't Enough

If physical therapy and avoiding relevé aren't cutting it, one option is a cortisone injection to reduce inflammation, as long as there isn't a stress fracture. This may be appropriate as a rare treatment if a dancer has an important performance or audition coming up. However, "repeated use of cortisone can have some detrimental side effects," says Shah. "Make this decision carefully with your doctor."

For dancers with persistent pain, surgery may be an appropriate option. "If you're on a ballet track, and you're getting posterior impingement every few months, you're going to have a hard time making it into a ballet company," says Weiss. Surgical methods, which involve removing extra bone from the back of the ankle, are improving so that surgery is less invasive, which may result in a quicker recovery.

Never Force Your Point

One of the first questions Weiss asks dancers is whether they're doing anything to force their point. If you are, stop! "There's no evidence that any of these stretches or devices actually help, and they really irritate the back of the ankle," he says.

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