left lateral ankle pain ongoing for 12 months after fibular fracture

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50 year old female complains of left lateral ankle pain weight bearing,towards the end of day lateral ankle is swollen.
Has to apply ice daily for relief and wear ankle support to walk in.

History
March 2012 a minimally displaced lateral malleolar tip fracture.
May 2012 left ankle still painful unable to comfortably weight bear and still using moonboot and crutches.
August 2012 ct of left ankle delayed union of a webber a fracture.
October 2012 non union of a webber a fracture of the distal fibular with mildly thickened anterior talofibular ligament consistant a low grade ligament injury
Jan 2013 open reduction,internal fixation of left fibular bone and grafting to left fibular bone.
Put into moon boot.
April and2013 started to wear runners as swelling had gone down ,had physio and wearing ankle support .

May 2013 ultra sound scan shows low grade strain to left anterior talofibular ligament with synovitis at the lateral ankle joint .
I was treating this lady's daughter when she mentioned the left ankle pain to me so have not assessed properly. Obtained history from hospital before seeing her next week.
Based on the above information it appears the ligament has not healed well since first injury in 2012 , wanting to know if any one has seen the same problem and if lateral wedging may help with her pain?
She does ankle exercises everyday.

Would appreciate any comments
Thanks
Jaynes

 

Hi,

When I had the same injury (fell out of a tree - don't ask!) it took over 12 months to be pain-free. I was 54 at the time. I was wading rivers and fishing within a week, but it was bloody painful.

I found cross-frictional massage and ankle mobilisations to help the most. Lateral forefoot wedging will help to stabilise the foot, but I think the frictions and mobs will have a more beneficial effect.

 

Thank you

 

Put the patient in slight calcaneal valgus to relieve stress on the anterior talofib lig. Could use a heel wedge or orthotics.
Good Luck
Teri Green
Atlas Biomechanics

 

Hi Jaynes,

I would recommend a new wb lateral x-ray to check for an anterior displacement of the talus. This is measured by checking for a break in the Cyma line.

If the talus is anteriorly displaced [a very common phenomenon with fibula #'s] then mobilising it posteriorly would be required to reduce the tissue tension on the lat ligamentous structures.

You can view how to check for the cyma line integrity as well as causes of anterior talar shifts at:

http://www.youtube.com/watch?v=BXRMoFTzP8g

The cyma line part begins around 39:20 and goes to 42:05.

Causes of anterior shifts of the talus are presented at 46:55.

Good luck!
Ted

 

Hi Ted
We did get another x ray done last Friday will see the lady and results tommorrow .

Thanks for the advice.
Jaynes

 

Hi Jaynes
Thats an involved history for a minimally displaced LM tip #- was the Weber A missed or is it the same fracture? I wonder how relevant the Lateral ligament findings are in the context of her surgical history and a potentially chronic synovitis.The ATF will have done its healing unless you think there are forces at play that exceed its tissue tolerances- the direction of which might then determine which way you go with posting etc. I would think palpation will be an important discriminator between boney tenderness, the ATF, scar in the anterolateral gutter and the joint line which is often revved up more generally in the presence of synovitis.
Also, watch out for CRPS. You'll obviously know more when you get you hands on her!
Jason