Hi all,
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I have a 45 year old female patient who presented yesterday with the following unilateral symptoms:
- Stiffness in ankle on first steps after a period of non-weightbearing and pain when pointing toes (end of range AJ plantarflexion).
- Able to play basketball / work (much standing), though more sore the next morning after a big day on feet / exercise.
- An uncomfortable feeling (not sharp or dull pain or ache) under the outside border of the foot.
- 5th toe feels like its not there
These symptoms have developed in the last 10 weeks following an acute onset of plantar heel pain where a 'pop' was heard under the same foot with pain following. This resolved rapidly in spite of no rest (spends most of every day on feet in her shop) and only a brief rest (1-2 weeks) from basketball. Nine weeks ago I advised calf and plantarfascial stretching and issued 6mm heel raises. Today, the patient reports no plantar heel pain.
Examination reveals the following:
- Ankle pain upon passive inversion (at end of range), active non-resisted inversion and eversion (at end of range) and active resisted eversion (throughout range). This is worst 1cm inferior to the tip of the lateral malleolus but extends along the course of the peroneal tendons about 1cm proximally and distally.
- The peroneal tendons were not found to sublux on STJ inversion / eversion or AJ dorsiflexion / plantarflexion.
- No pain at the insertions of the peroneals.
- 10g monofilament to the 5th toe reveals protective sensation is intact, but compared to the adjacent 4th toe, the sensation is dull dorsally and sharper plantarly.
- I should have done a percussion test (like Tinels for medial ankle).
I haven't been involved with many lateral ankle issues and I'm a bit lost. My thoughts at this stage are that the peroneal tendons and sural nerve are involved. In ordering an ultrasound, I think I should be looking for partial tears in the peroneal tendons and the superior peroneal retinaculum. And I will get the patient back in to percuss the sural nerve to check for tingling. I have put a wedge on the underside of the lateral side of the shoe insole (wears joggers all the time) to reduce tension on the lateral structures.
I would be most grateful for any further advice or insight into what might be happening here and any further tests / examination I should perform.
Many thanks.
Rebecca
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Re: Lateral ankle
Given your description of history and examination my thoughts would be that there has been a tear of peroneus brevis with concomittant injury to the sural nerve. Perhaps less likely would be an injury to the calcaneofibular ligament or the interosseous talocalcaneal ligament causing subtalar joint instability - this too could elicit pain on palpation of the posterior facet of the STJ, just inferior to the lateral malleolus.
Request an ultrasound examination of the peroneals and lateral ankle ligamentous structures, and consider immobilisation in a removable cast walker for 4-6 weeks.
LL -
Re: Lateral ankle
So if I look at it from a deep to superficial perspective (at the point of max tenderness), we're talking peroneal tendons, peroneal tendon sheath, superior peroneal retinaculum, calcaneofibular ligament and then sural nerve.
The interosseus talocalcaneal ligament is towards the distal end of the area of tenderness and I will get that looked at also.
I'll instruct the ultrasonographer to include images with the ankle joint at plantarflexion end of range as this is what reproduces the ankle symptoms.
The funny thing is that the original pain onset (in the heel 10 weeks ago when the 'pop' was heard) occurred when the patient was jogging (slowly) in a straight line (no jump, no inversion injury) at netball training. The rapid recovery makes me assume that there was no significant soft tissue tear. I can't see how / why it happened, just like how I can't see how / why the peroneal tendons and sural nerve would be symptomatic now.
Next visit:
- Percussion to sural nerve
- Supination resistance test - if low, it would explain the peroneal symptoms
- Did full length lateral wedge reduced symptoms - likely if low supination resistance.
If supination resistance is not low, lateral wedge does not reduce symptoms and ultrasound rules out soft tissue pathology, removeable cast walker 4-6 weeks required.
Does this sound reasonable?
Regards
Rebecca -
Re: Lateral ankle
Dependent on the exact area of maximum tenderness, from deep to superficial I would be thinking;
* posterior facet of STJ
* CFL
* peroneal/s (tendon sheath and retinaculum cannot be palpated as separate units)
* sural nerve or communicating branch to superficial peroneal N
The sonographer should be able to identify these easily. The interosseous TC ligament can only be assessed by clinical stability testing and MRI though.
If the sural N is involved, it is probably just an innocent bystander to the main event. If there is tenosynovitis or a tear, it is hopefully just suffering some light neuropraxia.
Beware the limitations of US, and be prepared to refer for MRI if pain continues or is atypical.
Once you have a diagnosis, treatment is easy - and often is just immobilisation followed by some rehab. Perhaps an orthotic if there are contributory issues for recurrence, or lateral ankle/STJ instability.
LL -
Re: Lateral ankle
I´m sure it quite rare but something to look out for. -
Re: Lateral ankle
Thanks guys! -
Re: Lateral ankle
When exactly did these lateral ankle symptoms follow the heel pain and pop? Was it pain following pop or pop following pain? Where exactly under the foot was the pop felt?
You say the pain resolved rapidly! What is the time scale of rapid here? Was it a couple of days or the nine weeks that you treated her with heel lift and stretches? You seem to be saying both?
What type of pain on palpation and inversion eversion? What was the patient’s response?
Does the STJ appear laterally unstable? Were there any biomechanical signs that would indicate lateral instability before or after onset of ankle symptoms. i.e. was there - lateral stj axis, valgus forefoot, low 1st ray/mpj that is stiff or compliant to GRF? Is the foot supinated or pronated in stance? How does this change in walking?
How much internal hip rotation past knee straight ahead is there? What is the foot placement – toe in or toe out?
Have any of these things changed since the pop?
Cheers Dave -
Hi Rebecca,
I'd check RoM and QoM of the distal fibula and the cuboid. Abnormalities (restrictions or direction of movements) in these joints will affect the related soft tissue structures. Long term joint dysfunction and compensation can lead to the symptoms you are describing in the tendons, sheaths and nerves.
Was the 'pop' a cavitation release or subluxation that precipitated the sequelae you've described? Possibly...
Ted. -
Re: Lateral ankle
Hi David,
Firstly, thank you for your interest.
In regard to the lateral foot, that was described as 'uncomfortable' and the patient denied any feeling of sharp pain, dull ache or pressure.
I will be seeing the patient tomorrow for further examination following PA advice.
Rebecca -
Re: Lateral ankle
STJ axis change change as well maybe not so much nonweightbearing assessments but the medial-lateral deviations can change in weightbearing a great deal.
If you see a patient with a slight lateral heel strike and you note slightly laterally deviated STJ axis at heel strike. Then see them 2 months later after ruptured lateral ligaments you will see a greater lateral deviation of the STJ axis at heel strike and it maybe lateral for longer. -
Re: Lateral ankle
Ian -
Re: Lateral ankle
3 main action of muscles
accelerate
deccelerate
stabilize
Muscles are slightly (not the greater word) contracting when you are standing still to act against gravity and hold the mass of your body up(stabilize). So if there is an inbalance say the Peroneus Brevis is weakened from overuse there will be less resistance to a supination force provided by your fingers.
or of the Posterior Tib is weakened to foot will be more pronated so your fingers will have more mass medially to move due to the fact that COP will have moved medially therefore your sup resistance testing results will have changed.
It may only be slight but it will be different. -
Heres another go to maybe not too clear the 1st time.
If we think about the foot with "normal "STJ axis in the morning then you work the Supinatory muscles for 2 hours so they are Fatigued.
Get the patient to stand the STJ axis would medially deviate slightly due to loss of vasoelastic properties and loss of muscle strength due to fatigue. Therefore your lever arm to supinate the foot with your fingers would be shorter, your work rate must increase to supinate the foot.
Next day foot back to "normal" stj axis work the pronatory muscles. loss of vasoelastic properties and strength , slight lateral deviation of STJ axis longer lever arm for your fingers less work required to supinate the foot.
I beleive that this will be of greater sinificance when ligaments are involved in the process but the same thing will occur.
Hope that makes more sense.
what you think? -
I commonly see inversion ankle sprains in my practice. Sounds like your patient has had a plantar fascial injury (pain at medial calcaneal tubercle) which has now somehow led to a mild peroneal tendinitis and sural neuropathy. Unless the peroneal tendons show swelling, I tend to doubt an acute peroneal tendon tear.
I like your idea of a valgus insole to reduce the tensile force on the peroneal tendons which could have resulted from the patient favoring the heel when it was sore. This is exactly what I would have done on the initial visit. I am not sure what caused the sural nerve issue but don't rule out compression force on the nerve from a shoe or brace or a tensile force on the nerve from an inversion ankle sprain as a cause of traumatic sural neuropathy.
The good news is that her symptoms are mild. Because of this, I would simply have her temporarily cut back on her running/jumping activiites, ice 20 minutes twice a day, wear the valgus wedge and try a course of NSAIDS for 1-4 weeks to see if this will help. In milder cases such as this, sometimes giving the patient some reassurance that her body just needs some time to heal itself is the smartest course of treatment.
By the way, from your excellent history, physical and treatment, she is lucky that she has you as her podiatrist.:drinks
Hope this helps. -
I'm conscious that we have slightly hi-jacked Asher's thread (sorry Rebecca!) - maybe we should save this for a new thread?
Ian -
Hello,
thanks all for a very interesting thread!! Peter -
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No worries.
In regard to may patient, I saw her this afternoon and she reports:
- 75% reduction in ankle "stiffness" (even when pointing toes ie: a non-weightbearing task where the valgus wedge is not in effect).
- 25% reduction in "uncomfortable" feeling at the lateral border of the foot.
- no change to the 5th toe.
Percussion to the sural nerve course was -ve. Supination resistance was moderate and the STJ axis was maybe a little more lateral on the right (affected) side (left normal). FPI zero both feet.
To provide more information about the onset of these symptoms, the semi-numbness / uncomfortable feeling started immediately following the heel injury 10 weeks ago and the ankle stiffness has only been around in the last 3 weeks.
So this all suggests to me that the sural nerve was involved with the initial heel injury and for some reason something has altered to mean that there is now more tension on the peroneals and that's why the valgus wedge worked. It also makes peroneal tendon tears less likely due to only recent onset.
Would one expect a positive sign (tingling) to percussion of the sural nerve if there was pathology? I've only done it to the posterior tibial nerve and its medial calaneal branches. I can't see why not.
To answer David's specific questions:
1. The heel pain resolved in 3 weeks.
2. The patient describes only "tenderness" to palpation of the lateral ankle.
3. There are no signs of lateral instability.
4. The peroneal tendons were no visible due to swelling at the lateral malleolus (some swelling unaffected side also).
5. Compliant 1st ray, moderate FF valgus, today no late midstance pronation visible. Both feet were neither in-toed or out-toed.
6. There is about 50 degree external and 25 degrees internal hip rotation in stance from patella position straight ahead - what are you hinting at in regard to this one David?
I think it might be reasonable to suggest that we might have got the ankle pain licked (given a bit more time, early indications are good) and that the nerve might take a little longer to resolve. And if it doesn't in say 4-8 weeks, maybe take further action ie: ultrasound.
Rebecca
After-thought: What about the possibility of an injury to the first branch of the lateral plantar nerve (Baxter's nerve) at the time of the heel injury. Where does that nerve branch off the lateral plantar nerve, near the plantar medial calcaneal tubercle or further distally? -
If the sural nerve has indeed been recently injured, it should display a Tinel's sign with light touch directly over the area of nerve injury. If the Tinel's sign is not present, check the contralateral side to see if possibly this is present bilaterally and just never noticed before by the patient. If numbness is the only symptom, then tell her she is very fortunate to not have burning, tingling, lancinating, or electric-like pain that can often occur from a nerve injury and that the numbness may take months to resolve.
Hope this helps. -
Rebecca
Sorry to hit you with all those questions :wacko:
I had a different scenario in mind and which Kevin has nipped in a stolen my wind:mad: I needed your replies to help confirm this theory - This what I thought:
Originally, before first evaluation, your patient had a low 1st mpj and 1st ray compliant to GRF, central STJ axis, valgus forefoot and equinus ankle. Before Pop injury this may have meant that the peroneus longus (PL) was over stressed by the action of the 1st ray being dorsiflexed.
This may have led to FncHL, which may have necessitated a compensation to avoid. Since there was a valgus forefoot a lateral deviation of the CoP may have been used i.e. inversion of the foot, this again loads the PL. This action plus the equinus ankle may have been overloading the plantar fascia, which eventually went POP! After the pop The plantar fascia may have been slack in the fibres that tore and so gave less resistance to Medial arch lowering, this may have increased load on the already overworked PL and increased FncHL.
However since you fited heel lifts and gave stretching exercise the PF had decreased tensional stress. Lifting the heel will increase lateral instability if the fore foot is valgus again increasing PL and all peroneal load. Therefore the peroneal pain was underlying before pop event and exaggerated but secondary to the pop injury, which is when you found tenderness by examination.
Then you fitted a valgus forefoot wedge and this reduced lateral instability and off loaded the peroneals, reducing FncHL (and so reduce achilles tendon tension). This also allowed off loading of the PL since GRF CoP was more lateral thru the stance phase and so 1st ray dorsiflexion moments were reduced. This then resulted in reducing PL strain and PF stress. The paraesthesia in the dorsal 5th may have been due to to any constriction by soft tissues stress or foot positional changes or tension in the nerve itself as the ankle became more laterally unstable.
Oh! the hip rotation thing: If there is restricted internal rotation of the hip then at contralateral swing thru this will cause an increased internal transverse plane moment about the knee and shank and so tend to externally rotate the tibia and the foot will become more laterally unstable. Conversely the patient will tend to toe out thru stance phase to avoid the excessive torsional moments and reduce peroneal tension and the risk of inversion sprain.
May be wrong, there's a lot of data to correlate from the different posts, but gives you some other perspective else to think about. Sounds like your fixing it anyway so that's great.:dizzy:
Cheers dave -
Many thanks to all for the advice provided!
Oh Ted, I forgot to address your suggestions. The lower tibiofibular joint had a good range and quality of motion so no mobilisation required. However, I neglected to check cuboid. I will keep this in mind though, thanks.
Rebecca -
Cool, this has been an interesting case to follow...particularly the neural consderations.
I'm keen to hear of the progress.
Ted.
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