Ankle Injuries: Fractured Steida's Process

The 2 photos below are of a patient who presents with an ankle sprain. Initial treatment for swelling and pain went well, but after 6 weeks the patient was not back to normal activities. The sprain was the usual type where the foot and ankle are inverted, but there was a fall afterwards which can produce more force. The patient did not remember what the ankle did in the fall landing forward and to her side. Initially the entire ankle was sore--laterally, anterior, posterior, and medially. It was the patient's first sprain, so she had nothing to compare this injury to. She was placed in a removable boot and on crutches. It took 3 full weeks to get safely off the crutches to full weight bearing with no increase in pain, and another 3 weeks in the removable boot progressing to full day to day activities without any flareups. An EvenUp was used with the boot on the other side to balance the hips. Physical therapy was done twice weekly from the onset to reduce swelling, and get the range of motion and some strength back. By six weeks, there was still some limited inversion which is common, but she was very sore when I plantarflexed the ankle (pointed her foot) in the back of the ankle which is uncommon in a typical sprain. The initial xrays taken at an ER were reported as negative, but I never saw them. Here are the 2 side views of the ankle at 6 weeks showing a fractured Steida's Process of the talus in the back of the ankle. 

This is a side view (lateral view) of the ankle showing the front and back of the ankle well. The marker is placed above the injured part of the talus which is it's back and lateral most prominence. When the ankle joint points too far (plantarflexes or bends downward), this prominence called Steida's Process can get damaged. Since many patients have this bone normally in a separate piece never completely fusing to the parent bone(called an  Os Trigonum), many times, including this time, the xray was read as normal with the presence of an Os Trigonum.

Here a blowup image of the area shows the jagged edges between the 2 pieces typical of a fracture not a extra bone like the os trigonum. If the piece of bone is an normal accessory ossicle, the borders between the bones are normally curved and smooth. Due to the possible surgical implications of having to remove this bone if the symptoms continue, either a bone scan or MRI is needed to confirm the diagnosis. Pain on plantar flexion of the ankle in this area, coupled with this xray, should be enough to go on at this point. To protect the bone, the removable boot will be left on for the full 3 months, and forced range of motion around the extra bone will not be done in physical therapy. The physical therapist is now notified that we may be dealing with a healing fracture, so the "no pain, no gain" rule commonly imploded will not be adhered to if the pain is coming from this area.

This is one of the most common problems in young ballerinas. If they are unlucky enough to develop this bone in the back of their ankles (starts forming around 8-9 and fully formed 14 or so years old), this could give chronic pain in the back of the ankle as pointe work is being accelerated.

The goal with this patient will be to calm down all the inflammation, rest the ankle for a total of 3 months removable weight bearing cast, then 2-6 week attempt at weaning out of the cast with an ASO ankle brace maintaining a pain free environment, build up the walking up to 60 minutes then a walk/run program. She is to avoid pointing the ankle, such as sitting back on the foot while kneeling. The sensitivity in the back of the ankle could take 2-5 years, but many patients can avoid surgery and return to full activities over a 6 month period. I have considered, but not used, a bone stimulator for this problem, but it is not contra-indicated. As with any fracture, diet counseling on Vit D, calcium, and also bone density history should be done so that the patient has the best chance of healing. 

Joint Dysfunctions: Help Through Mobilization Procedures

Blogging on Tuesday is Email Correspondance 

      Melanie and I have been working on her foot and ankle problem for the last 6 months. There was a component of nerve pain, called Tarsal Tunnel Syndrome, but she really responded more to anti-inflammatory, and less to nerve, treatments over all. I had emailed her after several months of not hearing how she was doing and this was the reply I got. Melanie is a typical sports medicine patient whom takes ownership in her problem and deals with it. I am highlighting her email since it represents a group of my patients who do extremely well with joint mobilization. And, it is normally not I who recommend it, but a body worker or physical therapy.


      I once had a patient Olivia (real name for once) who longed to be a professional ballerina. She even lied about her age so the San Francisco Ballet School would accept her. Well, Olivia was one day away from ankle surgery since I was convinced an extra bone in the back of her ankle (os trigonum) was causing her pain. I tried 6 months of physical therapy and could not get her better. Two days before her surgery she accompanied her friend to the friend's chiropractic visit. The friend asked if the chiropractor would look at the ankle. All I know was that there was some adjustment done, and now 20 years later, she has never had to have surgery. She had a great 16 year career in ballet, and now is the mother of three. I still see her mom and get the updates. I grew up a little more the day we cancelled Olivia's surgery. 

Hi Rich,

Thanks for your email.  As a diagnostic tool, about three weeks ago I went swimming for a little bit,  because last fall it felt really good to swim and I wanted to see a little more what was going on now.  I was also feeling that, although you were able to diagnose tarsal tunnel syndrome, I felt like I never really knew what the underlying root cause of that condition was, and that seemed to be a missing piece in the puzzle.  Anyway, my tarsal tunnel area and the arch of my foot both did really well during and after the swimming, but I had some pain through a low horizontal plane in the front of the foot (at about the talocrural joint).  So, that raised a question for me about maybe there was something else going on that was the root of the tarsal tunnel syndrome.

Shortly after that episode of swimming, I saw a person who indicated that my talus bone was out of alignment and he did an adjustment to bring the talus bone back into alignment.  This adjustment brought immediate relief in walking, without the boot and without any Aleve.  I was able to walk normally a short distance without pain (I didn’t push it), althought there was significant weakness of course.  Over the next couple of weeks after that, I have been doing rehab exercises including walking, balancing on one foot, and stretching (calf/achilles).  I have worked up to walking 20 minutes each day, in flat shoes, without pain (I started at 10 minutes per day, adding about one minute per day).  Now I am going to add 10% more walking time per week.  Interestingly, he also said that I should continue to walk in flat shoes and not point my toes for the time being, and that the rehabilitation should take 6-8 weeks.  He also said that the nerve activity, which is very minor now, will die down completely on its own within about nine months.

One question that I have is – would you be able to see an alignment problem like this on an MRI? 
Dr Blake's comment: I am not sure if you can ever document these joint dysfunctions on X-ray or MRI. 


  Anyway, I am hopeful that this approach will result in a full recovery in a fairly short period of time, but if for some reason it doesn’t, I might ask for your help again.  I am appreciative of all the things you have done to try to help me before this.  Thank you for that.

Melanie