{"id":26674,"date":"2025-12-15T12:00:04","date_gmt":"2025-12-15T11:00:04","guid":{"rendered":"https:\/\/www.physiotutors.com\/?post_type=research&p=26674"},"modified":"2025-12-14T12:47:29","modified_gmt":"2025-12-14T11:47:29","slug":"posterior-ankle-impingement-syndrome","status":"publish","type":"research","link":"https:\/\/www.physiotutors.com\/research\/posterior-ankle-impingement-syndrome\/","title":{"rendered":"Is It Really Achilles Tendinopathy? Considering Posterior Ankle Impingement Syndrome"},"featured_media":26675,"template":"","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":""},"featured-tag":[],"tracking_tag":[2198,2200],"class_list":["post-26674","research","type-research","status-publish","has-post-thumbnail","hentry","tracking_tag-ankle-foot","tracking_tag-diagnosis-imaging"],"acf":{"free_access":"unfree","app_link":"https:\/\/app.physiotutors.com\/research-reviews\/posterior-ankle-impingement-syndrome","sections":[{"acf_fc_layout":"page-header-small","background":{"background_image":26675,"background_image_alt_text":""},"heading":"Is It Really Achilles Tendinopathy? Considering Posterior Ankle Impingement Syndrome","subheading":"J-C Moati (2024)","benefits":[{"benefit":"This expert opinion article provides insights into an often overlooked diagnosis for posterior heel pain."},{"benefit":"This article discusses anatomical considerations, pathophysiology, diagnosis, and differential diagnosis of posterior heel pain."},{"benefit":"Despite a low level of evidence, this article provides a clinical framework to consider other potential diagnoses for a patient presenting with posterior heel pain."}]},{"acf_fc_layout":"content","background_color":"none","content_alignment":"left","content_editor":"

Introduction<\/span><\/h2>\r\nPain localized at the Achilles tendon insertion is frequently attributed to Achilles tendinopathy. However, patients who fail to respond to evidence-based interventions for tendinopathy may warrant evaluation for <\/span>Posterior Ankle Impingement Syndrome<\/span> as an important differential diagnosis. This narrative expert opinion review provides a comprehensive examination of <\/span>Posterior Ankle Impingement Syndrome<\/span>, including its anatomical basis, pathophysiology, clinical and differential diagnosis, diagnostic evaluation, and management strategies.<\/span>\r\n\r\nPosterior ankle impingement syndrome<\/span> predominantly involves osseous structures, such as the posterolateral talar process or an os trigonum, although soft tissue involvement, including synovitis and posterior ligament pathology, is also frequently observed. In addition, the flexor hallucis longus (FHL) tendon may present with tendinopathic changes. A readily implementable clinical test for the diagnosis of posterior ankle impingement is also detailed within this review.<\/span>\r\n

Methods<\/span><\/h2>\r\nThis article is a <\/span>narrative expert-opinion review<\/b> authored by a single clinician (J.-C. Moati) and published in a peer-reviewed journal. No methodological framework is described, including search strategy, study selection criteria, or critical appraisal of the literature. The content is therefore not based on a systematic or reproducible selection of available evidence but primarily reflects the author\u2019s clinical experience and interpretation of selected references. Consequently, the overall level of evidence provided by this article is low.<\/span>\r\n

Results\u00a0<\/span><\/h2>\r\nAnatomical Considerations<\/b>\r\n\r\nThe posterior ankle compartment is delimited superiorly by the distal edge of the tibial epiphysis and inferiorly by the retro-talar calcaneal aspect.\u00a0<\/span>\r\n\r\n[caption id=\"attachment_26676\" align=\"alignnone\" width=\"464\"]\"posterior From: Moati, revue du rhumatisme, (2024)[\/caption]\r\n\r\nFigure 1\u00a0<\/strong>\r\n\r\nPosterior ankle compartment: osteology.\u00a0<\/strong>\r\n\r\nPosterior talar aspect<\/b>\r\n\r\nBetween the posterior margin of the tibia and the calcaneus lies the posterior aspect of the talus, which can be more or less prominent (Figure 2). It has two posterior tubercles: a smaller postero-medial one and a larger postero-lateral one. The latter comes from the fusion of a secondary ossification center that appears between ages 8 and 13. Its size varies and it can be enlarged, sometimes exceeding 1 cm (Stieda process). Between the two tubercles is the intertubercular groove, where the Flexor Hallucis Longus (FHL) tendon runs.<\/span>\r\n\r\n[caption id=\"attachment_26677\" align=\"alignnone\" width=\"466\"]\"posterior From: Moati, revue du rhumatisme, (2024)[\/caption]\r\n\r\nFigure 2: Posterior aspect of the talus: 1 Postero-lateral tubercule 2: Intertubercular groove<\/strong>\r\n\r\nTrigonum bone\u00a0<\/b>\r\n\r\nWhen the secondary ossification center of the talus fails to fuse an os trigonum is formed (Figure 3). This accessory bone is found in 8\u201313% of the population and is bilateral in just under 2% of cases. Its size varies but is usually under 1 cm; it may be bipartite or even fragmented. It articulates with the postero-lateral tubercle of the talus via a synchondrosis, and sometimes with the calcaneus on its inferior surface. Failure of fusion appears to be promoted by repeated micro-trauma in plantar flexion, which may explain its higher frequency in football players who started training in childhood.<\/span>\r\n\r\n[caption id=\"attachment_26678\" align=\"alignnone\" width=\"850\"]\"posterior From: Moati, revue du rhumatisme, (2024)[\/caption]\r\n\r\nFigure 3: Trigonum bone.\u00a0<\/strong>\r\n\r\nLigaments<\/b>\r\n\r\nWithin the posterior ankle compartment lies <\/span>the deep portion of the posterior-inferior tibiofibular ligament<\/b>, the <\/span>posterior talofibular ligament<\/b>, running from the fibular malleolus to the postero-lateral tubercle of the talus and <\/span>the posterior intermalleolar ligament<\/b>: not present in all individuals. It extends from the fibular malleolus to the medial malleolus and may sometimes project toward the posterior talocrural recess<\/span>\r\n\r\nflexor hallucis longus (FHL) tendon<\/b>\r\n\r\nSurrounded by its synovial sheath, the tendon runs vertically through the tibial groove, then through the intertubercular groove, which is closed by the posterior annular ligament. It then changes direction, running downward and forward beneath the sustentaculum tali (Figure 4). Just medial to it lies the posterior tibial neurovascular bundle.<\/span>\r\n\r\n[caption id=\"attachment_26679\" align=\"alignnone\" width=\"748\"]\"posterior From: Moati, revue du rhumatisme, (2024)[\/caption]\r\n\r\nFigure 4: Flexor Hallucis Longus tendon.\u00a0<\/strong>\r\n\r\nPhysiopathology<\/b>\r\n\r\nAcute mechanism of injury\u00a0<\/b>\r\n