Ankle Sprain with Significant Ankle Problems: Email Advice

Hello Dr. Blake,

You had helped me immensely through a long sesamoid recovery 7 years ago. In the end, I made it through to fully healed with no pain! For anyone with bad sesamoid injury, you can and will make it through the nightmare!  It can be done. 

Unfortunately I return with a new issue. 2 weeks ago I twisted my ankle stepping off a curb. I had some pain, though the majority of that pain went away in a few days. Then a few days later i was pushing my kids in the stroller up a steep hill (I’m new to the Bay Area) which put my ankles into intense dorsiflexion. I started getting pain the day after and was not able to dorsiflex, but Especially plantar flex without pain in my ankle (in the back). I was able to walk on it for the next week,  but had to limit dorsiflexion to avoid pain. After seeing a podiatrist, I was recommended to wear a boot (talk about PTSD from my sesmoid injury). The majority of my pain is on the lateral side, right behind and under the boney bump of the ankle (fibula). 

Nothing showed on x-ray, which I’m starting to realizing doesn’t mean all that much.  Today I got MRI results back and was hoping you could help to interpret and provide your thoughts? Photos attached.  I clearly have a talar dome issue (cartilage), though my Dr. seems to think that’s been there for a long time. For a long time I’ve always had some minor stiffness and pain in this ankle, but it always went away after a few minutes of getting ready in the morning. I’m assuming that what that is. But since that issue is more on the medial side (whereas my pain is lateral), is it possible that’s not the driver of most of my current pain? Or could a lot of this be due to that and I will need surgery?

My Dr believes the majority of the pain is from the sprains (ligaments) that need to heal. Though I see some remarks in my MRI about “stress reaction” which makes me think that there is possibly a stress fracture, but for some reason that didn’t make it into the MRI’s concluding remarks. What are your thoughts?

The Drs plan is to stay in the boot and revaluate after 4 weeks? I also know better and will do contrast bath.  

Does all these seem reasonable?  I “feel” like there is enough pain to possibly be a fracture, but can’t tell if it’s ligaments and soft tissue issue we’re dealing with here. How long of a healing process do you think I’m really facing?  I just want to set the expectation for myself, my work, and my family correctly. 

Thank you,

Dr. Blake’s comment: thanks for the update on your sesamoid. You have a fragile ankle, and someday you may have to have it cleaned out, possibly bone graphed or replaced. Someday! I see people all the time that sprain their ankles and wake up a sleeping giant, which you could have done. You have to treat the worse possible scenario to protect you, so you place it in a boot for awhile, gradually wean out into a brace, gradually increase all activities and follow how the ankle behaves. With the goal of walking around with 0-2 pain as our guide, you go one month at a time. Have you achieved 0-2 in the boot? Do not let anyone put cortisone into your joint as it can weaken it further. If you get a bone scan, and it lights up, you can call this a stress fracture and qualify for the bone stimulator. That may just strengthen the bone enough to have you dodge the surgical bullet. Separate from your injury, I would get surgical consult from several orthopedist or podiatrists on what they would do if this does not improve. Hope this helps. Rich

Talar Injury in Tennis: Email Advice

The dark area above sensor is injured part of talus extending into tibia above

Dr Blake,

I want to check in with you to confirm diagnosis and treatment you gave me this week.  Again I sincerely thank you for taking your time and listening which is something I normally do not see from health professionals.  Also, thank you for actually looking at the MRI which strangely most Doctors (except Dr Loosli) did not attempt.



Diagnosis:  Talus stress fracture

Dr Blake's comment: Yes, that is my diagnosis. Acute ankle pain, out of the ordinary on 6/27/17, which has hobbled you ever since. It is easy to focus on the wear and tear arthritis in your ankle, but something different happened that day, that is normally a stress fracture due to the impact of tennis and the over pronation of the ankle. 

Please confirm this diagnosis.  This is all makes sense now after researching normal symptoms.  Obviously 37 years of USTA competitive tennis and hiking Mt Diablo contributed to overuse.  This all started with a major ankle injury in 1963 playing basketball (stepping on top of players foot) in High School.  I have injured this ankle many times over the years, most significant 2009, and I only made stress fracture worse by playing on it for the last year or two.  I completely stopped playing tennis 6/27/17 and since then have only walked on a flat surface up to 45 min.  I have re-injured since 6/27/17  a total of 7 times due to things like gardening, using a ladder to install lights, light hiking, etc.  Right now it feels strong and I walk every day 45 min with no pain or discomfort.

Treatment:

1) ice 2x daily for 15 minutes with reusable gel ice pack,
2) alternating heat 4 min and ice 1 min, each evening, 
3) wear heel 1/2 inch inserts in shoes,

Dr Blake's comment: The ankle has the most pressure internally, exactly where his fracture is, when his ankle is at a right angle or bent forward (as in a squat). The heel lifts are to keep him slightly plantarflexed at the ankle not to crowd the joint. 
4) bone stimulator to increase healing twice daily, and 
5) continue walking flat surface using wrap around brace.

Please confirm above treatment or add or edit.  You told me it will take at least 1 year to heal and to monitor with another MRI in January 2018 and 6 mo later. 

Dr Blake's comment: Another MRI in January will tell us if you are healing, and by approximately how much. This will be 6 months from your first MRI. Each month you do more activity to test how it is doing. So, think about what you will add in November, and then in December, and then in January. We want to slowly stress the area and see how it responds. 

 You also suggested I take bone density test (scheduled tomorrow) and get you copy.  You also suggested I look at Vit D level and I believe calcium level.  I know Vit D level is good (47 Ng/mL).  Calcium 9.2 mg/mL on 9/20/17.
Dr Blake's comment: I know Vit D is 32-80  normal range, and calcium is below 10.1 over 40 years old. Which we both are!!

Questions:

1) Is there a way to speed up significantly the healing process?  For example, wear a boot or plaster cast for several weeks, then rehab?

Dr Blake's comment: Time, not irritating the tissue, bone stimulation, contrast baths for a deep flush, various braces and/or orthotics, and then a gradually ankle strengthening program. Immobilization always weakens the bones, so we need to create that 0-2 pain level and slowly increase function. 
2) What was your source(s) of diagnosis?  I believe you based on my symptoms and MRI.

Dr Blake's comment: The MRI can be read as stress reaction, stress fracture, bone bruising, arthritic changes, but the acuteness of pain on that one day is diagnostic for a fracture until proven otherwise. And, good medicine dictates that you need to treat the worse case scenario (in your case a stress fracture that could lead to a full fracture and major disability).  
3) Can special heel inserts be made for my shoes?  Can you do this?  Or perhaps another specialist you can refer?  I have seen Dr Jason Hiatt in Walnut Creek and 2 other Podiatrists.

Dr Blake's comment: The biomechanical change is simple, and most podiatrists, shoe repair cobblers, and running stores to give or make them. It is up to you to tell us if they help. 
4) Is my walking every day prolonging the healing process?  Should I just stop all weight-bearing exercises?

Dr Blake's comment: We have to create the 0-2 pain level, and or course, stop when the pain comes on with activity. Or, have the brace ready to put on. 
5) After my ankle heals, am I risking injury again by playing tennis?

Dr Blake's comment: So much depends on bone density, how hard you play, if you play with orthotics and a brace, etc. Let us see in 4 months how volleying leisurely feels with your wife or tennis partner first and go from there. Hope this helps Rich
Thank you for everything and you are the best!

Posterior Tibial Tendon Injury: Email Advice

Good afternoon Dr Blake. I am writing you from New York City. First I want to say THANK YOU for the wonderful blog that you have created. I will be as short and concise with my situation. Like you I have a long history of playing basketball and also running wind sprints. I have sprained my ankle numerous times from basketball. This current injury is different as its the inside side of my left ankle that has PTT (posterior tibial tendon). 

In January I was running wind sprints up a hill in the park on concrete. After my workout, I felt some pain and swelling. I thought it odd that it was the inside side and I don't recall twisting my ankle.  I went to the doctor and he prescribed physical therapy. I went to 5 sessions over 3 weeks and all the pain went away. I did NO home exercises. Fast forward to July and I did the hill workout again. I felt tightness in my calves and some slight swelling but not pain. 2 weeks later I did a sprint workout at a soccer field. After my 4th sprint, my foot locked up on me. I thought it was the dreaded Achilles tendon tear and it hurt and I could barely walk. I elevated a few days, not too much ice. Went back to the doctor. Got a script for physical therapy. I STOPPED all jogging, skipping rope, doing wind sprints.  I went to one clinic 4 times over 2 weeks. I wore no brace. The therapist didn't believe in braces. I took Aleve for 10 days. I switched to another physical therapy clinic. Went there 5 times over 2 weeks. I wasn't getting better. I then went to an orthopaedic surgeon. I believed I needed an MRI. He took Xray and said no stress fracture. He did some manual tests and concluded I had an Unstable Ankle and Posterior Tibialis Tendonitis. He suggested one of the more expensive over the counter Orthotics(hard plastic type). He said I had flat feet but only when standing. He said I might only need the Orthotic for 3-4 weeks. He did not think I needed surgery at all anytime soon. He said 3-4 sessions of physical therapy would be beneficial. 

After 2 weeks of the swelling/inflammation not going down, I went to a new physical therapist. He concluded I didn't have swelling/inflammation and needed heat and home exercises. Things like calf raise (2 sets of 12 twice per day). Theraband for inversion (2 sets x 12 twice per day). The one legged balance for 30" (2 sets x 30" twice per day). Stretch the calves and soleous twice per day for 30". After 2 weeks of still the swelling not going down I went to a podiatrist. He ordered MRI and after the MRI he got me a knee high walking boot. He said to use the boot for 3 weeks (follow-up visit after the 3 weeks

Highlights of MRI:

Chronic postraumatic deformities of the tips of the medial and lateral malleolar are noted 
There is a chronic full-thickness tear of the anterior talofibular ligament 
There is marrow edema within the talar head and neck. Different considerations include a bone contusion or stress reaction. 
There is increased fluid in the posterior tibialis sheath consistent moderate tenosynoviitis with intermediate signal in inframalleolar component of the tendon consistent with mild tendinosis. 
A type 2 accessory navicular is noted with marrow edema within. 

A ganglion is noted with Kager's fat pad measuring 1.9 x 1.1 x 1.4cm 

I have yet to find a physical therapist who actually knows what to do for PTT. Also as nice as the podiatrist was I dont think he fully understands/emphasizes with my frustration as to what to do at home to best heal, strengthen, stretch.

The last physical therapist session was with a new person who suggested to STOP doing calve raises and to stop doing the soleous stretch. To do the theraband in the 2 directions that dont put any strain on the Posterior Tibialis Tendon. I am to return to that therapist in 2-3 weeks. They also said do NOT use heat but to ice 1-2/day. 

I dont know how long to wear the boot. I also dont know what is safe to do strengthening wise. My frustration is not getting the inflammation/swelling completely gone

Have you heard of Tendex Fast surgery?

http://www.tenexfastprocedure.com/medication-adhd-tenex-houston-tx.html

Oh yeah

What specialist would be able to tell if I have muscle weakness or tightness in my hips, thighs, hamstrings, or calves? I think the PTT is the result of some other problem in the chain.

I have placed the Orthotic in my walking boot. I will be watching all of your youtube clips regarding PTT. I wonder if even walking in a boot puts some stress/pressure on the PTT. Currently its is around a portion of the ankle bone where I still feel inflammation/swelling and some pain. The pain flares up when I walk too long. I am wondering if staying at home just reading and watching movies for say a week or two would be truly resting the PTT.

THANK YOU for your time. I appreciate any and all feedback

Dr Blake's comment: Thank you so very much for emailing. I will try to give you my impressions with the info you provided. The MRI was very helpful, and you need another one 6 months from now to check on the edema. I see no place now to consider a surgery. Surgery typically would be a year from now if you are not able to get back. I know it sounds long, but you have to get rid of the underlining talar head and neck bone edema due to impact stresses. It probably is the cause of all your pain with secondary posterior tibial tendon issues. If you rush a talar injury, the stress fracture or stress reaction which is there now could become a full-blown fracture. I have seen fast recoveries from these, but I can not predict. You have to go one month at a time. You want a 9-month course of Exogen bone stim, and a current bone density and Vit D test. You should avoid all impact for 9 months and work on your ankle strength. The ankle sprains could be coming back to haunt you with instability and abnormal stresses. As long as you can avoid painful exercises, do the posterior tibial strengthening program, also Single Leg Balancing, and the peroneus longus and brevis therabands. Do contrasts each evening as a good flush to the superficial and deep bone swelling. 
     The basic routine is to avoid deep ankle flexion as with landing from a jump or deep plie in ballet. Avoid stretching your Achilles for the next month, then one month only with the knee straight, and no negative heel stretching where you drop the heel off the stair. Contrasts each evening, and evaluate bone density for issues. Bone stim for 9 months, and repeat MRI in 6 months. Start a super strengthening program. Stay in the boot 3 months, and then transition to shoes. Monthly evaluations should be done to check progress. I hope this helps. Rich. 

Jay just answered. I read this as a talar injury first and foremost, with secondary PT changes. Keep me in the loop. Rich

Hi Dr Blake

Thanks for reading my email. Do you know of any good podiatrists or Orthopedic foot surgeons in the New York City area?

Dr Blake's comment: In the New York area, I tend to recommend Karen Langone, David Davidson, Tom Conenello, and Joseph D'Amico. I know Joe is in New York City at the podiatry school there. 

I have read quite a bit on your blog regarding Posterior Tibialis Tendonitis. 

Right now I am in a walking boot (for at least 3 weeks). I have Spenco orthotic inserts in the boot. I am icing 2-3 times per day.

What, if anything, would you recommend in terms of healing and recovery? Is the swelling/inflammation from the issue with the PT or the talar?

Dr Blake's comment: I think addressing the talus is the most important right now, although any inflammatory measures will affect both areas. Contrast baths each evening are great for deep swelling. A bone stimulator from Exogen will help with bone flow. I try to get patients doing some form of strengthening of the area, without producing pain, and some sort of both core and cardio work. 

Is there anything I can do for healing the talar? Maybe stay in boot longer than 3 weeks? 

Dr Blake's comment: The talus finding directs healing right now. The boot will be for 3 months with a new MRI to check progress. Can not see past that. One of my blog patients just told me about a good boot. Check out www.vacocast.com. 

If there are any posts on Talar in your blog I can read em too.

Do you take Medicare by any chance? Physical therapy for the Talar issue?

Dr Blake's comment: Yes, I do take Medicare. Physical therapy once a week to help you decide on exercises, cardio, anti-inflammatory is a good idea. 

I will be getting your book. 

Thanks again