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Lateral ankle pain conundrum

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Nov 15, 2018.

  1. David Smith

    David Smith Well-Known Member

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    Hi guys need some guidance

    Mal e56 years old no relevant med hist - weight 128kg 175cm tall.

    Patient c/o - walks on outside of shoes and getting pain on the lateral hips and knees both side after longer walks - also main concern pain on lateral ankle and forefoot - mainly right and a little on the left.

    Tenderness at palpation of GTs and around ITB insertion at knee - lateral foot pain cannot elicit today but maybe cuboid compression by symptom description
    both feet very lateral stj axes, lateral ray stiff to d/flexion, restricted hip/knee internal rotation rom - not quite to knee straight ahead.
    Lateral STJ axes - in gait has lateral edge foot placement - probably to avoid lateral instability - restricted hip rom cause external torsion thru leg at contralateral swing thru that adds to lateral instability - so toe out and supinated foot posture would help to compensate.
    very ankle equinus at -5dgs d/flexion (where 0dgs is foot sole perpendicular to tibia)
    cannot pronate/evert feet and lift right lateral foot off ground in weight bearing stance - left he can a little.
    added lateral posting to shoes from heel to posterior to met heads. add 6mm heel lifts. review 1 week
    8 days later ---
    he reports that perhap knee and ankle felt better but he had increased lateral right forefoot and ankle pain when using the insoles with lateral heel to f/foot posting in his work boots.

    pain today is on palpation of ATFL and CFL - ATFL most tender
    goto AM3 scan shows forefoot strike right with very lateral CoPP and left heel strike with lateral CoPP
    Mob ankles from right -5dg left 0dgs to right +8 dgs Left +11dgs.
    goto 2nd AM3 pressure mat scan shows much less lateral CoPP both and right has heel strike but with early heel lift both feet.
    In RCSP can now raise lateral ray of the ground.
    good hip abductor strength.
    Restricted eversion rom STJ both - stiff lateral ray - no rear to f/foot variation
    good 1st MPJ rom - level MPJs.
    slight genu varum
    medium heavy supination resist test (light if you consider body weight) light jacks test both
    in stance both feet have supinated posture
    no LLD noted in stance or sitting comparison after mobs.
    Coach's eye video treadmill walking - very supinated lateral foot strike https://www.coachseye.com/v/d7df906e383c4c62bbed335da206c740
    after walking on treadmill for a few minutes he complained of lateral ankle pain right - if STC compression this suggests increased pronation moments about the STJ axis but there is minimal visual pronation action. both feet similar.
    HMMM! problem there seems to be tension stress pain in lateral cfl, talocalc and atfl ligaments but lateral posting on shoe insoles caused increase lateral foot pain as if compression stress related
    Lateral posting increases lateral ankle pain but reduces hip and knee pain - but also lateral posting will inhibit CoM progression as the contralateral swing thru occurs because of restricted internal hip rom, which in turn tends to cause an external rotation moment about the standing leg and force stj inversion ie lateral instability, the lateral foot cannot invert off the ground much so cannot stand much lateral posting anyway. Medial posting will increase supination moments about the STJ and increase lateral instability
    So what to do to resolve lateral ankle pain.?

    attached are before (left) and after (right) mobs pressure mat scans and STJ axis orientation

    2018-11-15 (2).png Rogers A STJ.jpg
  2. efuller

    efuller MVP

    The lack of eversion range of motion and a laterally deviated STJ axis is a tough combination. If there is range of motion, you can evert the foot around the axis so the axis "becomes" more medial. If you don't have range of motion a valgus wedge will shift the center of pressure and tend to increase load on lateral forefoot.

    People with lateral axes and people with lack of eversion range of motion can get lateral column overload. This could be the lateral foot complaint. This could be made worse by a valgus wedge.

    From what you wrote I didn't see a hypothesis on which lateral ankle structure was hurting. It may be really hard to differentiate. Pain of end of range of motion will occur in the sinus tarsi. With a laterally deviated STJ axis you can get peroneal tendon pain. The lateral ankle ligaments won't really be stressed unless the foot inverts to the point where it's near supination end of range of motion.

    A valgus forefoot wedge can cause lateral column overload. If this happens you can use a valgus heel wedge still. You might need to consider working above the ground with an ankle brace of some kind that can create a pronation moment.

  3. David Smith

    David Smith Well-Known Member

    Yes thanks Eric, the only painful structures I could identify were the lateral and ligaments - ATFL - CFL - TCL. Supinating the foot and pressing on these ligaments is more painful than with a neutral foot. The most painful is the ATFL and Talocalcaneal ligament.
  4. David Smith

    David Smith Well-Known Member

    Oh yeah and I was thinking canvas ankle brace might be the answer too Eric
  5. efuller

    efuller MVP

    There might not be a good answer, but thinking in tissue stress, why do the ligaments hurt with everyday activity?
  6. David Smith

    David Smith Well-Known Member

    I know in general terms why ligaments hurt in everyday activities but not why the ones in the particular case do. One would imagine tension stress due to increased supination moments in regard to the lateral ligaments but a laterally posted insole = increased lateral ankle pain. Hmm! But however, I did not define if the increased pain was compression stress of the sinus tarsi and just assumed ligament pain as thats what hurt on palpation on later day. Maybe less lateral posting will reduce tension stress in ligaments but cause no excessive compression of sinus tarsi???
    Well I've just had milled an orthosis with lateral heel skive and 3dgs medial f/foot post 2-5th - give that a go and see what happens. Its a suck it and see case.

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