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Saturday, September 26, 2015

Ankle Snapping: Email Correspondence

Dear Dr. Blake,

How fabulous you are taking questions again! Just my wonderful luck and timing! Thank you!
Dr Blake's comment: I am hopeful to be more consistent now. I have had a wild year with my dad passing and my mom living with my wife and I part time. It has been great to have this time with my mom. I thank everyone for their patience, and I apologize to those I could never answer back. 

Peroneal subluxation. I’ve been scouring your blog looking for info on this. At this point I am self diagnosing (I know, I know) but with my myriad ankle issues I’ve read a lot of information over the years about different ankle esque conditions. I am now 43 years old, still very active. My left foot had the lovely sesamoid fracture which occurred at age 39 I believe. It appears to be fine now but a good year of healing and more time of tenderness ensued. Then I’ve dealt with a 20 + year ankle fracture that occurred during a hard sprain (I thought) while snowboarding. My outer ankle (again left foot) continues on with the multiple fragments hanging out in my subtalor joint. I’ve chosen to forgo surgery since I really have a few occasions a year of periodic swelling and pain.

So today I am writing on behalf of my right foot. Until now I’ve really had no issues with it but am realizing now it’s been taking up serious slack for my left foot. Here’s what’s happening.

I significantly ramped up my yoga routine over the last 8 months and I’ve done a lot of hiking over the summer. A lot of several hour jaunts up steep, very fast elevation gains. Since the trails are fairly smooth and clear with just some uneven areas I just wear Keen brand waterproof lace up low top shoes. Not a ton of support but it’s a nice low shoe that doesn’t bother my left ankle issues and seems to serve well in many trail conditions. Overall comfortable and semi supportive I guess. Have practiced yoga for 20 + years and the yoga I do is fairly strong, vinyasa flow. Lots of odd angles and pressure on the outer ankles doing pyramids, side angles, balancing poses on one foot, warrior I’s etc. etc. Yoga as much as I love it can be oh so hard on ankles and notice more and more pressures/sensitivities while doing it (left ankle is speaking of some Achilles issues at the moment..will save that for another day).

So about mid summer I began to notice this ‘snapping’ happening on the exterior of my right outer ankle, going up my leg a few inches. When I place my fingers over the area and rotate my foot clockwise I feel a band or bands shifting side to side (more over the back portion of the ankle bone). The snapping is especially noticeable climbing steps or hills or pushing off to the left in a side step motion with pressure to outside of right foot. Along with the snapping I found myself waking in the morning and rotating that ankle as I felt like it needed a stretch and multiple cracks sound off from the ankle area as I rotate it clockwise. Lots of cracking. It feels really good but now I’m trying not to do that.

Here’s the thing. There is NO pain in my right foot. Maybe after a long hike I feel a touch of soreness near outer part of ankle but there is no swelling, no pain during any movement. Definitely no pain or tenderness over the snapping areas. But the snapping seems is getting worse and it’s becoming very unpleasant. I haven’t been to a doctor yet because as I’ve mentioned I live in a remote area where each doctor visit begins with the most basic diagnosis, then a long wait ensues for a specialist in an area not usually related to the specific area you are requiring assistance for.

I would love any advice on bracing, exercises, taping, and/or suggestions I could offer to my physical therapist who may know little about the condition. If you feel like this could be masquerading as something else or would like me to get an x ray or consult with a physician before a reply I can do that. Hopefully I’ve done a good job self diagnosing :)

Thanks in a advance for any words you may have for me and thanks for the many you’ve already provided me!

Cheers!
 
Dr Blake's response:
     This syndrome of snapping ankles is does come from the peroneal tendons moving over themselves. There can be only muscular tightness involved, or a combination of tightness and inflammation. The treatment is exploratory. Most start and work on the inflammation with icing twice daily, and begin some form of peroneal muscle massage (say with a rolling pin or massage stick). You need to stay away from tendon massage since that is hard to avoid irritating. ART or soft tissue mobilization of the peroneal muscles (not tendons) can be very helpful. A few cases I have seen are joint related with some joint mobilization needed (to get it unstuck!! in the wrong position). I can image it can develop from weakness, but I have never seen that, so peroneal tendon strengthening seems to not be helpful. I see this over and over on the side that was not injured, as a secondary limping residue. It seems that if we want to take pressure off our left side, we love to go all the way over to the lateral (outside) of the right. A change in foot pronation (more!!) could cause this. Have you noticed any change in your right side mechanics? Hope this helps you. Rich

Here my wife Patty and I are walking into Azofra in Northern Spain Sept 2015

Patient Response:

Good afternoon Dr. Blake,

Awesome about your journey! The pics are wonderful! I had seen a bit about it on your blog but wasn’t too clear on how far you went.  That is quite a ways!!!! Wow! :) I’ve heard that trek is amazing and so inspiring and also that Spain is very very lovely. On a side note my condolences to you for the loss of your dad. Hope you all are making it through.

Thanks for you quick reply to my questions. Your post is great! It gives me hope that it’s not too serious and perhaps a simple fix! I have been told by several massage therapists that my lower legs are horrifically tight! There are also some adhesions here and there. I have just begun exploring foam rolling and use of a tennis ball for self massage and I will investigate this issue with that. I think you are right on. Right side mechanics? Wasn’t sure about that question. I don’t think I’ve had any issues if you were asking direct. In looking at my shoe soles each seem evenly worn on newer and old pairs. Only the tiniest bit of extra inner foot wear.

Wanted to pass on to you that I was able to get into my physical therapist who agreed yes the peroneals are for sure snapping on the right leg as I described. Then she told me braces or sleeves wouldn’t be very helpful and then gave me some oldish advice about strengthening. Oldish in that what I read was thats what they USED to advice patients. The new info is parallel with what you are saying that strengthening does little to assist the issue. I will get down to the business of experimenting and see what I can do for it and will update you.

Before I go I wanted to mention my left foot. The achilles pain I mentioned. Last week when emailing you the snapping in my right foot was far more annoying than the pain in my left but now it’s becoming critical and increasingly debilitating! It’s not constant but caused mostly by the weird pigeon toed bent back foot angle used in yoga warrior pose and the same type of foot position in surfing (left is my back foot). Today with every pop up and ride aaaagh the pain!!! Medium stabbing and burning. It’s been bothering me a bit more each time I go out but today was bad. The pain is very central to right behind the outer ankle bone running up an inch or two. But it’s actually really hard to locate exactly where the pain is originating from. Only about a 3 inch diameter area. My PT said it was not achilles. Had me going up on my toes and other moves and nothing hurt it moving or palpating except three inches above the ankle bone I get an electric shock sensation when I press on it. I know there’s a million things it could be. Old fracture, arthritis, bursitis, more peroneal business but does anything stand out to you? 

No hurry on this! In fact I’m sure I have hit my quota of questions. Like two years ago lol.

Have a beautiful day!

Dr Blake's response:

     The left is probably in neuro spasm. PTs typically can use electical stim to break the spasm. Docs will use trigger point injections with local anesthetic. You can try to use deep ice massage with some painful acupressure. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.