RAD blog

What is it? 

Posterior ankle impingement syndrome (PAIS) is a term used to describe pain in the posterior ankle that occurs with repetitive end of range ankle plantarflexion (Ribbans, Ribbans et al. 2014). Dancing requires extreme plantarflexion range of motion. This range of motion must be performed in sustained weight-bearing positions (ie Demi-pointe), and with repetitive activities such as jumping (ie Allegro). 

‍

Do you need an MRI? 

A thorough clinical assessment and history help guide management. Posterior ankle pain can be gradual and progressive, or it can occur after an acute ankle injury. The presence of pain with a Passive Plantarflexion Test helps to diagnose PAIS. Imaging findings are not consistently associated with pain. There are no clear associations between clinical features of PAIS (ie pain) and MRI findings (Baillie, Cook et al. 2021a).   

‍

Do you need surgery? 

PAIS was previously thought to be directly related to bony impingement – therefore surgical removal of the accessory bony structures made sense. Common causes of bony impingement involve the presence of an os trigonum (extra bone) or an enlarged Steida process (prominent bone process). The presence of these structures is likely incidental – meaning they are not associated with the clinical presentation of PAIS. It is interesting to note that these abnormalities occur in the general population at similar rates to dancers. This is reassuring – as these MRI findings alone are not career threatening (Baillie, Cook et al. 2021b). 

‍

What should you do? 

Activity modification (ie adjusting choreography) to limit sustained and/or repetitive end of range plantarflexion can help manage symptoms. Rest can also help manage symptoms of PAIS in the short-term. One barrier to rest is that dancers may opt to rest at a time that suits their schedule (i.e. between performances). This requires dancers to continue training and performing despite ongoing pain. Physiotherapy with a focus on education and activity modification can help in this space. Soft tissue techniques and joint mobilisation may help reduce symptoms to continue dancing in the short-term. Referral to a Sports & Exercise Medicine Physician may be indicated if symptoms persist. Pharmacological interventions, injection therapies, or a surgical opinion may be appropriate in some cases. 

‍

References: 

• Ribbans, W., et al. (2014). The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surgery. 21(1):1-10.
• Baillie, P., et al. (2021a). Posterior ankle impingement syndrome clinical features are not associated with imaging findings in elite ballet dancers and athletes. Journal of Science and Medicine in Sport. 24:17-17.
• Baillie, P., et al. (2021b). Magnetic resonance imaging findings associated with posterior ankle impingement syndrome are prevalent in elite ballet dancers and athletes. Skeletal Radiology. 50(12): 2423-2431.

‍