Posterior ankle impingement–an underdiagnosed cause of ankle pain in pediatric patients

BACKGROUND: Posterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population. AIM: To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients. METHODS: This descriptive prospective study at a tertiary children’s hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up. RESULTS: 35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94). CONCLUSION: This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.