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

Ankle Pain Unknown Diagnosis: Email Correspondance

Dr. Blake,

Over 2 months ago I started experiencing some pain in my left ankle after yoga. Got it checked out. I was told tendonitis/sprain. I did RICE for 4 weeks. Then put it in a boot for 2 weeks. But it still didn't heal.

About a week ago, a new doctor told me I have posterior tibial tendon insufficiency. My pain is also in the surrounding areas, on both sides of my ankle. She told me to get some shoes (I used to wear flip flops 99% of the time) and I also got an orthodic inside (New Balance). 

http://www.drblakeshealingsole.com/search/label/Posterior%20Tibial%20Dysfunction

I'm 23 years old, relatively healthy and fit, and haven't been able to workout in over 2+ months. Now, after doing the smallest things (i.e. driving, stairs, etc) my ankles start hurting. Both my left and right hurt now.

I am confused and frustrated, and don't know where to turn next. I've seen 3 doctors and the pain still isn't gone. Can you give me some advice? I'm happy to return the favor in anyway I can, please help me, this has me really down, please e-mail me back.

Thanks,

Dr Blake's comment: 

    First of all, you need to verify the diagnosis. MRI is a useful tool to help in that direction. I am hopeful you just bruised the back of the ankle, or something else minor, that may take time but will heal completely. Without the MRI, there are too many possibilities to give this much further direction. You are still in Phase I of Rehabilitation without a solid diagnosis. Phase I is the Immobilization/Anti-Inflammatory stage. Use ice twice daily around your ankle for 15 minutes and do one formal contrast bath every evening. Place yourself back in the boot, you may need a lot for the next 3 months, for any situation that produces over level 2 pain. Remember to create a pain free environment as best you can keeping the pain between levels 0-2. Read my blog post on Good vs Bad Pain and memorize. I hope this helps. Rich

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html