Ankle Snapping: Email Correspondence

Dear Dr. Blake,

How fabulous you are taking questions again! Just my wonderful luck and timing! Thank you!

Dr Blake's comment: I am hopeful to be more consistent now. I have had a wild year with my dad passing and my mom living with my wife and I part time. It has been great to have this time with my mom. I thank everyone for their patience, and I apologize to those I could never answer back. 

Peroneal subluxation. I’ve been scouring your blog looking for info on this. At this point I am self diagnosing (I know, I know) but with my myriad ankle issues I’ve read a lot of information over the years about different ankle esque conditions. I am now 43 years old, still very active. My left foot had the lovely sesamoid fracture which occurred at age 39 I believe. It appears to be fine now but a good year of healing and more time of tenderness ensued. Then I’ve dealt with a 20 + year ankle fracture that occurred during a hard sprain (I thought) while snowboarding. My outer ankle (again left foot) continues on with the multiple fragments hanging out in my subtalor joint. I’ve chosen to forgo surgery since I really have a few occasions a year of periodic swelling and pain.

So today I am writing on behalf of my right foot. Until now I’ve really had no issues with it but am realizing now it’s been taking up serious slack for my left foot. Here’s what’s happening.

I significantly ramped up my yoga routine over the last 8 months and I’ve done a lot of hiking over the summer. A lot of several hour jaunts up steep, very fast elevation gains. Since the trails are fairly smooth and clear with just some uneven areas I just wear Keen brand waterproof lace up low top shoes. Not a ton of support but it’s a nice low shoe that doesn’t bother my left ankle issues and seems to serve well in many trail conditions. Overall comfortable and semi supportive I guess. Have practiced yoga for 20 + years and the yoga I do is fairly strong, vinyasa flow. Lots of odd angles and pressure on the outer ankles doing pyramids, side angles, balancing poses on one foot, warrior I’s etc. etc. Yoga as much as I love it can be oh so hard on ankles and notice more and more pressures/sensitivities while doing it (left ankle is speaking of some Achilles issues at the moment..will save that for another day).

So about mid summer I began to notice this ‘snapping’ happening on the exterior of my right outer ankle, going up my leg a few inches. When I place my fingers over the area and rotate my foot clockwise I feel a band or bands shifting side to side (more over the back portion of the ankle bone). The snapping is especially noticeable climbing steps or hills or pushing off to the left in a side step motion with pressure to outside of right foot. Along with the snapping I found myself waking in the morning and rotating that ankle as I felt like it needed a stretch and multiple cracks sound off from the ankle area as I rotate it clockwise. Lots of cracking. It feels really good but now I’m trying not to do that.

Here’s the thing. There is NO pain in my right foot. Maybe after a long hike I feel a touch of soreness near outer part of ankle but there is no swelling, no pain during any movement. Definitely no pain or tenderness over the snapping areas. But the snapping seems is getting worse and it’s becoming very unpleasant. I haven’t been to a doctor yet because as I’ve mentioned I live in a remote area where each doctor visit begins with the most basic diagnosis, then a long wait ensues for a specialist in an area not usually related to the specific area you are requiring assistance for.

I would love any advice on bracing, exercises, taping, and/or suggestions I could offer to my physical therapist who may know little about the condition. If you feel like this could be masquerading as something else or would like me to get an x ray or consult with a physician before a reply I can do that. Hopefully I’ve done a good job self diagnosing :)

Thanks in a advance for any words you may have for me and thanks for the many you’ve already provided me!

Cheers!
 

Dr Blake's response:

     This syndrome of snapping ankles is does come from the peroneal tendons moving over themselves. There can be only muscular tightness involved, or a combination of tightness and inflammation. The treatment is exploratory. Most start and work on the inflammation with icing twice daily, and begin some form of peroneal muscle massage (say with a rolling pin or massage stick). You need to stay away from tendon massage since that is hard to avoid irritating. ART or soft tissue mobilization of the peroneal muscles (not tendons) can be very helpful. A few cases I have seen are joint related with some joint mobilization needed (to get it unstuck!! in the wrong position). I can image it can develop from weakness, but I have never seen that, so peroneal tendon strengthening seems to not be helpful. I see this over and over on the side that was not injured, as a secondary limping residue. It seems that if we want to take pressure off our left side, we love to go all the way over to the lateral (outside) of the right. A change in foot pronation (more!!) could cause this. Have you noticed any change in your right side mechanics? Hope this helps you. Rich

Here my wife Patty and I are walking into Azofra in Northern Spain Sept 2015

Patient Response:

Good afternoon Dr. Blake,

Awesome about your journey! The pics are wonderful! I had seen a bit about it on your blog but wasn’t too clear on how far you went.  That is quite a ways!!!! Wow! :) I’ve heard that trek is amazing and so inspiring and also that Spain is very very lovely. On a side note my condolences to you for the loss of your dad. Hope you all are making it through.

Thanks for you quick reply to my questions. Your post is great! It gives me hope that it’s not too serious and perhaps a simple fix! I have been told by several massage therapists that my lower legs are horrifically tight! There are also some adhesions here and there. I have just begun exploring foam rolling and use of a tennis ball for self massage and I will investigate this issue with that. I think you are right on. Right side mechanics? Wasn’t sure about that question. I don’t think I’ve had any issues if you were asking direct. In looking at my shoe soles each seem evenly worn on newer and old pairs. Only the tiniest bit of extra inner foot wear.

Wanted to pass on to you that I was able to get into my physical therapist who agreed yes the peroneals are for sure snapping on the right leg as I described. Then she told me braces or sleeves wouldn’t be very helpful and then gave me some oldish advice about strengthening. Oldish in that what I read was thats what they USED to advice patients. The new info is parallel with what you are saying that strengthening does little to assist the issue. I will get down to the business of experimenting and see what I can do for it and will update you.

Before I go I wanted to mention my left foot. The achilles pain I mentioned. Last week when emailing you the snapping in my right foot was far more annoying than the pain in my left but now it’s becoming critical and increasingly debilitating! It’s not constant but caused mostly by the weird pigeon toed bent back foot angle used in yoga warrior pose and the same type of foot position in surfing (left is my back foot). Today with every pop up and ride aaaagh the pain!!! Medium stabbing and burning. It’s been bothering me a bit more each time I go out but today was bad. The pain is very central to right behind the outer ankle bone running up an inch or two. But it’s actually really hard to locate exactly where the pain is originating from. Only about a 3 inch diameter area. My PT said it was not achilles. Had me going up on my toes and other moves and nothing hurt it moving or palpating except three inches above the ankle bone I get an electric shock sensation when I press on it. I know there’s a million things it could be. Old fracture, arthritis, bursitis, more peroneal business but does anything stand out to you? 

No hurry on this! In fact I’m sure I have hit my quota of questions. Like two years ago lol.

Have a beautiful day!

Dr Blake's response:

     The left is probably in neuro spasm. PTs typically can use electical stim to break the spasm. Docs will use trigger point injections with local anesthetic. You can try to use deep ice massage with some painful acupressure. Rich

Peroneal Tendonitis: Email Advice

Hello Dr. Blake,

     I have had severe peroneal tendonitis in my left foot for over a year now. MRIs and Xrays were normal. After failing conservative treatment, we chalked it up to psoriatic arthritis and I've used a walking boot and crutches to get around in. Started meds for arthritis that have helped joint pain everywhere else, but foot pain still bad.
Dr Blake's comment: With negative MRI, and negative response to anti-inflammatory meds, you need to think nerve injury or mechanical (over pronation or over supination). 

     Now, recently (in January 2014), I started getting the exact same type of pain, this time in the right foot. This time around, the pain is accompanied by a loud snapping sound behind the outer ankle.
Dr Blake's comment: This definitely sounds like mechanical inflammation of the peroneal tendons. The peroneal tendons are easily irritated by limping. If you are favoring your left foot, you typically place more weight on your right foot on the outside, with only the peroneal tendons to protect and stabilize you. 

    The pain gets worse and worse each day when I try to walk and snaps almost constantly. Went to ortho doc and was diagnosed with intrasheath peroneal subluxation. He said the tendons are snapping over each other. He wants me to do physical therapy. 
Dr Blake's comment: Physical therapy sounds great. The therapist should focus on your mechanics---use an EvenUp on the right when you wear a boot/walker on the left, correct for any over pronation or over supination tendencies, and work to avoid over stressing your right foot. The PT will also help you with peroneal strengthening and anti-inflammatory measures. 

     I'm 25 and have officially lost my ability to walk, as it is too painful. I don't leave my house. I was a straight A nursing student and very athletic a year ago, I don't understand how a person can lose the ability to walk that fast. I don't understand how physical therapy will make the tendons stop snapping over one another? It hasn't worked so far.
Dr Blake's comment: I am sorry for problem. And, you should definitely get an MRI to get a baseline on what the area looks like. There can always be surprises. So, why do the peroneal tendons sublux? Typically, they hypertrophy from the overuse of limping and the tighter tendons snap on each other as they move across. If they dislocate anteriorly out of their normal groove behind the outside ankle bone, then we are talking surgery. But, typically then stay in their place. Hopefully you are experimenting with braces to stabilize the ankle. A back doc should also evaluate you for possible low disc central disc bulge which can cause bilatteral peroneal spasms/pain/snapping.

    Neither have custom orthotics helped me due to the fact that I also have type two accessory naviculars and taking pressure off peroneal tendons puts pressure on the tibial tendons and has been causing arch pain. 
Dr Blake's comment: In biomechanics, we call this Medial/Lateral Instability. It requires orthotics/shoes/braces that carefully help both tendencies---pronation tendencies and supination tendencies. You need someone skilled at addressing both in the same person!! The Fettig Modication of the Inverted Orthotic Technique is one version of an orthotic device that tries to address both motions.

    I went to another ortho person to see if he could do a groove deepening procedure that I've heard about, and he feels that it's "too aggressive."
Dr Blake's comment: Thank you to God that that doctor cared about you. You do not have surgery for subluxation. It can be fixed conservatively. I know when you are in pain, disabled, surgery can seem like a way out, but I would not do any procedure on you unless 2 doctors said you needed it, and a top notch physical therapist (with no financial ties to the surgery). 

    I've gotten so depressed from not being able to leave my house that I've considered suicide as an option, as I've lost my ability to walk and don't know what else to do anymore. I don't know why they wouldn't want to do surgery to fix a problem that's obviously not responding to conservative treatment.
Dr Blake's comment: Wow!! Please listen to yourself, this has only been going on since January (4 months). Check the AAPSM website for local sports medicine podiatrists in your area. Have your low back evaluated. Consider a brace for your better left side and a boot/walker for your right side now. See one or two physical therapists and see if they can point you in the right direction. Definitely see a psychologist to help you focus correctly. Nothing you have said waves red flags suggesting permanent disability. This is run of the mill stuff in a sports medicine practice, although there are many things I have no clue of regarding your case. 

    I'm also curious as to whether or not the subluxation in the right could have caused the pain in the left side as well, although the left side never made a snapping sound. Any advice would be greatly appreciated. I don't need both feet to work again-I just want the right one to stop snapping so I can go some places in crutches again or with an aircast. I've never been this worried before in my life :( Why wouldn't they want to do surgery to fix the subluxation when nothing else is working?
Dr Blake's comment: I hope my comments above have been helpful. Get the MRI, go to PT, back doc, consider a RollaBout for getting a round little. Email me when you have more info. See if a Flector Patch can be prescribed since you can wear 24/7 for a few weeks. We need someone to give you an old fashion muscle test to rule out peroneal spasm and grade your overall peroneal strengthen. You need to constantly work on the orthotic devices to get them right. Good luck. Rich

Peroneal Subluxation/Dislocation Syndrome: Video Presentation