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This type of conflict refers to the abnormal contact of joint structures. In general, one of these structures becomes stuck in the joint, causing pain. These conflicts may be linked to the bone or fibrous structures and affect both the anterior or posterior part of the ankle.
presence of osteophytes (bone spurs) on the talus and tibia
With dorsal flexion, the osteophytes cause pain when they come into contact
Anterior conflict:
This is the most common type of conflict. It is observed in two forms.
The first is caused by the conflict between bone spurs (osteophytes) on the tibia and/or talus. When extending the ankle, these structures come into contact with each other, causing pain and a loss of mobility. The osteophytes may be due to reasons such as trauma, playing certain high-risk sports (football, etc.) or arthritis of ankle.
Thickened lateral ligament (here Bassett’s ligament) in conflict with the underlying talus.
The second form involves a conflict related to a soft and non-bone structure. It mainly affects the lateral section of the ankle and is usually observed in patients with a history of ankle sprain or instability. In this case, one or more ligament structures will thicken and these then block during ankle movements or rub on the cartilage surfaces of the joint. This is a common cause of sprains with a poor outcome.
os trigonum (in green), the bone located behind the astralgus
plantar flexion of ankle, the os trigonum enters into conflict with the posterior section of the tibia and calcaneus
Posterior conflict:
This is usually a conflict due to a supernumerary bone (os trigonum). Observed in around 15% of the population, it occupies a large space in the rear section of the ankle. When flexing this joint, the os trigonum may enter into conflict with the calcaneus, tibia and suffer an injury or fracture. This is a typically chronic condition that can affect other structures such as the flexor hallucis longus and the joint capsule.
The presentation depends on the type of conflict and its location. There is often a sensation of “jamming” or blockage of the ankle.
During the course of previous conflicts, the patient usually describes a specific antero-lateral (radiating to the outside of the ankle) or antero-medial (radiating towards the inside of the ankle) type of pain. It is aggravated by dorsal flexion, exercising and going up and down the stairs. A history of ankle sprains or playing sport such as football is usually reported.
Posterior conflicts are rarer and more difficult to diagnose. Postero-lateral pain is generally reported when the conflict is caused by the os trigonum or posterior-medial bones, when the conflict is due to the flexor hallucis longus tendon of the big toe. Dancers are most commonly affected by this type of injury given the very high stresses they place on their ankles (dancing in pointe and demi-pointe positions).
Although a specialised examination and radiography evaluation usually results in a correct diagnosis, tests are usually completed by a CT scan or MRI to determine the exact nature of the injury and ascertain whether other conditions require treatment (cartilaginous lesions, etc.).
It is advisable to seek expert advice in cases of recurrent ankle pain.
The surgical approach essentially consists in removing the structure causing the conflict. Although open surgery was previously used for such cases, this is the best indication for ankle arthroscopy and this technique must be proposed when the surgeon is experienced in this field.
Using this technique, the joint is approached via two orifices measuring a few millimetres. A camera and specific instruments are inserted in these orifices to perform a large number of actions using a minimally invasive approach.
The anterior arthroscopy (performed in a supine position) is used to remove osteophytes, thickened fibrous scars, free fragments or damaged cartilage.
The posterior arthroscopy (performed lying face down) allows the removal of osteophytes, the os trigonum or a decompression of the flexor hallucis longus.
Several different actions can be performed during the same arthroscopic procedure, as the overall clinical picture often results from a combination of several conditions. For example, the thickened ligament may be removed and an arthroscopic ligament stabilisation performed.