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,

Tuesday's Patient Question of the Week: Mysterious Ankle Pain from an old Ankle Fracture area

Hi Dr. Blake,

I realize this and the last email may have to fall to wayside of priorities of interest for you or patients and understandingly so. I have not received any recent x-rays or mri's to lead to any truly definitive idea of what is going on here with this pain that arose abruptly one morning as a sharp stabbing in the frontward area of my left (outside) ankle. The same ankle that was fractured roughly 18 years ago which was found out by an MRI about 12 years after the accident. The MRI did show several bits of bone fragment floating around in the vicinity of my ankle.
Dr Blake's comment: Definitely old bad ankle sprains with or without fractures can resurface 15-20 years later. The thought is that the original injury caused some small micro trauma to the cartilage which slowly degenerates leading to arthritic pain. 

The ankle has as I explained been tempermental with occasional swelling front and back of it and often if doing a lot of outward toe pointing as in pilates or wearing a boot or shoe that crosses the area it will become irritated and sometime "catch" with a sharp pain to follow that usually mellows out rather quickly.

Dr Blake's comment: Catching in the ankle can be a sign of a loose bone fragment (called a loose body) that is moving and occasionally getting in the way. This may require surgery to remove. It can also be a sign of some ankle weakness and overall wobble, so that the joint line (synovium) occasionally gets caught between two bones. This soft tissue impingement requires icing, some PT, and a lot of strengthening. The muscles/tendon must stabilize the joint which may have compromised ligaments. Prolotherapy, sugar water injections, into the ankle ligaments to irritate and scar is being used more in an attempt to avoid surgery. 

 Well that morning about two weeks ago I awoke with that catched feeling and stood up to walk it off and to no avail. It seemed almost stuck. No moving it side to side but point toe straight out or up seemed okay. It hurt at rest as well. And swelled. The doctor did no xray and dismissed as a sprain. I applied the RICE method, arnica, epsoms, and braced it a bit. After a week it started to work it self out. More range of motion each day. Then  a few days ago a little "pop" occurred while sitting on the sofa and adjusting in a pulled up leg position and voila! Any and all pain was dismissed?

Dr Blake's comment: This is classic for a bone fragment. It can be mainly cartilage so unfortunately may not show up in any test. That being said, xrays, CT scans, and MRIs may be taken to get more information. The catching can actually be from the ankle joint, or the smaller subtalar joint beyond, so have no surgical intervention unless the two joints are looked at thoroughly. If you have another episode that again limits side to side motion, try a diagnostic local anesthetic block into the subtalar joint to see if it is involved. 

I find this interesting is all and unique but perhaps it's easily explained by someone like yourself who is so steeped in this practice of feet! ;) I've been unable to pinpoint anything as the real cause other than walking in poor footwear for too long the day before the pain began and perhaps that is all the answer I need. Proper footwear!

Thanks for your ear ;)

Cheers, 

Dr Blake's comment: I hope my comments are helpful to you. It is important that you begin to strengthen your ankle on a daily basis so by next year you have tripled the strength in your ankle. The video below is the one to start with. Good luck and thanks for your patience with my response. Rich

http://youtu.be/-4OB7wcYTJE