Pain guide · Ankle pain

Posterior ankle impingement: pain at the back of the ankle when you point your foot, from rehab to surgery

Posterior ankle impingement is a pinch at the back of the ankle when the foot is pointed hard: on pointe or demi-pointe, kicking with the laces, or landing. It is commonest in ballet dancers and also affects footballers and other athletes, often with a small extra bone called an os trigonum. That bone is common, though, and most people who have one never have pain.

Rehab and a change in how you dance or train come first, and in published series more than half of cases settled without surgery, though no trial has tested it. If pain persists after about 3 months, an injection or an operation to remove the bone, now usually by keyhole surgery, can help. This guide explains the signs, what scans do and don't show, the evidence for each treatment, and a staged plan with 3D demos and written return-to-ballet and kicking steps.

3-stage exercise plan When to get help 32 sourcesUpdated 21 October 2026

When to get help first

Exercise is for pain that has been checked or is clearly mild and settling.

Get urgent medical help if

Call 999 or go to A&E: after an injury, you heard a crack, the foot or ankle has changed shape or points at an odd angle, a bone is sticking out, there is a bad cut over it, you're in severe pain, or the toes look blue or white, feel numb or are cold to touch. These can mean a broken bone. Don't drive yourself.
Same day (urgent GP appointment or NHS 111): after an injury, you can't put weight on it or walk more than a few steps, the pain is very bad or getting worse, there is a lot of swelling or bruising or it is getting worse, or it feels very stiff. If you think it's broken, don't treat it yourself.
Same day: a sudden snap or pop at the back of the heel, then being unable to walk on tiptoe or climb stairs. It could be an Achilles tendon rupture or a broken heel bone.
Same day: a sudden, very painful, hot, swollen, red joint, often the big toe, especially with a high temperature, feeling shivery or being unable to eat. It may be gout, but it could be a joint infection (septic arthritis), which is urgent.
After surgery: redness, swelling, oozing or a smell from the wound, or a fever. Contact your surgical team the same day, or NHS 111 out of hours.
Same day (GP or NHS 111): throbbing pain and swelling in one calf, with red or darker skin. It could be a blood clot (DVT). Watch for it after an ankle injury or time in a cast or boot.
Call 999: calf or leg pain or swelling with breathlessness or chest pain. It could be a clot that has reached the lungs.
Same day: in a cast or boot, pain that is getting worse, toes that are numb or burning, a cast that feels too tight, toes that are swollen, blue or white, or a bad smell from under the cast.

See a doctor or physiotherapist if

Pain at the back of the ankle that keeps coming back with pointing, kicking or landing: see a GP or physiotherapist. In many areas you can refer yourself to NHS physiotherapy.
Pain that isn't better after 2 weeks of looking after it yourself, is getting worse, keeps coming back, or stops you doing normal things.
Not better after about 3 months of good rehab, or it keeps a dancer off pointe or a player out of games: ask about seeing a sports medicine doctor or a foot and ankle specialist about an injection or surgery.
An ankle that keeps giving way months after a sprain.
One spot on a foot bone that hurts with every step and later at night: a possible stress fracture.
Tingling or loss of feeling in the foot, or a foot that feels weak.

Understand it

What it is

At the back of the ankle, the ankle bone (the talus) has a small knob that grows from its own growth centre in adolescence. If that centre doesn't fuse, it stays as a separate small bone, the os trigonum; if it fuses long, it forms a Stieda process. When the foot is pointed hard, the back of the shin bone and the top of the heel bone close together like a nutcracker, and the bone and the soft tissue around it can be squeezed and inflamed.

The soft tissue includes the joint lining and the flexor hallucis longus (FHL) tendon, which bends the big toe and runs in a groove right beside the os trigonum. Most cases involve bone (82.8% of 267 ankles in one surgical series), and many involve the FHL tendon too: it was affected in 69.4% of 111 ankles operated on in another series, where the bone was the only problem in 15.3%. In children, a low-lying FHL muscle can crowd the space as well.

Sources 1, 2, 3, 4, 5, 6

Who gets it

Ballet dancers make up most of the research (62% of the sports reported in one review). In a series of 240 athletes, ballet came first, then football, rugby, baseball, basketball and swimming, and studies of elite athletes include fast bowlers in cricket. It comes from repeated or sustained full pointing (pointe, demi-pointe and relevé), kicking with the laces, pushing off and landing.

It mostly affects teenagers and young adults: student athletes aged 12 to 22 (average 17) were the largest group in that series, and operated dancers averaged 18. One children's hospital treated 60 children over 10 years, average age 14.7, 49 of them girls. In 186 young trainee ballet dancers, 12 had pain at the back of the ankle, 6 of them with an os trigonum.

In two professional ballet companies, posterior impingement needed medical attention 0.16 times per female dancer per season and 0.07 per male. Outside ballet it is uncommon: about 3% of the ankle injuries that stop footballers playing.

Sources 3, 4, 7, 8, 9, 6, 10, 11

How it's recognised

Deep pain at the back of the ankle, often towards the outer side, brought on by full pointing, pushing off or landing, with tenderness there. A clinician will push the foot fully down to see if that brings on the pain, and the diagnosis rests on this examination. Pain behind the inner ankle with a big toe that catches, or pain when the big toe is bent back, points to the FHL tendon, which often comes with it.

Look-alikes include Achilles tendinopathy (the cord above the heel), a painful bump at the back of the heel bone (Haglund's deformity), the tendons behind the outer ankle bone, a stress fracture, and a crack in the back of the talus after a sprain. Our guides cover the first four. An injection of local anaesthetic into the area can help confirm where the pain comes from.

It can start after an ankle sprain: in 19 athletes with a painful os trigonum, 8 dated it to a sprain. Deep pain at the back of the ankle that hasn't settled about 6 weeks after a sprain, especially when pointing the foot or pushing off, is worth getting checked (our suggestion).

Sources 12, 4, 1, 5, 13, 14, 2, 15

What X-rays and scans do and don't meanEmerging evidence

An os trigonum is common: about 9% of feet across 41 studies of 36,612 feet (24% on magnetic resonance imaging (MRI), which picks up more), often in both feet, and 10.3% in a second review. Most never cause symptoms.

In 76 elite ballet dancers, footballers and fast bowlers who were all training and performing fully, MRI showed an os trigonum or Stieda process in 62%, and fluid and inflamed lining at the back of the ankle in over 90%. In 82 elite dancers and athletes, none of the imaging findings was linked with pain, the examination test or how well the ankle worked. In 31 professional dancers without symptoms, 82% of feet and ankles had bone marrow swelling somewhere, and only 2 dancers developed symptoms within a year.

In 23 ballet dancers who did have symptoms, the same fluid and inflamed lining were on every scan, but an os trigonum on only 7. A 2022 review found no earlier study comparing scans of people with and without the condition, and in the 82 elite dancers and athletes, the findings didn't differ between those diagnosed with it and those without. So a scan helps plan treatment once the examination fits, but doesn't make the diagnosis. In children scanned for suspected impingement, a larger os trigonum went with symptoms, while swelling inside the bone didn't.

Sources 16, 17, 1, 2, 7, 13, 18, 19, 20, 21, 22

How it usually goesMixed evidence

No study has followed its natural course. In case series, more than half improved without surgery: 12 of 20 cases, 9 of 12 young trainee dancers, and 31 of 65 children's ankles. Those whose pain persists after at least 3 months of good care are offered an injection or surgery, after which most return to their sport. In one series, a longer spell of pain before surgery went with a slower return.

Sources 3, 23, 10, 6, 2, 4

What helps, and how strong the evidence is

Rehab and a change in training come first, though no trial has tested themEmerging evidence

An NHS hospital lists rest, a change of activity, and taping with physiotherapy before surgery, and a review lists anti-inflammatories, ice, less weight-bearing and a change of activity. In case series, 12 of 20 cases improved without surgery, 9 of 12 young ballet trainees did well, and 31 of 65 children's ankles needed nothing more.

That is thin evidence: there are no trials and no prospective studies of non-surgical care, and one review found only 33 dancers' ankles across 6 papers on it. It is still the sensible first step, because it often works and carries little risk.

Sources 2, 1, 23, 10, 6, 3, 24

An 8-week programme in adult footballers: one group, no comparisonEmerging evidence

In 20 adult male footballers, an 8-week programme without steroid injections (holds and part squats, then lunges in several directions and balance work, then hops, rope jumping and run intervals, then running with cuts and turns) was followed by less pain and tenderness and better movement, function and long jump, though not vertical jump.

There was no comparison group, so some of the improvement may have happened anyway, and the players were adults. Its progression rules shape our plan.

Source 12

Injections: pain relief and a test, in case seriesMixed evidence

A steroid and local anaesthetic injection into the back of the ankle, usually guided by ultrasound or X-ray, can ease pain and help show where it comes from; an NHS hospital uses injections or scans to judge whether an operation is likely to work. In 19 athletes treated first with an injection, 6 needed a second and 3 went on to surgery. Professional footballers returned quickly after ultrasound-guided injections.

In children, early relief after a local anaesthetic injection (a median of 80%) didn't predict who later needed surgery. No trial has compared injections with rehab or a dummy injection.

Sources 2, 25, 15, 6

Surgery when rehab fails: high return rates in case seriesEmerging evidence

Surgery is offered when good non-surgical care has failed, usually for at least 3 months. The os trigonum and inflamed tissue are removed (the foot doesn't need that bone), and the FHL tendon is freed if it is involved. In a 2025 review, removing a painful os trigonum had the best results of any type of ankle impingement, with return to sport over 80% in every study.

Return times vary: 27 elite footballers trained again at 34 days and played at 41; dancers danced again at an average of 11 weeks (4 to 36) across 376 ankles; after keyhole surgery on 147 ankles, athletes trained at 6.3 weeks and returned to sport at 13.5; and 25 of 26 young athletes returned at 12.5 weeks after open surgery. These are case series, and your surgical team sets your timeline.

Sources 4, 9, 2, 14, 29, 24, 8

Keyhole or open surgery: a small trial favours keyhole, reviews are mixedMixed evidence

In a randomised trial of 52 athletes followed for 5 years, keyhole (endoscopic) surgery got people back to training in 4.6 weeks against 9.6, and to their sport in 7.1 against 11.5, with 1 complication against 6. A 2022 review of 32 studies found no significant difference in function, satisfaction or time back (8.9 against 10.8 weeks), with significantly fewer minor complications after keyhole surgery in the better studies; an earlier review of 16 studies favoured keyhole surgery.

Open surgery still did well in 26 young athletes, with 25 back to sport and no nerve injuries. Both approaches work, and the choice is one to discuss with the surgeon.

Sources 26, 27, 28, 9

How much pain is OK while you exercise?

The foot and ankle rule, staying short of the pinchEmerging evidence

Strength, balance and fitness work: discomfort up to about 5 out of 10 that settles within an hour, with no more swelling or stiffness the next morning, is fine. If it's worse the next day, do a little less, not nothing. The 5 out of 10 figure is an editorial starting point that matches our other foot and ankle guides, not a tested rule.

Full pointing: stay short of the sharp pinch at the back of the ankle. Calf raises, relevé and pointing exercises go only as high as you can without it, and go higher as it eases (our suggestion).

Moving on: in the footballers' programme (adults, one group with no comparison), players moved on when pain on full pointing was 4 out of 10 or less and only at the very end of the range, and went back to running and sport drills once hopping and landing were pain-free. The return-to-ballet protocol moves dancers on only when each step is pain-free.

The exceptions: pain in one spot on a bone should be pain-free, because it could be a stress fracture, and burning, tingling or numbness means stop that movement. After surgery, your team's limits on weight and movement come first.

Sources 12, 30, 2

The exercise plan: 3 stages

Start at the first stage. Each move opens a full guide with a 3D demo.

Stage 1

Settle: stop the pinch, keep moving (about weeks 0 to 2)

Cut out full pointing under load: pointe and demi-pointe, relevé, jumps landing on a pointed foot, kicking with the laces and downhill running. Keep training everything else: upper body, trunk, cycling, and swimming with a pull buoy. Ice after activity can ease it, and taping that stops the last part of pointing can help in the short term, as a physiotherapist advises.

Ankle CARs (controlled articular rotations) demonstrated on the 3D figure

3D demoAnkle CARs (controlled articular rotations)Beginner · No equipment

5 slow circles each way, morning and evening · Stay short of the pinch. The move page's editorial dose

Easier: Ankle circles · Harder: Toes-tucked kneeling (toe squat)

Knee-to-wall ankle rock demonstrated on the 3D figure

3D demoKnee-to-wall ankle rockBeginner · A wall

10 slow rocks each side, daily · The move page's editorial dose

Seated bent-knee calf raise (soleus raise) demonstrated on the 3D figure

3D demoSeated bent-knee calf raise (soleus raise)Beginner · A bench or box

2 sets of 15, through the middle of the range · Editorial dose

Harder: Slow calf raise

Towel toe curl demonstrated on the 3D figure

3D demoTowel toe curlBeginner · Other / check instructions + A bench or box

2 sets of 10 · Gently, if the big toe tendon behind the inner ankle is sore. Editorial dose

Harder: Short foot + toe splay

Single-leg stand demonstrated on the 3D figure

3D demoSingle-leg standBeginner · A wall

10 holds of 5 to 10 s on the sore leg · The footballers' programme's dose

Easier: Tandem stance and heel-to-toe walk · Harder: Single-leg reach matrix

Bodyweight squat demonstrated on the 3D figure

3D demoBodyweight squatBeginner · No equipment

4 holds of 5 to 15 s at about a 60° knee bend · On two legs, then one, as in the footballers' programme

Easier: Sit squat (partial squat) · Harder: Dumbbell goblet squat

Move on when: Walking and daily life are pain-free, and pain when the foot is pushed fully down is 4 out of 10 or less and only at the very end of the range, as in the footballers' programme.

Follow along: a timer, a cue and the next move, one step at a time.

Stage 2

Build: strength and balance in every direction (about weeks 2 to 6)

Calf strength through a growing range, ankle strength in every direction, balance and single-leg control, with strength work every other day (our suggestion).

Slow calf raise demonstrated on the 3D figure

3D demoSlow calf raiseBeginner · A wall

10 slow rises · Only as high as you can go without the pinch, building to full height over the weeks. The dance warm-up's 10

Easier: Seated bent-knee calf raise (soleus raise) · Harder: Standing dumbbell calf raise

Band ankle eversion demonstrated on the 3D figure

3D demoBand ankle eversionBeginner · A band + A bench or box

3 sets of 10 each foot · Without fully pointing the foot. The dancers' strength workout's dose

Easier: Isometric ankle eversion against a wall · Harder: Pogo hops

Band ankle inversion demonstrated on the 3D figure

3D demoBand ankle inversionBeginner · A band + A bench or box

3 sets of 10, slowly · The dose from an ankle instability trial, as on the move page

Harder: Single-leg calf raise from a step

Tibialis raise demonstrated on the 3D figure

3D demoTibialis raiseBeginner · No equipment

3 sets of 10 · The dancers' strength workout's dose

Harder: Single-leg tibialis raise

Reverse lunge demonstrated on the 3D figure

3D demoReverse lungeIntermediate · No equipment

2 sets of 4 lunges forwards, backwards and sideways · The footballers' programme's dose

Easier: Split squat · Harder: Split squat with dumbbells

Single-leg reach matrix demonstrated on the 3D figure

3D demoSingle-leg reach matrixIntermediate · No equipment

3 rounds of 5 reaches in each direction · The move page's editorial dose

Easier: Standing crossed-leg side reach · Harder: Single-leg Romanian deadlift

Move on when: 10 full calf raises cause no pinch, you can stand on the sore leg for 30 seconds, and your strength is within 80% to 90% of the other side, the entry point of the return-to-ballet protocol.

Follow along: a timer, a cue and the next move, one step at a time.

Stage 3

Power, then back to sport (about weeks 5 to 8, sometimes longer)

Hops and single-leg landings, quick bounces on alternate days, walk-run intervals 3 days a week, then running with speeding up, slowing down, cutting and turning, as in the footballers' programme. Then the ballet or kicking steps in the notes below.

Single-leg calf raise from a step demonstrated on the 3D figure

3D demoSingle-leg calf raise from a stepIntermediate · A step + A wall

2 sets of 12 each leg, lowering for 3 seconds · Full height only when it doesn't pinch. The dancers' strength workout's dose

Easier: Slow calf raise · Harder: Single-leg pogo hops

Ankle bounces (mini pogo) demonstrated on the 3D figure

3D demoAnkle bounces (mini pogo)Beginner · No equipment

2 sets of 20, every other day · Small, quick and quiet. The dance warm-up's dose

Harder: Pogo hops

3D demoPogo hopsIntermediate · No equipment

Build to 5 sets of 1 minute, every other day · The footballers' programme's rope-jumping block, done as pogo hops

Easier: Ankle bounces (mini pogo) · Harder: Single-leg pogo hops

Single-leg hop and stick demonstrated on the 3D figure

3D demoSingle-leg hop and stickIntermediate · No equipment

3 sets of 5 each leg · Land through the foot to the heel and hold. The dancers' strength workout's dose

Easier: Standing broad jump with stuck landing · Harder: Alternate-leg bounding

Treadmill jogging demonstrated on the 3D figure

3D demoTreadmill joggingIntermediate · Cardio machine

Walk-run intervals for 10 minutes, 3 days a week · The footballers' programme's dose

Easier: Treadmill walking · Harder: Sprint intervals

Shuttle runs demonstrated on the 3D figure

3D demoShuttle runsAdvanced · No equipment

2 sets of 5 cuts and turns each way · Wide, unhurried turns at first. The footballers' programme's dose

Easier: Treadmill jogging

Move on when: Hops, landings and sport drills cause no pain during or the next day; then the ballet or kicking steps; then full training. If it isn't better after about 3 months of good rehab, see a specialist about an injection or surgery.

Follow along: a timer, a cue and the next move, one step at a time.

What to change for now

Back to ballet: an expert protocol

These stages come from a return-to-ballet protocol for foot and ankle injuries, including posterior impingement, published in a 2022 review. It is expert opinion and hasn't been tested in a trial. Start once you can balance on the sore leg for 30 seconds, movement is pain-free and strength is within 80% to 90% of the other side. Work at the barre with two hands, then one, then in the centre, each only when pain-free. If your teacher or physiotherapist has a plan, follow theirs.

1. In trainers or jazz shoes: demi-plié to half range, tendus, rond de jambe à terre, and relevé on two feet. Any single-leg work uses the sore leg as the working leg, not the supporting leg.
2. Full demi-plié, building to grand plié; dégagé; relevé on one foot; bourrée; développé and arabesque. Turns only with the sore leg as the working leg.
3. Full barre without restriction; fondu, and turns with the sore leg as the supporting leg, singles first.
4. Fouetté and à la seconde turns on the sore leg; small jumps without beats, such as glissade, pas de chat and changement.
5. Small jumps with beats and all petit allegro except temps levé.
6. Grand jeté, tour jeté, saut de chat and temps levé, and partner work. Pointe work can start once this stage is pain-free.

Source 30

Back to kicking (our suggestion)

No kicking programme has been tested for this. These steps follow the same principles as the ballet protocol: pain-free first, short and easy before long and hard, and a step back if the pinch returns.

1. Short passes with the inside of the foot.
2. Longer passes with the inside of the foot.
3. Kicks with the laces at half power, with the ball on the ground.
4. Driven passes and shooting at three-quarter power.
5. Full-power shooting, long balls and set pieces.
6. Full training, then matches. Stay at each step for at least 2 pain-free sessions, and drop back a step if the pinch returns.

Dancers, footballers and runners

Dancers: stay off pointe, and leave out full demi-pointe, relevé and jumps landing on a pointed foot while it pinches. Barre work in soft shoes can come back when the physiotherapist agrees, and the teacher can adapt class meanwhile.

Footballers: pass with the inside of the foot rather than driving the laces through the ball, and keep running if it doesn't hurt. Runners: avoid steep downhill running for now. Taping that stops the last part of pointing can help in the short term, as a physiotherapist advises.

Sources 2, 4

After a sprain

Rebuild balance and strength fully after a sprain. Repeated sprains and a loose ankle may contribute to posterior impingement, and our chronic ankle instability guide covers an ankle that keeps giving way.

Sources 11, 15

After surgery (as your team allows)

Your surgical team's plan comes first. One NHS hospital's typical timings after keyhole surgery: crutches with only light weight on the foot for 1 to 2 weeks, a nurse clinic at 2 to 3 weeks, then more weight as pain and swelling allow and physiotherapy from a few weeks. Walking or cycling come first, vigorous sport such as football after 2 to 3 months, and full recovery can take over 6 months. After open surgery, one series used a splint for 10 to 14 days, then a boot.

Once your team agrees, the plan above picks up at the build stage.

Sources 2, 9

Positions to swap, and why

Habit or position	Why it matters	Instead
Pointe, full relevé and jumps landing on a pointed foot while it pinches	They force the end-range pointing that squeezes the back of the ankle.	Calf raises only as high as you can go without the pinch, such as the seated bent-knee calf raise, and barre work in soft shoes.Try: Seated bent-knee calf raise (soleus raise)
Kicking with the laces, long passes and shooting	The foot is forced into full pointing as it strikes the ball.	Inside-foot passing, then the kicking steps.
Child's pose with the tops of the feet flat on the floor	Body weight pushes the ankles to the end of pointing (our reasoning).	Tuck your toes under, or rest lying on your back.
Hero pose	You sit on pointed feet, which takes the ankles to the end of their range (our reasoning).	Leave it out for now, or sit on a chair.
Downhill running	Pointing under load can bring it on, an NHS hospital notes.	Flat routes, or cycling.Try: Stationary cycling
Band ankle eversion that ends in a hard point	The dancers' workout version points the foot, which takes the ankle into the pinch.	The same exercise without fully pointing the foot.
A pointed-foot flutter kick in swimming while it's sore	It repeats the end-range pointing (our reasoning).	A pull buoy, or lengths using the arms only.
Repeated steroid injections to get through a season	An injection can ease pain and help confirm the source, but in 19 athletes, 6 needed a second and 3 surgery, and no study has tested repeated injections in teenagers.	Rehab first, then a specialist's view on surgery if about 3 months of good care fail.

Routines to follow

Balance exercises routine

Balance practice in 10 minutes: tandem stance, single-leg stands, marches, heel walks, tree pose and floor transfers.

10 minBeginner7 movesA wall, A bench or box

Foot and ankle strengthening routine: toes, arches, calves and balance

A 15-minute barefoot routine for stronger toes, arches, calves and ankles, finishing with balance. You need only a towel, a wall and a resistance band.

15 minBeginner11 movesA wall, Other / check instructions

Strength workout for dancers: feet, hips, hamstrings, trunk and landings

A strength session for dancers, built on the professional ballet trial: calf and foot work, hip and trunk strength, Nordic lowers, step-downs and landings.

55 minIntermediate21 movesA wall, A step

Dance warm-up: feet, hips, spine and small jumps

A dance warm-up for class, rehearsal or performance: easy cardio, ankle circles and rises, leg swings, spine moves, turnout, balance and small jumps.

15 minBeginner16 movesA wall, A dumbbell

FIFA 11+ warm-up

FIFA's 11+ injury prevention warm-up as its manual sets it out: running drills, strength, balance and jumping at three levels, then faster running.

20 minBeginner20 movesCardio machine, A wall

More moves for this area

Questions people ask

What is posterior ankle impingement?

Pain from bone or soft tissue being pinched at the back of the ankle when the foot is pointed hard, as on pointe or when kicking with the laces. It is commonest in ballet dancers and also affects footballers and other athletes. When a small extra bone is involved, it is also called os trigonum syndrome.

What is an os trigonum?

A small extra bone behind the ankle bone, from a growth centre that didn't fuse in adolescence. About 9% of feet have one, often in both feet, and most people never know. It only matters if it is being pinched and causing symptoms.

How do I know if I have it?

The typical sign is deep pain at the back of the ankle, often towards the outer side, when you point your foot fully, rise onto demi-pointe or pointe, kick, land or push off. A clinician will push your foot fully down to see if that brings on the pain, and the diagnosis rests on that examination. A pinch at the front of the ankle when you squat or lunge is a different problem, anterior impingement, which has its own guide.

Do I need an X-ray or an MRI scan?

A scan helps plan treatment once the examination fits, but it doesn't make the diagnosis on its own. In elite dancers and athletes who were all training fully, MRI showed an os trigonum or similar bone in 62% and fluid at the back of the ankle in over 90%, and in another group the findings didn't differ between those with and without the condition.

How is it treated without surgery?

By cutting back the full pointing that pinches, then physiotherapy for movement, strength and balance and a staged return to sport or dance. Taping can help in the short term. In older case series, more than half improved without surgery, but no trial has tested it.

Will a steroid injection help?

It can ease pain and help show where it comes from, usually guided by ultrasound or X-ray. In 19 athletes, 6 needed a second injection and 3 went on to surgery. No trial has compared injections with rehab.

When is surgery needed?

When pain keeps you from dancing or sport despite about 3 months of good rehab. The bone and inflamed tissue are removed, now usually by keyhole surgery, and the foot doesn't need that bone. In a 2025 review, return to sport after removing a painful os trigonum was over 80% in every study.

Is keyhole surgery better than open surgery?

In a randomised trial of 52 athletes, keyhole surgery got people back to sport faster (7.1 against 11.5 weeks) with fewer complications. A review of 32 studies found no significant difference in function or time back, but fewer minor complications after keyhole surgery in the better studies. Both gave good results in published series.

How long is recovery after surgery?

Your surgical team sets the timeline. One NHS hospital advises crutches with only light weight on the foot for 1 to 2 weeks, vigorous sport such as football after 2 to 3 months, and full recovery sometimes over 6 months. In published series, elite footballers trained again at about 5 weeks and dancers danced again at an average of 11 weeks.

Can I keep dancing on pointe?

Not while it pinches. A published return-to-ballet protocol starts with barre work in soft shoes and adds relevé, turns and jumps step by step, with pointe last. Your teacher and physiotherapist can adapt class meanwhile.

Is it the same as Achilles tendinopathy?

No. Achilles pain is in the cord above the heel, and our Achilles guide covers it. Posterior impingement is deeper, behind the ankle joint, and comes on with full pointing. Pain behind the inner ankle with a big toe that catches can come from the big toe flexor tendon, which often comes with it.

Can it start after an ankle sprain?

Yes: forced pointing or a sprain can injure an os trigonum or the back of the ankle bone, and in one series of 19 athletes, 8 dated their pain to a sprain. We suggest getting it checked if deep pain at the back of the ankle hasn't settled about 6 weeks after a sprain.

Related exercise guides

Other pain guides

Sources

Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.