Systematic review of anterior ankle impingement: subtype-specific diagnosis & intervention.

BACKGROUND

Anterior ankle impingement syndrome (AAIS) causes chronic ankle pain and dorsiflexion limitation, especially in athletes. Although AAIS has anteromedial (osteophyte‑dominant) and anterolateral (soft‑tissue‑dominant) subtypes with anterolateral, anteromedial, syndesmotic, and diffuse subgroups, subtype‑specific management remains controversial. This systematic review synthesizes evidence on diagnosis, intervention, and prognosis.

PURPOSE: To systematically synthesize evidence on the diagnosis, intervention, and prognosis of AAIS, with emphasis on subtype‑specific outcomes.

STUDY

DESIGN

Systematic review and meta‑analysis of published clinical studies.

METHODS

Following PRISMA, we searched five databases (2000‑2025) for randomized controlled trials (RCTs), cohorts, and case series (n ≥ 10) in adults with confirmed AAIS. Risk of bias was assessed with RoB 2 (Risk of Bias 2 tool) and MINORS (Methodological Index for Non‑Randomized Studies); evidence quality with GRADE (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

40 studies (5,217 patients; mean age 32.8 years, predominantly male and athletic populations) were included. Diagnostic sensitivity: dynamic ultrasound 83% (95% confidence interval [CI] 78‑88) for anterolateral impingement; MRI 92% (89‑95) for osteophytes/cartilage; oblique anteromedial impingement (AMI) radiographs 93% (88‑96) for anteromedial osteophytes. Tibial coverage ≥ 0.67 had 86% sensitivity, 83% specificity. Arthroscopic 3‑portal debridement (AOFAS +30.5, recurrence 10%) and combined reconstruction (AOFAS +33.8, recurrence 7%) were optimal for severe/unstable AAIS. Needle arthroscopy (recurrence 8%, return‑to‑sport 6 days) and conservative treatment (AOFAS +12.5, recurrence 25%) suited mild/soft‑tissue cases. Anterolateral soft‑tissue AAIS had best outcomes (recurrence 8%), anteromedial worst (28.6% in males with body mass index [BMI] > 26). Adverse prognostic factors: smoking (odds ratio [OR]  = 10.6), preoperative arthritis, advanced cartilage lesions (OR = 3.6). Increased anterior talofibular ligament (ATFL) apoptosis links instability to AAIS.

CONCLUSIONS

AAIS requires subtype‑specific management: arthroscopic debridement for anteromedial bony AAIS, conservative/needle arthroscopy for anterolateral soft‑tissue AAIS, and combined procedures for unstable cases. Dynamic ultrasound, MRI, and oblique radiographs enable accurate diagnosis. Balance training and leukocyte‑poor platelet‑rich plasma (PRP) reduce recurrence.