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Ankle Pain 11 year old boy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Jo jo, Apr 19, 2011.

  1. Jo jo

    Jo jo Active Member

    Members do not see these Ads. Sign Up.
    I wonder if anyone could enlighten me with some insight about one of my puzzling cases

    11 year old boy/ very active
    hx of orthotics; 4 deg inversion
    has suffered from ankle and calf pain in the past

    Rearfoot valgum approx 4 deg
    Excessive pronation through gait
    Very limited dorsiflexion 0 deg

    Had outgrown orthotics so Ive put him into some CFA's (semi customised) forefoot inv post and inv rearfoot. Which have corrected him quite nicely. He is still experiencing some ankle pain but has had no hx of recent serious ankle sprains.

    In the past he has not been hugely open and discussed what he has been feeling with either his parents or myself but the last time I saw him without his parents present he told me at times when running his ankles lock up and he almost falls over. It appears to be when his foot is in the plantarflexed positon. Pain is then apparent for up to a day after. Pain is felt when standing on tip toes- dorsum foot/ front of ankle but not when moving his foot into a plantarflexed position in non weightbearing

    I have given him calf stretches and some ankle strengthening exercises.

    With a pronated type foot he has quite a flat ankle mortise.

    I have been reading up on ankle pathology and will be doing xrays but not too sure what to be looking for in particular yet.

    If anyone can shed some light would be much appreciated.
  2. METaylor

    METaylor Active Member

    Has he got a strained tibialis posterior? If so he will be tender at the insertion under the navicular and 1st cuneiform. Prolotherapy would strengthen the attachment of the tendon to the bone and this would stop the reflex inhibition that is inhibiting use of the muscle when it is loaded, ie when standing. Come to my workshop 5th June 2011 in Adelaide South Australia - see my website www.drmtaylor.com.au for the theory and more details. Dr Margaret Taylor
  3. markleigh

    markleigh Active Member

    Wouldn't it be better to find out WHY it is strained & devise a treatment plan first? Sorry Dr Taylor but this seems more like a plug for your course than anything else.
  4. I would agree almost spam in fact.

    jo jo is the pain boney or soft tissue. Something about this seems to indicate the talus position is the cause of the pain. In a "pronated" foot or one with a medial deviated axis the talus will be in a diferent position from a foot with a less medial deviated axis.

    So maybe the medial,plantar position of the talus combined with plantarflexion of the ankle is causing the bone compression forces to increase from the posterior aspect of the talus and tibia.

    It always hard in these cases without the foot
  5. METaylor

    METaylor Active Member

    Sorry, I made it sound too simple, didn't I. I thought I was giving a way of diagnosing it and that people would look up tib post syndrome on the web, which is how I found out about it.
  6. I was thinking something else............. and being that most of us are Podiatrists I would hope that most people know what PTTD is and where the pain and location of the TP insertion points are. ME here are some threads to expand your knowledge on PTTD - PTTD threads

    ME not sure on your anatomy knowledge - but I would not be thinking Posterior Tibialias in this patient when the Jo jo wrote -

    I know you said - Has he got a strained tibialis posterior? If so he will be tender at the insertion under the navicular and 1st cuneiform.

    But if you read rather than promoting you course Tíbialis Anterior pain maybe, locking of the ankle - more likely bone on bone with compression from being plantarflexed while weight bearing or even a combination etc etc.

    Just some thoughts
  7. Jo jo

    Jo jo Active Member

    Mike, it appears to be osseous related pain. Agree with what you are saying and it is definately quite likely. Orthotics have not signifcantly eased the ankle pain however. I guess xrays would be warrant before considering what tx could be implemented.
  8. Sounds like a good idea to me.
  9. METaylor

    METaylor Active Member

    Looking at Travell and Simons I think you are right about Tib ant. The trigger point in TA has a pain pattern that is over the ankle joint and goes into the big toe. It would be nice to be able to examine the boy. And whereever its coming from, or where its tender, it would probably resolve with some lignocaine (and perhaps a bit of weak glucose as well). I'm shocked that you feel that way about my teaching. Most teachers in any area lose money by teaching and I'm no exception. Podiatrist Michael Gillies, Scotland wrote after I visited him in 2006
    “Just to say a big thank you for introducing me to prolotherapy! I can't imagine how I managed before I discovered prolotherapy. I remember your enthusiasm for prolo when you came to Brechin and it has rubbed off on to me!! I have been treating a 14 yr old lad with Osgood Schlatters. He is a promising young footballer and no one that he had seen before could help him. I have done 2 sessions of prolo (using autologous blood mixed with bupivicaine 0.5%). A marked difference has been seen - he has managed to play a few games without any pain at all!” I drove from Edinburgh to visit him and made not a cent from teaching but the joy of thinking of all the pain he's been able to relieve as a result of my 1 or 2 hour visit is worth a million dollars. In my workshops I am very respectful of the knowledge that podiatrists have that I don't have, and can share a technique that can be used with the expert anatomical knowledge that podiatrists have. I didn't want to do a big scientific rave, just lightly mention it so that if anyone is looking for it they can find it.
  10. I would say that if you want to promote your teaching do it in the appropriate area - ie the conferences area or even a link in your signiture, if you want to help people with advice give it but stop promoting yourself at the same time - see the difference.

    Great Michael enjoyed your course but does not help Jo jo with her patient, see the difference.
  11. Ian Drakard

    Ian Drakard Active Member

    Dr Taylor

    I think what you're missing here is some forum etiquette. There is a conference section if you want to promote a course- don't hijack threads to do this as you just did again.

    Many contributors here teach and lecture but don't use every single post as self promotion
    IMHO you are more likely to get attendees by earning some respect from considered posts if you have anything of benefit to add.
  12. Ian Drakard

    Ian Drakard Active Member

    Sorry Mike- cross posted there :drinks
  13. Great minds and all that :D
  14. drsarbes

    drsarbes Well-Known Member

    Hi Jo Jo:

    If you feel your history is correct and your young patient is truley getting "locking" then I would do the following.

    Plain films/MRI scan.

    You need to rule out some common causes of ankle "locking" such as early tarsal coalition, chondromatosis, osteochondral defect, os trigonum syndrome, any STJ pathology, any bone lesions in this age bracket.

  15. Jeff S

    Jeff S Active Member

    My guess is that you have decompensated his ability to dorsiflex his ankle - causing jamming of his ankle with the inverted device; Additionally, he may have an OCD - may want to get MRI.

    SJ Siegel, DPM, FACFAS
  16. Jo jo

    Jo jo Active Member

    Thanks all. Very helpful
  17. drsarbes

    drsarbes Well-Known Member

    You're welcome Jo Jo;
    I just want to reiterate that radiographs are ALWAYS INDICATED in this age category with pain in or near a joint, especially large to medium (i.e., ankle)

  18. Frederick George

    Frederick George Active Member

    JoJo - looking at some specifics, on the lateral Xrays you will want to see if there is an anterior impingement limiting the dorsiflexion. With this, if the child is running, and misses compensating with his achilles (limiting dorsiflexion) only one time, it will be quite a sharp pain, which would persist for some time.

    Alternatively, if he is running on the ball of his foot (with ankle equinus he would have to), and has a flexible (pronated) foot, for stability he will tend to overuse his peroneus tertius. This anatomy more closely approximates your reported symptoms.

    Also check for a drawer sign, if the talus slips forward while running, it can have a "nutcracker' effect on subsequent dorsiflexion at the ankle, popping it back into position, causing joint pain.

    And further, make sure the medial dorsal cutaneous nerve, and intermedial dorsal cutaneous nerve are not impinged, or sensitive (+Tinel sign). Tight shoes, or laced up too high can cause this, as well as an underlying hyperostosis.

    Just some thoughts.

  19. Jeff S

    Jeff S Active Member

    Agree completely! JS
  20. drsarbes

    drsarbes Well-Known Member

    Hi Frederick George:

    I read with interest your previous post.

    None of these possibilities are pathologies I would have looked for in this patient.

    An 11 year old with a tibial/talar neck impingement (without a tarsal coalition) would be quite unusual.
    A positive drawer sign in someone with no trauma (or possibly Lig laxity) would be unlikely as well.
    And I have to admit to having never seen an ISOLATED peroneus tersius teninopathy.

    I'd like to hear what others have experienced when examining peds.

  21. Frederick George

    Frederick George Active Member

    Hi Steve

    The impingement can look like a "free" or separate calcification, almost like a plica in the knee. Probably from a previous excessive dorsiflexion (jumping off the jungle gym). Children, especially in the prepubescent growth spurt, have a heightened inflammatory reaction.

    Ligamentous laxity is coincident with the hypermobile foot, but not really with the limited ankle dorsiflexion. Therefore, possible bony block? Children sprain their ankles often without reporting it, so it could be old trauma and loss of the ATF ligament.

    The child would be compensating using all the peroneals to prevent inversion, especially if an unstable ankle, but the longus and brevis may not be painful, and unless stressed and palpated may not be symptomatic. As I pictured the symptoms described, the tertius seemed to coincide with the location of the symptoms. The posterior tibial did not.

  22. drsarbes

    drsarbes Well-Known Member

    Hi Fred:

    It's just that I have never seen an anterior ankle impingement in an 11 year old. I have seen early talar beaking in tarsal coalitions, but at 11 years old even this would be very unusual in a male.
    I think the youngest I have ever performed surgery on for true impingement (i.e., decreased dorsiflexion at the ankle due to bony growth at the tibia and/or talus) was 15 or 16. Hockey player.

    In addition, (with all due respect, and I truly don't mean to be argumentative) I don't think there are many 11 year olds with traumatic rupture of the ATF ligament that went unnoticed.

    I have seen many many Salter fractures of the distal tibia but I cannot ever recall seeing a solitary calcification (not including anatomic ossicles) at the anterior ankle in this age bracket. Even intra articular ankle chondromatosis in an 11 year old would be very unusual.

    Perhaps I don't see as many pediatrics as you, if so I stand corrected. I do see a fair amount (times 32 years)

  23. Dananberg

    Dananberg Active Member

    From what you have described, this sounds like a peroneal inhibition due to ankle equinus, and a substitution phenomena involving the anterior tibial. I have actually seen this combination many times.

    The key to resolving these symptoms involves manipulating the ankle and calcaneal cuboid joints. Symptoms often will spontaneously resolve. Stretching is far more effective once ROM is reestabilished.

    I have posted this on youtube. Link is below.


    I would also be careful about RF posting is a case like this. Posterior tibial often overpowers the inhibited peroneal group, leaving the foot chronically inverted during gait. Overdoing RF posting further exacerbates this inversion process, and with chronic ankle pain, this needs to be considered.

  24. drsarbes

    drsarbes Well-Known Member

    Hi Howard:

    I did watch this youtube.

    I think the pre and post manipulation results for dorsiflexion were a bit "manipulated"

    Pre manipulation dorsiflexion your hand was on the metatarsal head area with the camera angle slightly proximal to distal and it appeared very little force was being applied.

    Post manipulation dorsiflexion your hands were up around the digits and you were pushing with all your weight behind it as well as having the camera angle directly lateral.

    Sorry, I'm not convinced this manipulation did anything.

  25. Dananberg

    Dananberg Active Member


    There was no "manipulating" of the manipulated subject. Your comment is actually insulting as it would imply that there was fabrication involved. I clearly have no need for that at this stage of my life. Manipulation can be a rather amazing tool when used appropriately.

    Prehaps you missed this, but in September, 2000, I did publish the results of an ankle manipulation study on 20subjects measure twice before and twice after manipulation (and the person doing the measuring was not the person performing the manipulations). There was an average increase of 5+ degrees IMMEDIATELY, with a range of 0 to 17 degrees of change. (Dananberg, HJ, Shearstone, J, Guiliano, M “Manipulation Method for the Treatment of Ankle Equinus, “ Journal of the American Podiatric Medical Association, 90:8 September, 2000 pp 385-389).

    The written records of manipulation pre-date Hippocrates by 1500 years! Techniques which last for 4500 years usually have some reason why they do.

    What is more valuable about manipulating the fibula is that there is often a related arthrogenic inhibition to the peroneal muscles when fibula motion is restricted. This is why subjects following ankle sprain sense that they will easily roll over again. It is the imbalance between the inverting post. tibial muscle and the inhibited peroneal group that predisposes the inverted foot position. Ankle manipulation can restore this imbalance immediately and the outcomes are extremely rewarding.

  26. drsarbes

    drsarbes Well-Known Member

    Hello Howard:

    This is science, is it not?
    "Insulting" has no place, nor did I intend for this to be insulting.
    I was merely pointing out my observations of your YOUTUBE.

    Observation is a large part of the scientific method.
    Anyone watching this video can either agree with my observations or not.
    No need to get emotional over this.

    As far as your stage in life; I appreciate anyone who devotes years to his or her profession.
    On the other hand, "experience" does not offer anyone a free pass.

    I know very little about manipulation. I do know a bit about examining a lower extremity. I watched your YouTube and commented on it.

    If you do not want any feedback, positive or negative, then perhaps you should remove the video.

  27. Dananberg

    Dananberg Active Member


    I was not really all that insulted by your technical manipulation comment, but rather in insinuation that the result was somehow fabricated. You are entitled to your opinion, but when it suggests some type of fraudulent action, I am sure you would have a similar response had it been said about you. Enough said.

    One of the major practice revelations for me was when I learned that joint motions are modulatable. With proper technique, joints that appear limited can be changed safely and rapidly. I realize that this is not taught in podiatry school, and that lack of exposure makes this a rather foreign concept. The You Tube postings were designed to share this with as many practitioners as possible. The videographer was someone who I had never met, and we really only had one shot at this. Sorry if there was a change in camera angle. It was unintentional but the change in ROM was real.

  28. drsarbes

    drsarbes Well-Known Member

    Hi Howard:
    Fair enough.
    I do apologize if I offended you, it was unintentional.
    I'll read up on the subject.
  29. Dananberg

    Dananberg Active Member


    Nice to see an open mind. As you research this, I am quite sure you will be pleasantly surprised. And while you are reading, check out the concept of arthrogenic inhibition. Fascinating. Since muscles protect the joints about which the function, muscular dysfunction (inhibition) can be symptomatic as joint pain. One of the manipulation effects is to reset the inhibition/facilitation process and restore functional muscle strength. Think of chronically painful post op bunion being resolved with an ankle manip that restores normal peronal facilitation and thus improves 1st ray function. Outcomes can be astounding at times, most gratifying, and they are much more common than you might think.

  30. Frederick George

    Frederick George Active Member

    Hi Steve

    We are all limited by our experience, and I think the primary benefit of this forum is the ability to expand this experience by looking through the eyes of others, worldwide.

    Because you haven't seen an anterior ankle impingement doesn't mean I haven't seen one, and you're welcome. I haven't seen chondromatosis in a child, as you mentioned in your differential of 21st April. I had thought Reichel's disease was pretty much confined to middle age.

    Thank you.


  31. TedJed

    TedJed Active Member

    Hi JoJo,

    From the history you have given, it seems to me that there may be a shift or displacement of the talus from its normal functional position as Mike has suggested.

    Weight bearing plain films that show the talus clearly (this usually has to be requested because radiographers usually expose the foot for forefoot clarity). I would request DP and Lateral views of both feet to help you compare with the non symptomatic foot.

    An anterior or antero-medial shift of the talus will show a break in the cyma line of the talo:navicular-to-calcaneo:cuboid joints on both the DP and Lateral views. (Refer to Gamble & Yale or Christman's texts on Foot Radiology if required).

    This will give you a clear measurable result to determine if the talus is displaced. If a displacement is displayed, your patient will probably benefit from mobilisation of the talus to improve its position.

    Hope this helps,

  32. drsarbes

    drsarbes Well-Known Member

    Hi Fred:

    I think my exact words were that an anterior ankle impingement in an 11 year old would be "quite unusual" - I also said that I had never seen an isolated anterior calcification in this age bracket.

    I haven't. I was making a statement. I was also commenting on the fact that none of the items you supplied in your D/D I would have looked for. Pretty straight forward.

    I gave an honest, up front opinion on your post as well as Howard's video.

    I will grant you that chondroma intra ankle would be unusual as well in an 11 year old, although it is consistent with the symptoms present. Also, IMHO an isolated chondromatosis (a condition of a a non ossified intra articular loose body) differs from the so called Reichel's Syndome.

    Hopefully Jo Jo will supply us with a definitive diagnosis.

    Post on.

  33. Jeff S

    Jeff S Active Member

    Hey guys - great commentary and dialog. I would just focus on tightening up the biomechanics - the kid is just hitting his growth spurt - probable strong gastroc equinus and because of his level of sports activity - having a hard time compensating and he is probably just over-using his PTT. Like most of you, I also treat a lot of kids - for me, I would stretch him aggressively, unpost his orthotics, send him to PT, ICE and aleve. As a side note, I just operated on a kid with a dorsal talar neck osteochondroma - the 1st in 20 years. I will post a pic soon. J.
  34. Jo jo

    Jo jo Active Member

    Thnks everyone so far. Have been learning alot. Will post up results of xrays when they are done. If anything pain has been improving with stretching.
  35. Jo Jo:

    I have read most of the responses and I think that the key to this injury is the boy's equinus. Often times, in these cases, ordering both the normal standing lateral view and a stress-lateral view gives you significant information about whether there is an ankle impingement possibly occurring due to the anterior tibial plafond abutting up against the talar neck in the maximally dorsiflexed position which will occur in running activities.

    In addition, in preteen boys and girls, the tibia is growing quite rapidly and may outpace the elongation of the gastrocnemius-soleus-Achilles tendon complex creating a transient equinus condition. This seems to especially occur during growth spurts. In these active pre-teens, I have a long discussion with the parents and child on the vital importance of gastrocnemius and soleus stretching in order to decrease any restriction in passive dorsiflexion at the ankle that may cause the anterior ankle pain. I will also put 1/4" heel lifts into the child's shoes on the first visit and instruct the parents and child that they need to wear these at all times during running and sports activities.

    Finally, in this age group, I spend a lot of time instructing the parent and patient on how important icing therapy is and how it should be learned by the child even at this age, especially if he or she plans on a life of sports activities. The child should be icing 15-20 minutes once to twice daily, especially after running and playing in order to reduce the inflammation in the anterior ankle.

    I see may young athletes in my practice and have enjoyed seeing these types of patients frequently in my practice over the past quarter century. In my experience of treating these young individuals with anterior ankle pain, by simply having the young athlete consistently stretch, ice and use heel lifts, and nothing else, the pain in the anterior ankle improves by 75% in about 2 weeks time.

    Please keep us informed of this young athlete's progress.
  36. musmed

    musmed Active Member

    Dear Howard and others
    I could not agree more with Howard.
    Precise Mobilisation/manipulation can instantly (even faster!) change a chronic ankle/foot pain and dysfunction irrespective of age of the problem or the patient's age.

    As Howard states, it is something that is missing in the undergraduates course. The sad thing is, it is not hard to learn.
    I started mobilisation and manipulation of the ankle in 1992 and I am still doing it. I teach this programme and I tell every student it is the most important thing I have ever learnt because the of changing foot mechanics has a total being effect from the ankle to the pelvis to the shoulder and neck.

    Regards to all
    a pinch and a punch on the 1st of the month!
    Paul Conneely

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