Working Diagnosis:
Flexor hallucis longus tendinosis and posterior ankle impingement secondary to stieda process.

Treatment:
Our patient was initially diagnosed with Achilles tendonitis due to location of pain and ultrasonic findings. She was treated with heel lifts and physical therapy for 5 weeks, which provided moderate relief as pain decrease from 7/10 to 3/10. After 6 weeks, her pain location shifted to the posteromedial ankle and she was subsequently diagnosed with posterior tibialis tendonitis. This was further treated with arch support insoles and continued physical therapy. Despite activity modifications, Tylenol, NSAIDs, shoe modifications and therapy, she improved only to 60% of baseline then had exacerbation of pain, back to 7/10, and stopped swimming. After which, x-rays and MRI were ordered showing edema around the flexor hallucis longus tendon. Her continued pain was treated with 4 weeks of immobilization in CAM walking boot with limited pain relief. Due to continued pain with conservative care, autoimmune labs were checked and returned negative. Podiatry was then consulted, who provided a lace up ankle brace and ordered a CT scan and ruled out an atypical fracture. After coordinating care with Podiatry and reviewing advanced imaging, it was determined that our patient had FHL tendinosis and posterior ankle impingement from a stieda process. She underwent an ultrasound guided corticosteroid injection to the flexor hallucis longus tendon sheath without sustained pain relief. She was then referred back to Podiatry for surgical intervention with arthrotomy of the posterior talus.

Outcome:
2 months after posterior talus arthrotomy, our patient's posterior ankle pain has resolved. She currently has transitioned to a lace up ankle brace only as she begins her return to running and swimming.

Editor's Comments:
Although posterior ankle impingement does not often present a problem in the non-athletic population it can be quite disabling for an athlete. Impingement can be caused by a variety of factors including soft tissue and bony structure which can often lead to delayed diagnosis. However, surgical repair of the offending culprit has been shown to be very beneficial in this athletic population.

References:
Ribbans, W; et al. The management of posterior ankle impingement syndrome in sport: A review. Foot Ankle Surgery 2015; 22(1): 1-10

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