All star guard Tyler Herro underwent surgery on September 19th to address posterior impingement syndrome of his left ankle. According to team physicians, Herro attempted conservative options including physical therapy, cortisone and PRP injections to avoid surgical intervention. Herro underwent surgery by Dr. Thomas San Giovanni, assisted by Heat team physicians Dr. Harlan Selesnick and Dr. Frantz Lerebours at Doctors Hospital Surgery Center in Miami.
Posterior impingement syndrome causes sharp pain to the posterior ankle with plantarflexion. This occurs due to the presence of an os trigonum, or accessory bone that can develop behind the talus during adolescence. Os Trigonum Syndrome refers to posterior ankle pain and reduced plantarflexion caused by “the nutcracker-phenomenon”. When an os trigonum is present, this accessory ossicle together with surrounding soft tissues can become wedged between the tibia, talus and calcaneus. This can lead to inflammation and impingement of the involved structures. The presence of an os trigonum isn’t sufficient to create the syndrome/symptoms. It is usually combined with a traumatic event.
Although conservative efforts are always attempted first, 40% of cases require surgery.
Surgical intervention for posterior impingement syndrome involves arthroscopic excision of the bone or soft tissue causing the conflict in the back of the ankle during plantarflexion, a procedure with lower morbidity and faster recovery than traditional open surgery. Surgeons make small incisions to insert instruments and a camera, removing the offending structure to relieve pain and restore ankle function. Typically, two portals are made medial (PM) and lateral (PL) just adjacent to the Achilles tendon just below the tip of the fibula. A 4 mm arthroscope with a 30° inclination is commonly used for superior visualization. Care must be taken to avoid damage to the sural nerve by advancing the trocar with the sleeve carefully through the PL portal to touch the posterior aspect of the talus by directing it toward the first interdigital web space. A shaver is used to debride fatty tissue anterior to the Achilles tendon and retrocalcaneal bursa to locate the intermalleolar ligament. The FHL tendon is localized and confirmed by great toe movements. Since vital neurovascular structures lie medial to FHL, instruments need to be placed laterally to the tendon while visualizing the fibro-osseous tunnel. Bony projections are resected with a shaver and burr. The subtalar joint is assessed for arthritis and synovitis. After satisfactory removal of bony projections and debridement are completed, the surgical site is closed with skin sutures. Recovery involves physical therapy to regain range of motion and strength, with a return to full sports often occurring within 6 months. In the case of Tyler Herro, the expected recovery time is 8 weeks and will be sidelined to start the 2025-2026 season.
