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Friday, March 28, 2014

Friday's Patient Problem of the Week:Supination and ankle problems

Good Evening Dr. Blake 

    I am a 33 year old  young man living in Los Angeles CA. I have been having ankle inflammation in my right ankle which started about 1 year and 7 months ago. It was a pretty simple episode that I got ankle cramp and I manipulated my ankle with my finger and got inflamed for over 8 months.
Dr Blake's comment: Inflammation in the ankle in somehow who stands like you do is very very common. It normally is a combination of muscle fatigue and mechanical stresses (flat feet, high arches, loose ligaments, tight muscles, etc). Typically, you place yourself into some logical problem of rest, bracing, anti-inflammatory, and stretching and strengthening. The rest part is activity modification where you try to sit more at work, or at least get a soft mat to stand on, and use weekends (days off) to recover. 

   During this time,  I was trying to not put pressure on my right ankle so I was putting my body pressure on the left foot. The inflammation was not going down with taking lots of Ibuprofen 800 mg twice to 3 times daily. I was having burning sensation and warmth feeling around my ankle all the way down towards my heel.
Dr Blake's comment:Burning can be from a lot of causes---neurological coming from local or as high as your spine, vascular with poor circulation, and inflammatory with marked swelling. Unless there is more swelling than you describe, this burning may be from some stress on the nerves, however could be from swelling deep within the ankle joint.

    I have high uric acid level which is approximately around 9.2 or little less over the past 12 years, and while suffering from burning and discomfort,  my ankle would get a warmth feeling when I was wearing shoes. I saw couple of podiatrists where one gave me lidocaine injection to increase blood flow to reduce the inflammation, but it did not help me. 
Dr Blake's comment: Nothing in the history you give sounds like gout, although there is mild versions of it. Typical Gout is red, hot, and swollen area, where you worry that there could be an infection in your workup. The high uric acid blood test could have just been a red herring. 

   Over the phase of 1 year I received 3 cortisone shots in my right ankle that it finally helped with the inflammation going down. When my ankle was inflamed, I was experiencing tingling sensation around my ankle which the tingling would be less when I was laying down on my bed.
 Dr Blake's comment: So, your tingling was probably from deep swelling putting stress on the tarsal tunnel nerves. Nerve pain is so debilitating, and your body goes quickly into a self preservation mode to relieve it. However, this preservation mode normally produces way too much muscle atrophy and severe weakness settles in. 

   After about 1 year my left foot started burning around the ankle and I have changed many shoes but I would feel the burning getting worse as I wore every shoes. My wife noticed that I walked not straight and she brought it up to me every time I walked. After reading and doing a lot of research online, I came to conclusion that I have severe supination and I still have a little inflammation on the right ankle with the burning sensation and tingling.
Dr Blake's comment: Best to send me a photo of you standing, barefoot and in shoes, from the back of the heels. The photo should be from 2-3 feet behind you in good lighting. This will help me understand the severity of your severe supination. Supination, with the lateral instability it causes your ankle, could explain all of your symptoms. That would be nice.

    I have been seeing physical therapy for couple of sessions and they have gave me stretches and some work out but I need your help Dr. Blake. Please respond back and try to eliminate my pain and suffering that I am having for the past 1 year and 7 months. My job is a Pharmacist and I stand on my feet over 8 hours. Please please get back to me to find a solution to my suffering. I would really appreciate your concern and attention Dr. Blake if you can make my wishes of walking normal without any pain. GOD may bless you and your family for helping a young married man gain back his strength and be pain free.

my cell phone number is XXXXXXXXX  please contact me if you have to and please help me with all my suffering.

Dr Blake's response:

     Thank you so very much for your email. I have tried to give it some attention. I am glad you are going to the Physical Therapist since they can be my eyes in my attempt to help some. 

The questions I would have from them:
1. Are you excessively supinating and, if so, can they design an inserts that completely eliminates that stress?

2. Do they think you have inflammatory pain or neuropathic pain? Neuropathic pain is true suffering. Ask them to teach you neural flossing and test for low back involvement.

3. Can they give you an Air Cast Ankle Brace for more stability but not a lot of compression?

4. If it is neurological, you should have a doc involved that can give you oral meds, topical medications, and be able to order MRIs, EMGs, etc as indicated. All your pain can be coming from the low back because it is so hard to stand in spine neutral constantly in your job.

5. Ask the  physical therapist if an ergonomic evaluation of your work place can be done to make sure you know all the tricks at keeping your ankles and back healthy and minimally stressed. 

I sure hope this helps you some. 

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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.