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Wednesday, October 18, 2017

Talar Injury in Tennis: Email Advice

The dark area above sensor is injured part of talus extending into tibia above
Dr Blake,

I want to check in with you to confirm diagnosis and treatment you gave me this week.  Again I sincerely thank you for taking your time and listening which is something I normally do not see from health professionals.  Also, thank you for actually looking at the MRI which strangely most Doctors (except Dr Loosli) did not attempt.



Diagnosis:  Talus stress fracture
Dr Blake's comment: Yes, that is my diagnosis. Acute ankle pain, out of the ordinary on 6/27/17, which has hobbled you ever since. It is easy to focus on the wear and tear arthritis in your ankle, but something different happened that day, that is normally a stress fracture due to the impact of tennis and the over pronation of the ankle. 

Please confirm this diagnosis.  This is all makes sense now after researching normal symptoms.  Obviously 37 years of USTA competitive tennis and hiking Mt Diablo contributed to overuse.  This all started with a major ankle injury in 1963 playing basketball (stepping on top of players foot) in High School.  I have injured this ankle many times over the years, most significant 2009, and I only made stress fracture worse by playing on it for the last year or two.  I completely stopped playing tennis 6/27/17 and since then have only walked on a flat surface up to 45 min.  I have re-injured since 6/27/17  a total of 7 times due to things like gardening, using a ladder to install lights, light hiking, etc.  Right now it feels strong and I walk every day 45 min with no pain or discomfort.

Treatment:

1) ice 2x daily for 15 minutes with reusable gel ice pack,
2) alternating heat 4 min and ice 1 min, each evening
3) wear heel 1/2 inch inserts in shoes,
Dr Blake's comment: The ankle has the most pressure internally, exactly where his fracture is, when his ankle is at a right angle or bent forward (as in a squat). The heel lifts are to keep him slightly plantarflexed at the ankle not to crowd the joint. 
4) bone stimulator to increase healing twice daily, and 
5) continue walking flat surface using wrap around brace.

Please confirm above treatment or add or edit.  You told me it will take at least 1 year to heal and to monitor with another MRI in January 2018 and 6 mo later. 
Dr Blake's comment: Another MRI in January will tell us if you are healing, and by approximately how much. This will be 6 months from your first MRI. Each month you do more activity to test how it is doing. So, think about what you will add in November, and then in December, and then in January. We want to slowly stress the area and see how it responds. 

 You also suggested I take bone density test (scheduled tomorrow) and get you copy.  You also suggested I look at Vit D level and I believe calcium level.  I know Vit D level is good (47 Ng/mL).  Calcium 9.2 mg/mL on 9/20/17.
Dr Blake's comment: I know Vit D is 32-80  normal range, and calcium is below 10.1 over 40 years old. Which we both are!!

Questions:

1) Is there a way to speed up significantly the healing process?  For example, wear a boot or plaster cast for several weeks, then rehab?
Dr Blake's comment: Time, not irritating the tissue, bone stimulation, contrast baths for a deep flush, various braces and/or orthotics, and then a gradually ankle strengthening program. Immobilization always weakens the bones, so we need to create that 0-2 pain level and slowly increase function. 
2) What was your source(s) of diagnosis?  I believe you based on my symptoms and MRI.
Dr Blake's comment: The MRI can be read as stress reaction, stress fracture, bone bruising, arthritic changes, but the acuteness of pain on that one day is diagnostic for a fracture until proven otherwise. And, good medicine dictates that you need to treat the worse case scenario (in your case a stress fracture that could lead to a full fracture and major disability).  
3) Can special heel inserts be made for my shoes?  Can you do this?  Or perhaps another specialist you can refer?  I have seen Dr Jason Hiatt in Walnut Creek and 2 other Podiatrists.
Dr Blake's comment: The biomechanical change is simple, and most podiatrists, shoe repair cobblers, and running stores to give or make them. It is up to you to tell us if they help. 
4) Is my walking every day prolonging the healing process?  Should I just stop all weight-bearing exercises?
Dr Blake's comment: We have to create the 0-2 pain level, and or course, stop when the pain comes on with activity. Or, have the brace ready to put on. 
5) After my ankle heals, am I risking injury again by playing tennis?
Dr Blake's comment: So much depends on bone density, how hard you play, if you play with orthotics and a brace, etc. Let us see in 4 months how volleying leisurely feels with your wife or tennis partner first and go from there. Hope this helps Rich
Thank you for everything and you are the best!

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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.