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Ankle Bone or Joint Injury

Posterior Ankle Impingement (PAIS)

Minute Read


Posted 1 year ago


Last updated: 19/03/2023


by James McCormack

Posterior Ankle Impingement: Anatomy

The posterior ankle joint comprises the lateral and medial malleoli and the talus bone. There are ligaments and tendons connecting these three bones, and their function is to provide stability to the joint. In some cases, there is an extra bone called an Os Trigonum.

Posterior Ankle Impingement is characterised by a collection of conditions that cause back at the back of the ankle.

Posterior Ankle Impingement Symptoms

The primary symptoms of Posterior Ankle Impingement are pain and swelling at the back of the ankle during plantarflexion.

Symptoms can be eased by pointing the toes upwards.

In irritable cases of Posterior Ankle Impingement, there may be a low-level dull ache at rest, while wearing high heels irritates the posterior ankle. It may be tender to touch and can be misdiagnosed as Achilles Tendonitis.

Causes of Posterior Ankle Impingement

There are numerous causes of Posterior Ankle Impingement. Boney growth formations called a Stieda Process, or an extra bony formation called an Os Trigonum, can become irritated by repetitive plantarflexion.

Repetitive Trauma to the back of the ankle from kicking a ball, jumping, or going en-pointe can irritate and back of the ankle, causing pain and swelling. In Ballet Dancers, this condition is referred to as Dancer’s Heel.

There are numerous soft tissue structures, such as the Flexor Hallucis Tendon and accessory muscles or loose bodies, that can also lead to posterior ankle impingement.

Posterior Ankle Impingement is commonly seen in:

  • Ballet Dancers (6.5% Prevalence)
  • Gymnastics
  • Football
  • Jumping Sports
  • Running Downhill
  • Fast Cricket Bowlers


A clinical examination with a medical professional such as a Physical Therapist or a Sports Medicine Doctor is recommended for symptoms of Posterior Ankle Impingement. A careful clinical interview followed by a physical assessment can ascertain if it is likely that Posterior Ankle Impingement is present. Forced hyper plantarflexion of the ankle joint should elicit posterior ankle pain, known as the heel trust test.

An x-ray can identify bony changes to the ankle, such as a Steida process or an Os Trigonum, while an MRI scan as this can identify bone spurs, swelling or irritation of soft tissue structures in the back of the ankle.

Posterior Ankle Impingement Treatment

Posterior Ankle Impingement treatment with a Physical Therapist is recommended to resolve the condition. Treatment can involve ankle mobilisations, soft tissue massage, and strengthening and stability exercises.

Taping, custom insoles, and footwear modifications can also help to relieve pain. A gait analysis may be required to address any biomechanical issues.

If symptoms fail to settle with these strategies, you may require an ultrasound-guided steroid injection to reduce pain and swelling in the area.

Surgery may be performed to remove an Os-Trigonum or any bony spurs, such as a Stieda process if conservative management is unsuccessful. This is usually followed by 4-6 weeks of rehabilitation with a Physical Therapist.

Related Article: Posterior Ankle Impingement Exercises

Physiotherapy with James McCormack

This is not medical advice. We recommend a consultation with a medical professional such as James McCormack. He offers Online Physiotherapy Appointments.

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