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Wednesday, November 8, 2017

Ankle Pain with Email Advice

Hello again, dr Blake

I hope you are well. I am sorry to bother you once again. I am sure you are a very busy man. Since last I contacted you, I can report that I have gotten hold of the exogen stimulator, and taking Vitamin D and Calcium supplements (right foot sesamoid problems).

However, I am not writing about my right foot metatarsal problem now. Unfortunately, I have a more acute problem with my left foot. 

Originally, after my running injury 2 years + ago, I ended up with very bad pain in both feet. The pain got so bad that I ended up using a wheelchair for 4 months. About a year after I was diagnosed with sesamoiditis in the left foot after MRI (oedema in both sesamoids). I suspected that I actually had had a sesamoid stress fracture in the left foot too and that it was healing ok. But I also had strange aching pain in all of the left foot and continued difficulty wearing shoes and tight socks. This pain got better very slowly but seemed to get worse every time my right foot metatarsal pain flared up, and I focused on offloading that with more "flat walking". I mentioned it to several doctors, but it seemed to be written off as pain connected to my forefoot-issues. But all the time I had a feeling that while my pain level matched the diagnosis of my right foot, it was not so with the left one.

About a month ago, my left hind foot had gotten quite painful again, and then I felt a sudden stinging pain at the back of my ankle/over my heel. It then felt like I shouldn't place weight on my heel afterwards. In the following week, the pain got worse. After negative x-rays and being written off by my doctors once again, I decided to pay for an MRI myself. This was the description I got:

"Mild tenosynovitis in peroneus tendon sheaths with possible small longitudinal spilt of peroneus brevis tendon distally to the lateral malleolus. The tibial posterior tendon is a little thickened distally against the attachment to os peroneum. Very mild tenosynovitis in the flexor tendon sheath." I have excluded the rest of the description, which was of normal findings.

I have read a lot about these tendons afterwards, and today I was at a physiotherapist with diagnostic ultrasound expertise. He confirmed that it looks like a split right below the malleolus, although a very short one. I have a history of 2 ankle fractures and following sprains (with a major knee injury after 1 sprain) in the left foot since my childhood, so I am thinking there might be a connection there. 

My question to you now would be, what now? I feel that the pain gets very bad with any weight-bearing at the moment. I tried offloading with crutches for a week, but my right foot cannot handle the additional weight. I also have gotten some new pain in the ankle area of the right foot. It doesn´t feel nearly as serious as the in the left, but I suspect some inflammational tendon issues there too. I have used a wheelchair at home for 10 days now, and I feel a lot of pain reduction when offloading the feet.

I read that some use cortisone to get rid of the inflammation, but others say it can damage the tendon more. I see some statistics that look very bad for conservative treatment of tendon split, and that many end up with surgery. Others claim that conservative treatment could work well, after all. Do you have a position on this? Or any advice on how long to offload the foot, before attempting to walk again? 
Dr Blake's comment: I need you to send me the MRI for review, at least a copy. Your symptoms do not match the findings of the MRI. If the physio tests the tendons, do they hurt? You can try resting the ankle in an AFO custom made at a local brace shop. They are prescription items. I see these split tears in some, with absolutely no pain in the area, and no pain on the contraction of the tendon against some resistance when you are testing the strength. I think for some people they are normal variations of that tendon--to not present like a hold piece but to present as multiple strands. Yes, I do not like cortisone for tendon inflammation as there can be some weakening. The 9 classes of NSAIDs could be tried first to find one that works well. Ibuprofen in one class, diclofenac in another, Celebrex in another, and so on. It sounds almost nerve tension, so consider neural flossing, Neuro-eze gel massage, and neurological eval by a doc or neuro PT. Hope this helps some. Rich

Hope for a response from you, yet again.

Kind regards,

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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.