Posterior Ankle Impingement Syndrome in Dancers

Abstract

Posterior ankle impingement syndrome (PAIS) is a condition characterized by posterior ankle pain, typically resulting from forced or repetitive plantar flexion. It is one of the most common injuries in ballet dancers, making appropriate diagnosis and treatment essential. The purpose of this narrative review is to summarize the anatomy, pathology, diagnostic assessment, and treatment strategies of PAIS, with special emphasis on dance-specific biomechanics and return-to-dance considerations following treatment.

The etiology of PAIS is diverse, encompassing osseous causes such as the os trigonum and Stieda process, as well as soft-tissue abnormalities, including hypertrophy or fibrosis of the posterior capsule and ligaments. Flexor hallucis longus (FHL) tenosynovitis is frequently associated with PAIS, further complicating clinical presentation. Accurate identification of the underlying pathology through detailed physical examination and imaging—such as radiographs and magnetic resonance imaging—is critical for effective management. Treatment options include both conservative and surgical approaches. Conservative therapy aims to reduce inflammation, relieve pain, and prevent recurrent impingement through rest, modification of activities, physiotherapy, nonsteroidal anti-inflammatory drugs, and injections. Surgical intervention is indicated when conservative management fails to relieve symptoms. Both osseous and soft tissue impinging structures can be excised using open or endoscopic techniques. FHL tendon release is often performed during surgery. Endoscopic surgery, being minimally invasive, is expected to facilitate an earlier return to activity. In dancers, targeted physiotherapy to reduce posterior ankle loading plays a vital role in both prevention and rehabilitation. A comprehensive, individualized treatment strategy that addresses both biomechanical and anatomical factors is essential for achieving optimal outcomes and a safe return to performance.

Figure 5cLateral radiograph in maximum plantarflexion showing impingement of the os trigonum between the posterior talus and calcaneus (arrow).