Posterior Ankle Impingement
Compression of posterior ankle structures during the delivery stride — a cricket-specific ankle condition frequently misdiagnosed as Achilles tendinopathy or general ankle pain.
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What is Posterior Ankle Impingement?
Posterior ankle impingement occurs when the soft tissue or bony structures at the back of the ankle are compressed between the tibia and calcaneus (heel bone) during plantarflexion — the position where the foot is pointed downward. In cricket, this compression occurs at the moment of front-foot landing in the delivery stride.
The most common cause is an os trigonum — an accessory bone at the posterior talus that is present in a proportion of the population. When this bone becomes compressed in the delivery stride, it can cause significant posterior ankle pain. In the absence of an os trigonum, soft tissue impingement of the posterior joint capsule and FHL (flexor hallucis longus) tendon can produce identical symptoms.
This injury is specifically relevant to fast bowlers because of the high plantarflexion load at front-foot landing — a biomechanical demand that doesn't occur in most other sports to the same degree. It is frequently misdiagnosed as Achilles tendinopathy because the posterior location of pain is similar.
Key distinction from Achilles tendinopathy: Posterior ankle impingement pain is felt deep in the back of the ankle, is provoked by plantarflexion (pointing the foot), and is often reproduced by direct palpation deep posterior to the Achilles — not along the tendon itself. If Achilles tendinopathy management isn't working, impingement should be considered.
Symptoms
Managing Posterior Ankle Impingement in Fast Bowlers
Conservative management works well for most cases. Surgical referral is reserved for those that don't respond — particularly os trigonum presentations.
How We Manage Posterior Ankle Impingement
Accurate Diagnosis
Clinical assessment including the posterior impingement test — passive plantarflexion to reproduce symptoms. Imaging to identify os trigonum or soft tissue impingement. Differentiating from Achilles tendinopathy, FHL tendinopathy, and other posterior ankle pathologies that can present similarly.
Load Modification
Temporary reduction in bowling volume while acute symptoms settle. Batting and fielding (without diving) are usually well tolerated. We identify which elements of the bowling action most provoke symptoms and modify accordingly where possible.
Rehabilitation
Posterior ankle soft tissue work, calf and ankle strengthening, and proprioception exercises to support ankle stability. For os trigonum presentations that are managed conservatively, we trial an injection referral if initial rehabilitation is insufficient before considering surgical options.
Return to Bowling
Graduated return to bowling with symptom monitoring. For conservatively managed cases, return is guided by symptom response. For post-surgical cases, we manage the rehabilitation from 2 weeks post-op through to full return to bowling at 12–16 weeks.
FAQ — Posterior Ankle Impingement
No — many cases respond well to conservative management including load modification, soft tissue work, and rehabilitation. Surgery (os trigonum excision) is considered for cases that don't respond to a thorough conservative program — typically those with a confirmed os trigonum that is consistently symptomatic with bowling.
The location of pain is similar — both produce posterior ankle/heel pain. The key distinction is that posterior impingement is provoked by plantarflexion (pointing the foot), while Achilles tendinopathy is provoked by loading the tendon in a lengthened position. Clinical assessment and imaging distinguish the two reliably.
It depends on severity. Mild presentations may allow continued bowling with load modification. More significant impingement — particularly with an os trigonum — typically requires a period of reduced bowling to allow the acute irritation to settle before a rehabilitation program can be introduced.
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Posterior Ankle Pain Affecting Your Bowling?
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