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Unexplained Ankle Pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kerrie, May 5, 2011.

  1. Kerrie

    Kerrie Active Member

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    Right, I'm gonna need to make this as short as I can because if I go on forever it will surely be the next war in peace.
    I have been seeing a 43 year old lady in clinic recently who attended complaining of lateral ankle pain on the left foot localised to the medial malleolus. It is worse after long periods of rest and particularly getting up in the morning. She remarks that it is incredibly painful to touch and that if she knocks it on anything it will amke her burst out in tears from the agony. She also reports 'it is like the pain is in the middle of my ankle joint and eminating out' She did slip and fall off the stairs 4 years ago which caused the ankle to swell and eccymosis to develop but she never sort medical care as she was on her way to the airport for 4 weeks in the carribean :bang:. She is highly pronated.
    Well at my initial appointment with her I sent her straight for an x-ray and blood work (dunno why the blood work but she was showing some signs of systemic RhA symptoms) which all came back negetive. No break, fracture or arthritis and blood work clear. Hmmmm she says.
    So we went down the route of arch supports to correct her pronation and advised that she see a GP for pain relief medication. Our initial thoughts here were soft tissue injury, come back and see us in 2 months we say...
    2 months she return ' the pain is better but not completely gone, I hit it on a desk at work and it was agony I could blearly walk home' at this point the patient crys because she thinks that she is going to have to have a her foot off to solve this :craig:
    So we have tried ultrasound around the area assuming that it is soft tissue as a trail and her to review her tomorrow.
    Reason that I am asking is I was just looking through her file and though that it was best to ask the masters WHAT CAN CAUSE A MEDIAL MALLEOLUS TO HAVE SCREAMING AGONY ON PALPATION AND KNOCKING IF NOT A FRACTURE OR ARTHIRITIS?
    Any help much appreciated and if you need any more info please let me know
  2. timharmey

    timharmey Active Member

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!

    I work for NHS an we would send her to the pain clinic ie the problem is not mechanical there is nothing we can do ,that sounds like i am passing the buck , but i dont see how u can help
  3. Griff

    Griff Moderator

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!


  4. G Flanagan

    G Flanagan Active Member

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!

    Forgetting the lateral ankle pain at the medial malleoli????

    Firstly hold your horses Tim, we are the foot and ankle specialists. Granted if everything has been excluded and treatments exhausted then the pain clinic COULD be an option. Yes you are passing the buck, and whilst not getting at you personally, this is the problem with a lot of biomechanical "specialist" Podiatrists. Since when do we only treat mechanical problems!

    Kerrie you mentioned " the pain is in the middle of my ankle joint eminating out ". This sounds like sinus tarsi syndrome. You could try a diagnostic sinus tarsi nerve block?

  5. Lab Guy

    Lab Guy Well-Known Member

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!

    Pain is not proportional to her injury. No matter what she may have, the pain should not be this bad. I would be thinking of regional complex pain syndrome. Sounds like an anxious patient that has had much stress in her life. I would also think about a total ankle block with Marcaine mixed with a short acting cortisone to help break up the pain cycle.
    Injecting the Sinus Tarsi should be done as well.

    Would also think of ordering an MRI and make sure there isn't anything your missing such as an osteochondral defect.

    I would also get a good history of her. There are patients out there that want to keep their pain as they want attention and it is there crutch in life. No matter what you do for these folks, they will not respond. You want to rule this out as well as regional complex pain. Referring to a quality pain clinic where they also have mental health practitioners on staff is a good idea. Pain comes from many levels...body, mind and spirit.

  6. Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!

    I kind of agree here - I agree with what you say George and kind of think it fits but the description is a bit confusing .


    maybe redo the pt description

    and have a read of these threads see if it fits your patient.

    Sinus tarsi Threads
  7. Kerrie

    Kerrie Active Member

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!

    Ok, yeah I was typing that really fast inbetween my patients but as it is my lunch I can now correct my errors. I read it afterward and instantly thought oh Kerrie you stupid girl lol.
    Right to correct the big mistake there her pain is MEDIAL ankle, it is localised to the MEDIAL MALLEOLUS. She is PRONATED.
    Sorry guys, trying to do too many things at once there. I'll have a look at the sinus tarsi threads
  8. David Smith

    David Smith Well-Known Member

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!


    My thoughts:

    Have you tried and anterior drawer test and inversion stress test X ray. If the anterior talofibular ligament is torn or the syndesmosis is stretched wide or torn inferior tibiofibular ligament, then the ankle joint is unstable and the talus rotates in the frontal plane then the medial prominence impinges on the inferior aspect of the medial mal and causes a lot of pain. This will not be evident without the correct x ray. Sometimes there can be damage to the articular surface and or small bone fragments come off the talar head and are in the joint which might be difficult to visualise on an X ray if not specifically looked for. Anyway from experience this type of trauma causes extreme pain similar to what you describe except that it is usually aggravated by sudden impact from running but can also remain swollen and tender all the time.

    You mention she is very pronated, is this a compensation for lateral ankle instability after injury perhaps there is also a lateral stj axis, i.e. peroneals firing to stop inversion stress and trauma? Maybe she doesn't need her pronation correcting :eek:

    Perhaps she got a bit better because the 'arch supports' you prescribed to 'correct her pronation', (ooh! my teeth are on edge now) changed the nominal position of the talus in the malleolar mortice but if you haven't established the stability of the ankle then this may ultimately result in an unwanted worsening outcome.

    Regards Dave
  9. efuller

    efuller MVP

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!

    Osteochondral defect can often be missed on plain films. Doesn't quite make sense with the bumping makes it really hurt. Although, the only thing that makes sense with the slight bump is CRPS. Thinking medial ankle... soft tissue.. Post tib tendon.

    Don't you just hate it when patients present with some of the diagnostic criteria for several conditions simultaneously.

  10. Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!

    Oh Kerrie. I KNOW you know better than that!!

    Can you elicit whether the pain is in the talo crural articulation or the Sub talar? That would be a start!

    Personally I'm inclined to doubt the x ray.
  11. footdoctor

    footdoctor Active Member

    Re: Unexplained Ankle Pain - PLEASE PLEASE HELP!


    What kind of pain does the patient experience? Incredibly acute neuro pain?

    Orthotics helped yeah but not complete resolution? Increase correction/ posting on rear foot?

    What about tarsal tunnel syndrome? Is there any radiation of the pain plantarly?

    Patient probably really wound up now which always makes matters worse.

    Would think L.A/ cortisone shot into this region primarily.


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