英汉对照骨科患者指南012：踝关节撞击症

Ankle Impingement

踝关节撞击综合征

A Patient’s Guide to Ankle Impingement Problems

踝关节撞击综合征患者指南

Introduction

引言

Ankle impingement occurs when soft tissues around the ankle are pinched or nipped. Impingement mainly happens when the ankle is fully bent up or down, leading to pain either in the front or back of the . Problems near the front of the joint are usually associated with past ankle sprains. Pinching in the back of the ankle occurs most often in ballet dancers and is usually due to irritation around a bony prominence on the back of the ankle.

      当踝关节周围的软组织被挤压或卡住时，就会造成踝关节撞击综合征。这通常是在踝关节朝上或朝下弯曲时发生，进而导致了踝关节前方及后方的疼痛。踝关节前方的疼痛通常与既往踝关节扭伤有关。芭蕾舞演员通常后会发生踝关节后方的软组织挤压，这主要是由于踝关节后方的骨赘刺激所致。

This guide will help you understand

· how ankle impingement problems occur

· how doctors diagnose the condition

· what can be done to treat it

本指南有助于你了解：

• 踝关节撞击综合征如何发生的?

• 如何诊断该疾病?

• 如何治疗该疾病?

Anatomy

解剖

What parts of the ankle are involved?

      毛病出在踝关节哪些部分?

The ankle joint is formed where the bones of the lower leg, the tibia and the fibula, connect above the anklebone, called the talus. The tibia is the main bone of the lower leg. The fibula is the small, thin bone along the outer edge of the
tibia.

   踝关节由小腿骨（包括胫骨和腓骨）与距骨组成。胫骨是小腿骨主要组成部分，腓骨是其中较小而细的骨头，位于胫骨的外侧缘。

The ankle joint is a hinge that allows the  to move up (dorsiflexion) and down (plantarflexion). The ankle is asynovial joint, meaning it is enclosed in a joint capsule that contains a lubricant called synovial fluid.

      踝关节是一种铰链关节，它能允许踝关节朝上运动（背屈）及朝下运动（跖屈）。踝关节还是一种滑液关节，它被关节囊所包裹，内含有起润滑作用的滑液。

Strong ligaments surround and support the ankle joint.The ligament that crosses just above the front of the ankle and connects the tibia to the fibula is called the anterior inferior tibiofibular ligament (AITFL). The anterior talofibular ligament (ATFL) supports the outer edge of the ankle. The ATFL goes from the tip of the fibula and angles forward to connect with the talus.

      踝关节被坚强有力的韧带环绕并支持。走形于踝关节前方并连接胫腓骨的韧带叫下胫腓前联合韧带(ALTFL)。踝关节外侧的韧带称为距腓前韧带(ATFL)，它起自腓骨远端，向前方以一定角度止于距骨。

The talus rests on the the heelbone (the calcaneus). The joint formed between these two bones is called the subtalar joint. The calcaneus extends backward below the ankle, forming a shelf on which the talus rests.

      距骨位于跟骨上方，这两者组成的关节称为距下关节。跟骨在踝关节下方向后延伸，作为支撑距骨的平台。

Two small bony bumps, called tuberosities, project from the back of the talus, one on the inside (medial) edge and one on the out 37 41283 37 15287 0 0 3216 0 0:00:12 0:00:04 0:00:08 3216er (lateral) edge.

      距骨后方后两块小的骨性隆起，称为距骨结节，一块位于距骨内侧缘，一块位于距骨外侧缘。

In some people the lateral tuberosity is not united to the talus. The separate piece of bone is called an os trigonum. This separation of the os trigonum from the talus is usually not a fracture. About 15 percent of people have an os trigonum. An os trigonum sometimes causes problems of impingement in the back of the ankle.

      部分患者的外侧距骨结节并没有与距骨成为一体。这个独立的骨块称为三角骨，通常三角骨自距骨分离并非是由骨折所造成。大约15%的人存在三角骨，三角骨的存在会引起踝关节后方的撞击综合征。

Related Document: 

参考阅读：踝关节解剖患者指南英汉对照骨科患者指南001：踝关节解剖

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Causes

病因

Why do I have this problem?

      为什么我会有这个问题？

Pinching of tissues in the front of the ankle is called anterior impingement. Athletes who have had several mild ankle sprains or one severe sprain are most likely to have anterior impingement. This is especially true for athletes who repeatedly bend the ankle upward (dorsiflexion), such as baseball catchers, basketball and football players, and dancers. Over time, irritation along the front edge of the ankle can lead to impingement.

      踝关节前方的组织受挤压，称为前踝撞击综合征。有过多次轻度踝关节扭伤或一次严重踝关节扭伤的运动员很容易形成前踝撞击综合征。尤其多见于经常反复朝上运动踝关节（背屈）的运动员，如棒球接球手、篮球及足球运动员，舞者。随着长时间的反复运动踝关节，刺激踝关节前缘，最终导致了撞击综合征。

Irritation in the lower edge of the AITFL and the front of the ATFL can thicken these ligaments. The irritated ligaments become vulnerable to getting pinched between the tibia and talus as the foot is dorsiflexed. These ligaments may also begin to rub on the joint capsule of the ankle. This can inflame the synovial lining of the capsule, a condition called synovitis.

      对下胫腓联合前韧带下缘及距腓前韧带前方的反复刺激，会导致韧带发炎，并使这些韧带增厚。这些发炎并增厚的韧带，在踝关节背屈时，很容易卡压于胫骨与距骨之间，并对踝关节囊造成摩擦。这会引发关节囊滑膜内衬的炎症，称为滑膜炎。

A similar problem can happen after an . As the torn or ruptured ligament heals, the body responds by forming too much scar tissue along the front and side of the ankle joint. This creates a small mass of tissue called a meniscoid lesion. Dorsiflexing the ankle can trap the tissue between the edge of the ankle joint, causing pain, popping, and a feeling that the ankle will give out and not support your body weight.

      踝关节扭伤后通常会导致一些小的问题。随着拉伤或撕裂的韧带的愈合，机体会在踝关节前方及侧方反应性的形成过量的瘢痕组织。这会造成一个小的软组织团块，称为类半月板病变。当踝关节背屈时，这些软组织卡压于踝关节之间，从而引起踝关节疼痛、弹响，并产生踝关节空虚感，自觉踝关节不足以支撑身体。

Over time, damage from past ankle sprains may also lead to the formation of small projections of bone called bone spurs. Bone spurs can form along the bottom ledge of the tibia bone or on the upper surface of the talus. As the ankle hinges into dorsiflexion, the bone spurs may begin to jab into the soft tissues along the front edge of the ankle joint, causing symptoms of anterior impingement.

      随着时间流逝，既往踝关节扭伤还可以造成一个小的骨性凸起的形成，即所谓的骨刺。骨刺可位于胫骨的基底部边缘或距骨的上关节面。当踝关节背屈时，骨刺可戳入踝关节前方的软组织，从而引发前踝撞击综合征。

Posterior impingement occurs in the back of the ankle. It is most common in ballet dancers who must continually rise up on their toes, pointing their foot downward into extreme plantarflexion. Other athletes are rarely affected but may have problems if they routinely plantarflex their feet.

      后踝撞击综合征发生于踝关节的后方。这最多见于芭蕾舞演员，因为她们经常持续用脚尖站立，踝关节极度跖屈，脚尖朝下。其他运动员很少发生后踝撞击，除非他们也经常跖屈踝关节。

The usual cause of posterior impingement is an os trigonum (described earlier). This normal fragment of bone is a separation of the lateral tuberosity from the talus. When an os trigonum is present, it can cause problems, especially among ballet dancers who constantly rise up on their toes into the dance position called pointe. Pointe is a position of extreme ankle plantarflexion. As the foot points downward sharply, the os trigonum can get sandwiched between the bottom edge of the tibia and the top surface of the calcaneus (the heelbone). This can trap the tissues above and below the os trigonum, leading to symptoms of posterior impingement.

      后踝撞击最常见的原因是距后三角骨（见前述），这一正常骨性结构自外侧距骨结节分离而来。当存在距后三角骨时，会引发一些症状，尤其是经常用脚尖站立的芭蕾舞演员。脚尖站立意味着踝关节极度的跖屈，在这个姿势下，三角骨就像是三明治一样，被夹在距骨基底部边缘和跟骨上表面之间。这造成软组织卡压于三角骨周围，进而造成了后踝撞击综合征的一系列症状。

Posterior impingement can also occur in a ballet dancer who has had a previous ankle sprain. Damage from the past ankle sprain may create too much instability in the ankle. As the dancer rises up on the toes, the talus may be free to slide forward slightly. This allows the shelf of the heelbone to come into contact with the back of the tibia, pinching the soft tissues in between. Posterior impingement from ankle instability can also happen in other athletes. But this is uncommon, because forceful plantarflexion is rarely required in other sports.

      后踝撞击综合征也可能发生于有过踝关节扭伤史的芭蕾舞演员。既往踝关节扭伤可造成踝关节不稳。当用脚尖站立时，距骨可能会轻微的向前方滑移，这就使得跟骨的上方平台与胫骨后方接触，然后造成软组织卡压于两者之间。踝关节不稳造成的后踝撞击也可能发生于其他运动员，但并不多见，因为极度跖屈踝关节在其他运动中很少见。

Related Document: 

Symptoms

症状

What does ankle impingement feel like?

      踝关节撞击会引发什么症状？

Anterior impingement may feel like ankle pain that continues long after an ankle sprain. The ankle may feel weak, like it can’t be trusted to hold steady during routine activities. When anterior impingement comes from ligament irritation, pain and tissue thickening are usually felt in front and slightly to the side of the ankle. This is the area of the ATFL. The pain worsens as the foot is forced upward into dorsiflexion. If the ligaments have irritated the synovium of the ankle joint capsule, throbbing pain and swelling from inflammation (synovitis) may also be felt in this area.

      踝关节扭伤后的前踝撞击会引起踝关节持续的疼痛，踝关节会有无力感、并且在日常活动中不能维持原有的稳定性。如果前踝撞击是来自于韧带发炎，通常会在踝关节前方或稍侧方出现疼痛及组织增厚，这一区域即是距腓前韧带。这一症状会随着踝关节反复被动背屈而加重。如果增厚的韧带刺激到了关节囊滑膜，则在相应的区域会出现滑膜炎，表现为跳痛及肿胀。 

Symptoms of posterior impingement include pain behind the heel or deep in the back of the ankle. There is usually tenderness just behind the bottom tip of the fibula, by the outer ankle bone. Pain is usually worse when the foot is pointed down into plantarflexion. A painful clicking sensation may also be felt as the foot is twisted in and out.

      后踝撞击综合征的症状包括足跟部疼痛及踝关节后方深部的疼痛。通常，在腓骨远端，踝关节的外侧存在有压痛。当踝关节跖屈时，疼痛症状会加重。当踝关节来回反复扭伤时，还会出现痛性弹响的感觉。

Diagnosis

诊断

How do doctors diagnose the condition?

      医生如何诊断该疾病

The diagnosis of ankle impingement is usually made by examining the ankle. The doctor will move your ankle to see what movements or positions cause your pain. If anterior impingement is suspected, the doctor may bend your ankle upward or ask you to squat down. To check for posterior impingement, the doctor may push your foot downward or have you rise up on your toes. Tenderness can usually be pinpointed over the tissues that are being pinched.

         医生通常是通过检查你的踝关节来做出踝关节撞击综合征的诊断的。他会活动你的踝关节，来检查在何种运动下及何种姿势下会诱发踝关节疼痛 。如果怀疑是前踝撞击综合征，医生会朝上弯曲你的踝关节或者叫你蹲下。如果怀疑是你后踝撞击综合征，医生会朝下推你的踝关节或叫你用脚尖站立。通常，医生能准确的发现被卡压组织表面的压痛点。

If the doctor believes that pinching in the back of the ankle is from an os trigonum, a numbing medication may be injected into this area. If it feels better, the problem is a posterior impingement from the os triogonum. If the pain doesn’t change, the problem could be in the tendon that runs along the inside edge of the os trigonum.

      如果医生考虑后踝的软组织卡压是由于三角骨造成的，他会在这这个区域诊断性的进行局麻药的注射。如果注射后，踝关节疼痛缓解，那么说明三角骨引发的后踝撞击综合征诊断是正确的。如果疼痛无明显缓解，这说明撞击是由沿三角骨内侧缘走形的肌腱引发的。

The doctor will probably order X-rays if impingement is suspected. X-rays can show if there are bone spurs on the tibia or talus. In cases of posterior impingement, an X-ray can show if an os trigonum is present. You may be asked to squat down or rise up on your toes during the X-ray. This helps show if impingement is due to bone pinching the soft tissues.

      医生也可能会让你去拍X片。通过X片能发现胫骨或距骨是否存在骨刺。在后踝撞击综合征的患者中，X片能发现是否存在三角骨。在拍片的时候，医生可能会让你下蹲或脚尖站立，这有助于发现撞击是否是由骨性结构卡压软组织所致。

A bone scan may be recommended in select cases, such as when surgery is being considered. In general, MRI scans are not helpful for impingement problems, but they may be ordered to check for other ankle problems that could be causing your pain.

      CT扫描有时会建议某些患者使用，如准备手术的患者。一般来说，磁共振扫描对诊断撞击综合征没有太大的帮助，但对于其他引起踝关节疼痛疾病，磁共振还是有一定的意义的。

Treatment

治疗

What can be done for the problem?

       这种病有些什么治疗方法？

Nonsurgical Treatment

非手术治疗

You may be told to rest the ankle for a short time to reduce swelling and pain. A special walking boot or short-leg  may be recommended to restrict ankle movement for up to four weeks. Mild pain medications and anti-inflammatory medicine, such as ibuprofen, may also be prescribed. An ice pack can also help alleviate swelling and may encourage a faster return of normal ankle movement.

      你可能会被建议休息一段时间，以减轻肿胀和疼痛。特殊的步行靴或短腿石膏会建议使用，以限制踝关节使用越4周。中度的止痛药及消炎镇痛药物，如布洛芬，会被建议使用。冰袋的使用有助于减轻肿胀，并能加快返回正常踝关节运动的时间。

Your doctor may recommend a  into the painful area. Steroids are strong anti-inflammatory medications. A steroid injection can help relieve irritation and swelling in the soft tissues that are being pinched, reducing their tendency to get pinched.

Your doctor may suggest that you work with a physical therapist to help you regain normal use of your ankle. Patients often progress in a series of exercises including stationary cycling, range of motion, and ankle strengthening.

      你的医生还可能会建议你去理疗师那里就诊，以使你重获踝关节的正常功能。一些运动如：固定脚踏车、踝关节活动度锻炼、踝关节肌力锻炼会使得患者得到益处。

Surgery

手术

If nonsurgical treatments do not work, surgery may be recommended. The type of surgery will vary depending on the location and cause of ankle impingement.

      如果非手术治疗没有效果，就需要考虑手术治疗了。手术的方式取决于踝关节撞击的位置及病因。

Debridement

关节清理术

Debridement is the most common surgery for anterior ankle impingement. Many surgeons prefer to perform this procedure with an arthroscope. An arthroscope is a tiny TV camera that can be inserted into a very small incision. It allows the surgeon to see the area where he or she is working on a TV screen.

      关节清理术是前踝撞击综合征最常采用的手术方式。很多医生更愿意在踝关节镜下进行该手术。关节镜手术即通过一个小的切口，插入摄像头，然后医生通过电视屏幕来观察踝关节内部结构。

To begin, two small incisions are made through the skin on each side of the impingement area. The surgeon inserts the arthroscope to see which area of the tendons or joint capsule are irritated and thickened. The arthroscope lets the doctor see if a meniscoid lesion (mentioned earlier) is present. A small shaver is used to clear away (debride) irritated tissue from the affected ligaments. The surgeon also debrides the tissue forming a meniscoid lesion and any areas of the joint capsule that are inflamed. Small forceps may also be used to clear away irritated or inflamed tissue.

      医生首先会在撞击区域的两侧取小的切口，然后插入关节镜来检查哪部分肌腱或关节囊发或增厚。在关节镜下，医生能发现是否存在类半月板病变，然后使用刨削器来清除类半月板病变，及任何累及关节囊的发炎的组织。有时也会使用小的血管钳来清除炎性组织。

Small bone spurs on the tibia or talus are removed. If the spurs are large, the surgeon may decide to create a new incision over or next to the spur. This allows a special instrument, called an osteotome, to be inserted. The surgeon uses the osteotome to carefully remove these larger bone spurs.

      胫骨或距骨上小的骨刺也需要被切除。但如果骨刺较大，医生就可能会考虑在骨刺上方或旁边做一个新的切口，然后插入一种特殊的工具，称为骨凿，小心仔细的凿出那些较大的骨刺。

Before concluding the procedure, a fluoroscope is used to check the debridement and to make sure no bony fragments remain. A fluoroscope is a special X-ray machine that allows the surgeon to see a live X-ray picture on a TV screen during surgery. When the surgeon is satisfied that debridement and removal of bone fragments is complete, the skin is stitched together.

      在结束手术之前，常规会进行荧光透视，以确保没有骨性残留。荧光透视是一种特殊的X线机器，医生可以在术中屏幕观察实时的X线片。当术者，认为清理满意且确认无骨刺残留，则关闭皮肤切口。

Os Trigonum Excision

三角骨切除术：

The goal of an os trigonum excision is to carefully remove (excise) the os trigonum to alleviate pinching of the tissues above or below it. It is standard to use an opensurgical method which requires a one- to two-inch incision over the outer part of the back of the ankle. An arthroscope is not routinely used for os trigonum excision because there are many nerves and blood vessels in the back of the ankle that could be injured by an arthroscope.

      该手术的目的就是小心的切除三角骨，以松解卡压在三角骨周围的软组织。通常标准的术式是采用开放式入路，在外踝后方取长约1-2英寸的皮肤切口。一般此处并不常规使用关节镜。因为在踝关节后方有很多的神经和血管走形，采用踝关节镜很容易损伤这些神经和血管。

This surgery begins by placing the patient face down on the operating table. The surgeon makes a small incision over the lateral side of the back of the ankle, just behind the outer anklebone. A retractor is used to carefully hold the nearby tendons, nerves, and blood vessels out of the way. The surgeon locates the os trigonum. A scalpel is usually sufficient to dissect the os trigonum. However, if a bony bridge binds the os trigonum to the talus, the surgeon may need to use a chisel or osteotome.

      术前，患者取俯卧位趴在手术床上，术者在踝关节后外侧取一个小的切口。用拉钩将神经、血管、肌腱小心的牵开。充分显露三角骨，通常使用刀片就可以用切下三角骨。但有时如果三角骨与距骨见存在骨桥，就需要使用骨凿以切除三角骨。

A fluoroscope is used to check for any remaining bony fragments. When the surgeon is satisfied that all bone fragments have been removed, the skin is stitched together. Patients are placed in a special splint designed to protect the ankle and to keep the foot from pointing downward.

      然后，术中透视确认没有骨性碎片残留，术者认为手术清理满意，则关闭切口。患者的踝关节穿上特制的支具，以防止踝关节跖屈。

Rehabilitation

康复

What should I expect following treatment?

      我还有什么后续的治疗?

Nonsurgical Rehabilitation

非手术治疗的康复

Even if you don’t need surgery, you may need to follow a program of rehabilitation exercises. Your doctor may recommend that you work with a physical therapist. Your therapist can create a program to help you regain ankle function. It is very important to improve strength and coordination in the ankle.

      即使你没有接受手术治疗，你也需要一个康复计划。你的医生会建议你与康复师进行沟通。你的康复师会帮你制定计划以恢复踝关节的功能，最重要的是恢复踝关节的肌力和协调性。

After Surgery

术后康复

After debridement surgery, patients are usually placed in an ankle splint. Patients begin by using crutches. The amount of weight put on the foot is gradually increased over a period of one to two weeks. Patients generally advance quickly in rehabilitation and are able to resume normal activity within four to six weeks.

      踝关节清理术后，患者通常会穿一个支具。最开始的时候，使用拐杖。在最初的1-2周内，患足负重逐渐增加。通常患者需要4-6周的恢复时间重返正常活动。

Rehabilitation after excision of the os trigonum is a slower process. You will probably need to attend therapy sessions for two to three months, and you should expect full recovery to take up to six months. Patients are kept in the ankle splint for up to two weeks. Crutches are used during this time as the amount of weight borne on the foot is gradually increased.

      三角骨切除术后的康复是一个缓慢的过程，你可能需要两到到三个月的康复过程，如果需要完全恢复，则需要六个月的时间。患者需要使用踝关节支具两周时间，在这期间需要使用拐杖，患足的负重逐渐增加。

After removing the stitches and the ankle brace, patients are usually able to begin formal physical therapy. Initial treatments begin with gentle range-of-motion exercises for the ankle and toes. The first few physical therapy treatments are also designed to help control pain and swelling from the surgery. Ice and  treatments may be used. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

      拆除缝线及移除支具后，患者就可以开始正式的理疗了。最开始是治疗包括轻柔的踝关节及足趾的活动度的锻炼。最开始的理疗还被设计用于控制术后的疼痛并减轻肿胀。然后会使用一些冰敷和电刺激治疗。你的理疗师还会采用一些按摩及其他的手法治疗来缓解肌肉痉挛及疼痛。

As the symptoms from surgery begin to ease, you may be shown how to do easy ankle motions on a stationary bicycle. After three or four weeks you may start doing more active ankle exercises. Exercises are used to improve the strength in the ankle muscles. Your therapist will also help you regain position sense in the ankle joint to improve its stability.

      随着术后症状的缓解，你可能还在一个静态自行车上进行简单的踝关节活动。三到四周以后，你可能回开始做一些更主动的踝关节锻炼，用来提高踝关节的肌力。理疗师还会帮你重获踝关节的本体感觉，以提高踝关节的稳定性。

The physical therapist’s goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your ankle. When you are well under way, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

       理疗师的目的之一就是控制疼痛，提高活动度，提高肌力并稳定你的踝关节。当时恢复顺利时，定期的康复科门诊可以停掉。你的理疗师仍然是你的资源，但你自己仍要坚持锻炼，作为家庭计划的一部分。

（任甜甜    译）

译者介绍：

       任甜甜，主治医师，博士在读。硕士毕业于复旦大学附属华山医院。曾在英国伦敦大学学院（UCL）进修学习。宁波大学医学院留学生部讲师。参与市级课题三项，国家卫计委课题一项。获院级“十佳优秀青年医师”，院级中青年论坛一等奖，中华骨科好医生大赛浙江赛区第二名。

        技术专长：手足外伤及四肢骨折的微创治疗，周围神经卡压综合征的诊治，手腕及足踝小关节炎的诊治。四肢软组织及神经肿瘤的诊治。踝关节扭伤，跟痛症，拇外翻，平足，高弓足等足部畸形的诊治。

门诊时间：周一下午

门诊地点：宁波市第一医院1号楼4楼外科诊区

患者指南，图文并茂，

分门别类，构思巧妙。

深入浅出，中英对照，

医患携手，共同探讨。

能力有限，时间仓促，

错误难免，诚惶诚恐。

恳请各位，留言指导，

以利再版，更加周到。