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Wednesday, April 5, 2017
Ankle Pain and Instability: Patient Email Discussion
This is from a patient I saw several weeks ago. Since the email was so full of great information, I thought I would answer the best in the venue where I could give it the time it desires. She has had chronic ankle sprains with the last one in 2015 causing chronic soreness. She wants to be more active. Has had PRP injections to help tighten the ligaments, which still had some laxity. Her ankle was loose in the normal tests, including what I call translation of the subtalar joint. If I grabbed the heel, it would shift with pressure more than normal side to side. This can easily pinch the capsule (joint lining) when you move. I was not sure if the PRP addressed the ankle joint alone, or the subtalar joint also. I have seen cases of patients having surgery to tighten the ankle ligaments (most obvious) only to have the surgery fail since the problem was in the joint below (the subtalar joint). She walked with lateral instability (outward roll), and the arch of her orthotics (not really designed for supinators) made her worse. She looked slightly better without the orthotics. Her MRI was negative for surprises (no bony problems). I started her on taping to stop supination, contrast bathing for less swelling (this makes the joint more stable since fluid floats the joint surfaces on themselves making them more wobbly), an occasional use of an ankle brace when needed for stress situations (I would wear for basketball), and strengthening (you can always get your ankle 3 times stronger). I told her that each month for 24 months she should increase 3-4 ankle exercises by the amount of reps, sets, time, or level of difficulty guaranteeing that she is doing more and more. At followup, making some new orthotics may be done to control supination. I have placed a video after the email.
Hope you’re doing well! I wanted to email my follow-up, and I also have some issues about which I would appreciate some advice.
I’ve stopped using my old orthotics in my running shoes as you suggested. It totally made sense to me that they were causing stress on my ankle. However, I didn’t realize how present my sesamoid problem still is. The sesamoid area on my right foot has started to get a little soar now that I am not wearing insoles - not nearly as bad as it has been in the past, but I can tell if I do not address it the pain in my sesamoid will return in full. In trying to find a solution I went to On the Run, and they suggested a pair of Sauconys (for the wide toe box) and an insole especially for sensitive sesamoids (made by On the Run). After walking in the shoes for 20 min the insoles started to bother other parts of my foot (there was extra padding on the outside of the ball of my foot that squeezed that part of my foot uncomfortably, and the insoles dropped off a little under the toes to take pressure off, but it wasn’t comfortable). I think I need a decent amount of arch support to take the pressure off of my sesamoid, but not as much as my old orthotics provided. Do you think that is correct? Do you suggest I go back to On the Run to see if they have a different insole recommendation? Or do you have a specific recommendation?
Dr Blake's comment: Since the old orthotics protected your sesamoid, I would go back to them in the new shoe. I will adjust them to stop some of the outward roll, and we can talk about another orthotic that both stabilizes the ankle, and protects the sesamoid. If you see my sesamoid videos, at least getting a dancer's pad on to the store's inserts.
My ankle was pretty irritated the first couple of days after I saw you when I stopped wearing my orthotics in my running shoes and changed my day-to-day shoes (since the street shoes I brought to our appointment were making my ankle roll out). I’ve been trying to find other shoes that work for both my ankle and my sesamoid and have had a bit of a hard time. Do you have any suggestions of brands? Is there any style of shoe you would particularly recommend (for example low top vs high top)?
Dr Blake's comment: The Altra is a soft cushion front with zero heel drop so not adding more pressure on the fore foot while keeping the shoe close to the ground. The Saucony Triumph was always a good shoe for supinators. I love that high tops boots are still in style. But, it is what we are putting in them that is at least half the battle.
The tape has been noticeably helpful already. Even when my ankle has been a little soar, the tape alleviates at least some of the pain. I have been using it daily.
Dr Blake's comment: Great!!! I use the opposite taping that is in the video below for pronators. It is a J strap for supinators.
I have been doing contrast baths about every-other day. It is a little soothing. I don’t notice the same kind of relief as the tape provides.
Dr Blake's comment: That is okay. Still important to do. You have a mechanical problem so the tape, orthotics, shoes, brace, strengthening are the most important. Keep doing them for now.
I haven’t been consistent with the 5-minute icing after exercise (often I forget). When I’ve done it I notice some immediate relief, but it doesn’t seem to last long after I remove the ice.
Dr Blake's comment: Okay, you can stop that for now.
I am going to cut down to every other week with the physical therapist and focus on doing my exercises at home. Over the weekend I pushed my ankle a little too hard doing my exercises (jumping onto a pillow), so I’ve been laying off a little the past few days due to pain, but will go back to my regular routine once I feel up to it (today my ankle is feeling better than the last couple of days, so I think I can pick my regular program back up). Also, the therapist said she faxed over a note to your office before our appointment on 3/24 - did you receive it?
Dr Blake's comment: I will look for it.
Thank you! I really appreciate having you on my team.
Dr Blake's comment: I am happy to be on your team!!