Understanding Posterior Ankle Impingement (PAI): Causes, Symptoms, and Treatment
By Dr. Mo Mommersteeg, Chiropractor
What is Posterior Ankle Impingement (PAI)?
Posterior Ankle Impingement (PAI) occurs when bone or soft tissue at the back of the ankle becomes pinched between the tibia, fibula, and talus bones. This often worsens with plantar flexion (pointing the toes), whether under load (like standing on tiptoe) or at rest.
It’s a common source of rear-ankle pain, especially in active individuals or those with a history of ankle injuries.
What Causes Posterior Ankle Impingement?
There are two main causes of PAI:
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Repetitive strain and overloading of the ankle joint can lead to inflammation and irritation in the soft tissues. This is common in athletes and dancers who frequently perform movements involving end-range plantar flexion.
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Previous ankle sprains or direct impact can lead to subtle joint changes or soft tissue scarring, causing chronic impingement.
Traditionally, PAI was thought to be caused by structural abnormalities—such as an Os Trigonum (an extra bone) or an enlarged Steida’s process on the talus. However, recent research shows that these bony changes don’t always cause symptoms. This means biomechanical and soft tissue factors play a larger role than once believed.
Who is Most at Risk of PAI?
You may be more likely to develop posterior ankle impingement if you participate in:
Ballet or dance
Running or sprinting
Jumping sports (basketball, volleyball, netball)
Kicking sports (soccer, AFL)
A sudden increase in training load or poor recovery between sessions can also contribute to inflammation in the posterior capsule or tendons.
The Role of Soft Tissue in PAI
Chronic ankle instability or repeated sprains can cause the talus bone to move abnormally, compressing nearby soft tissues. Over time, this leads to thickening, irritation, and pain.
One key structure often involved is the flexor hallucis longus (FHL) tendon, which runs along the inside of the ankle and helps push off through the toes — especially active in dancers and runners.
Common Misdiagnoses
PAI can often be mistaken for other ankle or lower leg conditions, including:
Achilles tendinopathy
Peroneal or tibialis posterior tendinopathy
Tarsal tunnel syndrome
Osteoarthritis of the talus
FHL tendinopathy
Sural nerve irritation
Lumbar radiculopathy
That’s why a thorough movement assessment and diagnosis is essential to guide the right treatment plan.
Recognising the Symptoms
Common symptoms of Posterior Ankle Impingement include:
Deep, hard-to-locate pain at the back of the ankle
Pain when going on tiptoe, pointing the foot, jumping, or walking downhill
Sharp or dull ache that worsens with activity
No nerve-related symptoms (e.g., tingling or numbness)
Preventing Recurrence
Once symptoms improve, focus shifts to:
Correcting ankle and foot biomechanics
Building posterior chain strength (calf, hamstring, glute activation)
Improving balance and proprioception
Gradually returning to sport or dance
Consistency with rehab and movement re-education helps prevent future flare-ups.
Treatment Options for Posterior Ankle Impingement
At Momentum Health & Chiro Townsville, our chiropractors focus on restoring proper movement, reducing inflammation, and improving soft tissue function through evidence-based care.
Treatment may include:
Dry Needling – to release tension in the impinged soft tissue.
Graston Technique / Soft Tissue Therapy – to mobilise scar tissue and improve flexibility.
Joint Adjustments or Mobilisation – to restore normal ankle biomechanics.
Floss Band Compression (Flossing) – for fascial release and improved blood flow.
Rehab Exercises – including posterior chain strengthening and joint-opening drills.
Intrinsic Foot Stability Training – to enhance balance and long-term resilience.
Your Next Step
If you experience persistent pain at the back of your ankle, particularly during plantar flexion or high-impact movement, you may be dealing with Posterior Ankle Impingement.
Our team at Momentum Health & Chiro Townsville can perform a detailed assessment to pinpoint the cause and create a tailored treatment plan to help you move without pain.
