Desperate for Help - Chronic Ankle Pain diagnosis

[GregasGP]

Hi all,

I've posted a few times, but thought I'll give a full run down of my ankle woes to see if anyone out there can help a person who has nearly been driven insane from the ankle problems.

25 year old male, consider myself to be fit and healthy and scored 98/100 on BUPA fitness and Medical test. Been training for RAF so excellent cardio etc and no other joint problems.

• Never had any problems prior to ankle sprains. Could always run a fair distance +5miles 3 or 4 times a week with no pain and no need for orthotics

• LEFT ANKLE: May 2006. Severe sprain to the left ankle. A traumatic fall injury from approximately 2 feet landing on the side of ankle. X-ray was taken 2 days later and no fracture/break/lesion was identified. Proceeded with RICE treatment and all seemed to heal well.

• RIGHT ANKLE: September 2006. Playing football on a very poor pitch wearing standard trainers and slipped on the sand. Turned straight over and felt immense pain by a very loud audible crack. Immediately taken to hospital for Z-ray which came up all clear

• October 2006 – February 2007: Injuries seemed to heal fine and no pain or stiffness throughout rest of 2006. Continued training at the gym but hardly did much running and high-impact activities.

• March 2007 – May 2007: Started training for the RAF which consisted of occasional running outdoors in special ASICs overpronation trainers (prescribed by Birmingham runner). Had a feeling of instability in the ankles and frequent stiffness following the run. Was not ‘confident’ in the strength of my ankles

• June 2007: RAF Fitness test which consisted of Assault Course and Bleep test. Ankles began to constantly click and crack. Whilst there was no pain, they felt very unstable and again I was not confident in them

• July – September 2007: Went away on holiday and didn’t participate in any running activities. Occasional game of football each week and that was it. No pain, but instability and clicking and popping felt worse.

• October 2007: Began training for RAF fitness again by doing 2-3 miles a couple of times a week on the treadmill in gym. Began getting shin splints which I’ve never had before, ever. Saw a Podiatrist who suggested some custom orthotics to help with over-pronation. These didn’t seem to help

• November 2007: Began to have a dull pain in ankles whilst resting and pain with activity. Went to a physio who suggested some lower limb stretches and ankle strengthening exercises, but nothing helped. Saw another two Podiatrists who prescribed more orthotics, one pair to resolve a limb length discrepancy. Pain became progressively worse. Even with rest it was a dull ache. Exercise rarely added to the problem, in fact often I had no pain when exercising. Insoles I feel may have caused greater problems.

• December 2007 – Pain became chronic, constant, intense and at times unbearable. Stopped all running except for 30 minutes at weekend for game of football. Used Private Healthcare to see an Orthopaedic Surgeon. He examined my ankles and suggested possible ankle instability and inflamed lateral ligaments. Order an MRI scan to confirm.

• January 2008 – MRI scan on ankles (copy of findings available separately). Showed diffuse thickening of anterior talo-fibular ligament, nearly double the size and evidence of chronic ankle sprains.

• January 2008 – February 2008 – Put on a course of physio for 6 weeks to try and heal the painful ligaments. The physio didn’t help one bit. Relieved some of the pain initially whilst having treatment, but it came straight back. Tried stretches and wobble board, proprioception exercise and nothing helped.

• March 2008 – Referred to a Chiropractor and Podiatrist. He performed a cuboid manipulation which immediately relieved all pain for about 4-5 days. Sadly, it came back again. Acupuncture helped a little, but pain was always present day after as per before. Cuboid manipulation performed and told to wear orthotics, effects of this soon wore off a day after and back to usual constant pain. Again, I feel the orthotics could of heightened the problem.

• April 2008 – Went back to Orthopaedic Surgeon who recommended an ankle arthroscopy on left ankle first. Operation was on 5th April and the OS expect to find some scar tissue and debris, but he came across a small tear (approx 2 cm long and 1-2mm wide) in articular cartilage of the talus. He repaired it using a Microfracture Chondroplasty technique. The flap of articular cartilage was luckily still intact, folded into the tear, so he microfractured the subchondral bone and then pulled the flap over the blood clot/defect in the hope it would heal perfectly. Was non-weight bearing for 3 weeks, partial for 1 week. Pain is still there as it was pre-op. I am sure the cartilage tear was not causing my ankle joint pain.

Where is the pain?
• Hard to really pinpoint. Have pain constantly on the lateral outside area of the ankle near the cuboid (ATFL?)
• Frequent pain also present in inner ankle ligament
• Pain also present in bottom of shin/ankle joint and again, it’s not a deep, deep pain but feels like two ligaments are inflamed.
• Occasional heal pain on left ankle, probably from surgery and tight calf’s.

How bad is the pain?
• Constant. It never relinquishes and is driving me absolutely insane. There every time I wake up to the moment I go to sleep. For the first minute when I awake, there is no pain, but straight after that it comes back.
• Pain in morning is about 5 / 10. Pain in evening is about 7-8 / 10.
• Nothing seems to work. No ibuprofen gels, arnica cream, ice etc. Ice sometimes numbs the pain for a little while.
• Jacuzzi and whirlpool does relieve the pain and light exercise such as cycling also helps a lot. In fact, the pain is rarely there when I am exercising but constantly there when resting. This is probably the worst scenario as my job is a desk based job.

How has this impacted on my life?
• Massive impact. Feel down and depressed because nothing has seemed to work. The RAF was my dream and I have been told that this is no longer an option for me as I should try to refrain from all high-impact sports and running.
• Severely affecting quality of life. Feel bitter and moody and can’t enjoy all the activities I love so much, football, walking and just being normal at rest! Affecting my work too as I can’t focus without thinking about the pain.
• Seriously been thinking about joint replacement and fusion as I don’t think I can live with this pain.

Next options:
• Prolotherapy or strong pain relief medication
• More arthroscopic surgery (Autoglous Cartilage Implantation) or other
• Joint replacement/fusion

Has anyone please got any advice for me?? Anything that might help relieve some of the pain? Anything please??

Thanks

Greg

[Heidi]

Wow! I don't really know what to say!

All I can recommend, before you go down more serious surgical routes, is to try a good, reputable sports therapist or rehabilitator.

You seem to have had most of the treatments which I personally would use for you, but not all in conjunction, over the same period. Treatment seemed to be to try one thing, see if that works, move on to something else. Am I right or have I read it wrong?

If you came in to see me, I would be using a combination of treatments methods, fairly intensively for the next 6-8 weeks at least. This would include:

Biomechanical assessment of feet, ankles, knees, hips/pelvis (correct orthotics/trainers if necessary)
Massage to any tight structures and friction massage to damaged liagments
Ultrasound to break down excessive scar tissue and encourage healing
Stretching, both for you at home and partner type, MET stretches
Strengthening (using resistance bands and then weight bearing) for ankles and any other weak areas (could be thigh/hip muscles)
Proprioception training

All of this would be used in conjunction, ideally twice a weeek, with obviously things you could do at home daily as well.

I know this probably seems like stuff you've seen before, but I would definately advise you to think twice before you go down the road of more surgery.

It seems to me that your treatment needs to look at the whole picture, not just the individual parts which seem to have been treated so far.

Hope this helps in some way

[GregasGP]

Hi Heidi

Thank you very much for the reply. I agree too. Everything the OS, Physio and Podiatrist has treated has been in isolation - I just don't know where to turn or what to do anymore. The physio said my ankles were pretty strong and in good shape (prior to surgery) and that my balance seemed ok too.

I have been doing wobble-board excercises and have a good ankle rehab and strengthening programme off the net, but again it was only used for a bit prior to surgery. I also had some ultrasound on the ligament to break down the scar tissue, but it still hurts and doesn't feel right. I was hoping prolotherapy treatment might help here.

I'm so confused. Shame that you are so far away. Anyone you could recomment around the West Midlands area?

Thanks for your help so far, it truly does mean a lot.

Greg

[Heidi]

Hi Greg,

I don't know a lot about prolotherapy so i'm afraid I can't really advise on that.

I also don't know anyone with the same qualifications as me in your area. Try our find a clinic page:

http://www.sportsinjuryclinic.net/clinics/united+kingdom/west+midlands/

Try to go for someone who looks like they offer a range of services including biomechanical assessment, massage, rehab etc. Ask specifically for frictions to the ATFL ligament and any others which have been damaged.

Sorry to not be more help!

[GregasGP]

UPDATE:

Hi all,

I went to see two specialists yesterday for a second opinion. They did the following tests on my ankles:


* Strength Testing - pushing against force etc - OUTCOME WAS EXCELLENT. STRONG ANKLES

*ROM testing - any pain when moving ankle etc - OUTCOME WAS EXCELLENT. NEAR PERFECT ROM

*Balance testing - proprioception/one leg stands/toe walking etc - OUTCOME WAS EXCELLENT. PERFECT BALANCE.

*Instabsility check Ligament/Trigger point check - OUTCOME WAS EXCELLENT. ALL LIGAMENTS STRONG AND INTACT NO SIGNS OF INSTABILITY

The second specialist did find some major major on my Anterior-Tibia tendon (?) that goes down to the front of the ankle joint and also along the Peroneal tendon. However, they are both bemused at my symptoms being pain whilst resting and NWB, and less/no pain when exercising and walking.

Apparently, there is a chance that I could have extreme referred pain to the ankles.

Any other ideas?? This really is a troubling case and nodoby seems to have any answers.

Thanks

Greg

[jojo]

Hi Greg,

I can so identify with what you are going through! I have sprained my left ankle many, many, times due to loose ligaments and have always had some ankle instability. About six months ago I began to notice some swelling and had some pain on the outside of my ankle. I went to my General Family Dr and he gave me an air brace to wear and said it was just basically the way it was due to my prior injuries. I wore the brace for about a week and the pain went away. A short while it came back and I went to a specialist as the pain has been increasingly worse. Had x-rays and an MRI and found I have tendonidis and legions and injury to the cartilige in the joint. Dr gave me cortison shot today...ow... and it took the pain away for about 2 hours but it came back.

Says I have to wear brace constantly that's not fun but the next step is the surgery like you had done. I am so up for it ONLY if it will stop this pain!

It hurts so bad to be off it like laying down or me too at a desk job it kills while I am sitting! What pain meds are you taking? I am going to try celebrex as it's an anti imflamitory and hopefully that will help some!

How painful was the surgery?

Hope you are feeling better!

[Tennis05]

I am going through something similar with the right ankle. I have already had ankle surgery (almost 2 years ago) and the pain has been worse since then. I have found a good sports medical doctor that is not a surgeon coordinating my care among 3 doctors. He has taken the time to determine that there is more than 1 thing going on.

I have the same level pain as you and I wanted the surgery, but the Sports doctor amazingly said to wait until we determine the root cause so that there is patient satisfaction (I get out of the surgery what I want - pain free).

I would recommend finding a good physical therapist (or more than one) that you trust to recommend a doctor that will take the time to listen to you and be patient enough to determine the root cause. A good PT sees all of the local doctors handi work and knows who will take the time with you. This may take some time, but is well worth the effort.

Hope this helps

[mkhill]

You might want to check out platelet rich plasma therapy. Its similar to prolotherapy in principal I guess, they draw your blood, run it through a centerfuge and isolate the white blood cell platelets and inject those concentrated platelets into the injured site. There is a story of a kid from Stanford university who tore 75% of his knee tendon off the bone, failed to heal after surgery and had PRP therapy done with excellent results. Also look at a company called Regenexx, they extract stem cells from your hips and cultivate them in a lab.. they then inject those cells into your injured area. Both are expensive and not covered by insurance but it might be an option for you depending on your financial situation.

[crowcity]

Hi. Sorry to hear about your troubles. I'm going through something really similar (ankle tendons) and can make a suggestion that might help.

I've just bought an ultrasound machine to use at home. I know that ultrasound really helped before the NHS physio decided I'd used enough of their resources.

This is it http://www.ultralieve.com/

Using ultrasound three times a day seems to be what helps footballers etc to heal so rapidly.

I'm at the point where I'll try anything - have already had to give up my job. I'll let you know how it goes.

[jayjay23]

Hi Greg, i feel like i may have the exact same problem as you, and its difficult to find anyone going through the same thing.
How is your ankle pain at the moment?
Mine drives me absolutely insane. to the point where i want to saw off my foot to be free from the pain.
It's also so difficult to get help or to get doctors to understand the pain or the absolutely unavoidable need to crack.
Like yourself, my pain is best in the morning and worse at night. And worse at rest than when excercising.
Anyway, you don't need to be told about the pain, you already know.
I thought of a few things which may help you.

1. You are probably already doing stretches advised by your physio but if you need some more advice or a different stretch i have found a few things which work for me. (a bit). let me know if you want to know.
2. Keep good supportive trainers or shoes on all the time, at home, on holiday, everywhere, only take them off for bed, or a shower.
3. Go to a swimming pool and jog in chest high water if you still find it difficult to go for a run, its good excercise without the impact.
4. Try, really TRY HARD not to crack, its best in the morning because overnight you dont do it, each crack irritates the tendons and makes them swell, and makes you feel more in pain and you want to crack more, which is why when you go to bed at night its the hardest time of all to try to stop cracking them.
5.If you live in a house without stairs or moved into one recently it may have made your condition worse. I moved into an apartment and out of my parents and the lack of stairs seemed to really have an impact on me.

I will attach some info i have found on the condition and possible causes etc below, its some stuff i copied for myself but though it might be useful to you, there are some links in there too for more info so hover over relevant bits to see if there is a link.



Ankle Problem

http://www.eorthopod.com/public/patient_education/6581/peroneal_tendon_subluxation.html
The injury to the retinaculum may be overlooked at first while treatment focuses on the injury to other ankle ligaments. This means the subluxation may begin much later, and it may not seem to be caused by the initial ankle sprain. If not corrected, this snapping of the tendons can become a chronic and recurring problem.

An acute dislocation of the peroneal tendons is rare. It occasionally happens during sport activities that force the foot up and in, for example during skiing, ice skating, or soccer. At the moment the foot turns up and in, the peroneals violently contract to protect the ankle. This can cause the retinaculum to tear, allowing the tendons to slip out of the groove.
Differences in the anatomy of the groove may predispose some people to peroneal tendon subluxations. The groove may be too shallow. Or the ridge that helps deepen this groove may be too small or even absent. Sometimes, the retinaculum that keeps the tendons in the groove may be too loose.
In these cases, patients may not recall any injury to explain the persistent snapping of the peroneal tendons
Patients describe a popping or snapping sensation on the outer edge of the ankle. The tendons may even be seen to slip out of place along the lower tip of the fibula. It is common to feel pain and tenderness along the tendons. There may also be swelling just behind the bottom edge of the fibula.

Your doctor may order a magnetic resonance imaging (MRI) scan of your ankle. MRI scans can show abnormal swelling and scar tissue or tears in the tendons. However, MRIs won't always show subluxation of the peroneal tendons.
What can be done for the problem?
Nonsurgical treamtment for peroneal tendon subluxations helps control symptoms. However, nonsurgical treatment of acute subluxations in active patients is successful only about 50 percent of the time. Chronic cases of peroneal subluxation that have not responded to nonsurgical measures generally require surgery.
Retinaculum repair is gaining popularity. This procedure restores the normal anatomy of the retinaculum that covers and reinforces the tendon sheath around the peroneal tendons.



The Snapping Tendon
By Thomas Souza, DC, DACBSP
My point of reference or stimulus for a column is usually from the current literature. This month, I would like to present what is largely an opinion article based on my own personal experience with a relatively common complaint: snapping around a joint.

Snapping will be herein differentiated from popping at a joint by the more common description of snapping as a superficially felt sensation. Snapping is generally caused by a tendon and/or bursa. The tendon or bursa may be inflamed, and if so, will often cause painful snapping. If the snapping is more of a nuisance, it is more likely that either an underlying joint looseness is present or some new biomechanical change has occurred causing the tendon to snap.
Common structures and locations include:
• peroneal tendons -- outer ankle
• semimembranosis tendon -- posteromedial knee
• medial plica -- anteromedial knee
• iliotibial band -- outer hip
• iliopsoas -- inner hip/thigh
• biceps femoris tendon -- posterior hip/buttocks
• extensor carpi ulnaris tendon -- outer wrist (forearm pronated)
• biceps tendon -- anterior shoulder
• infraspinatus/teres minor -- posterior shoulder
• levator scapulae -- superior-medial scapula

Most of the above sites include an interposing bursa. Snapping may occur over the bursa or over a bony prominence.
From a general diagnostic standpoint, it would seem important to distinguish between bursa versus tendon as a cause, however, this is often difficult. Discrete tenderness deep to the tendon may be found if the bursa is inflamed. Distinguishing between a benign, biomechanical versus pathologic snapping is usually possible and helps convey to the patient and answer as to the seriousness of the snapping. Most causes of pathologic snapping are traumatic in origin. For example, constant snapping at the outer ankle subsequent to a major ankle sprain is a strong indicator or rupture of the retinaculum that binds the peroneal tendons down. The same would be true of a new, constant snapping at the ulnar styloid following a fall onto the wrist indicating a rupture of the retinaculum binding the extensor carpi ulnaris down.

When snapping occurs at the biceps tendon, it is often assumed that it is due to dislocation of the biceps tendon caused by tearing of the transverse ligament. It was also assumed that the transverse ligament is the primary restraint to biceps tendon dislocation. However, the primary restraint is the coracohumeral ligament and edges of the subscapularis and supraspinatus tendons.1 It is rare for these to tear. The snapping is believed to be due primarily to an inflamed biceps tendon snapping over a supratubercular ridge or spur.

Most snapping seems to be movement specific. The movement specific patterns for each are:
• peroneal tendons -- passive or active circumduction of the ankle or resisted eversion
• semimembranosis tendon -- passive or active extension of the knee or resisted knee flexion with knee slightly flexed
• medial plica -- passive or active extension of the knee; most commonly 40 degrees of flexion to full extension
• iliotibial band -- passive or active hip abduction coupled with flexion or extension of the knee
• iliopsoas -- passive or active hip abduction or external rotation
• biceps femoris tendon -- passive or active hip flexion/extension
• extensor carpi ulnaris tendon -- passive or active wrist circumduction or simply ulnar deviation
• biceps tendon -- passive or active abduction of the shoulder with coupled internal and external rotation
• infraspinatus/teres minor -- passive or active internal and external rotation coupled with horizontal adduction (shoulder abducted to 90 degrees or higher)
• levator scapulae -- shrugging of the shoulders coupled with protraction of the scapula

Assuming there is no damage to the supporting structures that bind down tendons to bone, most snapping is due to looseness or tightness and can often be improved by strengthening or stretching the corresponding muscle or other stabilizers around the joint. In performing stretching or strengthening exercises for these tendons, it is important to avoid the provocative maneuvers or positions.

In some cases, snapping will persist, yet in most cases is no more than a nuisance. Dancers, for example, commonly have iliopsoas snapping over the lesser tronchater or iliopectineal eminence. This is often a result of needed adductor flexibility coupled with repetitive movement. Strengthening of the adductors may reduce the snapping. Iliopsoas snapping is more commonly due to tightness and requires stretching. My personal choice is to use a myofascial release technique. Snapping at the medial/posterior knee is most commonly the semimembranosis tendon and appears to respond more to strengthening and/or biomechanical correction/support through rotational adjusting of the knee and the use of a medial heel wedge.
Additionally, I have patients avoid hyperextension maneuvers or postures for several days. If there is an associated bursitis, the snapping may be painful. Treatment of the bursa also includes the above-mentioned biomechanical approaches plus physical therapy to reduce swelling.
When tendon snapping follows major trauma, tearing of support retinacular structures may have occurred and warrants an orthopedic consult if the snapping is either painful or limits function.

[jayjay23]

SOME MORE STUFF

Chronic injuries include longitudinal tears5,6,7,8,9 and recurrent subluxation10,11,12 of the peroneus brevis tendon.13 These chronic injuries are usually associated with ankle or subtalar arthritis and ankle instability. People with "bad" or "weak" ankles may have peroneal tendon pathology. Core and lower extremity biomechanics must be evaluated in any chronic atraumatic peroneal tendinopathy, as flaws in those mechanics are usually the culprit.
http://emedicine.medscape.com/article/91344-overview
Injuries to the peroneal tendons are common but not always clinically significant.1 They are misdiagnosed as a lateral ankle sprain most of the time,
• Peroneal tendon subluxation
o Snapping along the lateral ankle is present, with a sense of weakness or pain. A painful snapping sensation over the lateral ankle is the classic indication of peroneal tendon subluxation

• 50% of acute subluxations tend to recur in active athletes. This would normally result in either surgery or a retirement from the sport. There are 3 common surgical techniques – rectinaculum repair, groove reconstruction orcConstruction of a bony block. Post-surgical physiotherapy will be essential to get you back to sport.

http://redsports.sg/2008/09/29/snapping-ankle-its/

it appears the links have not copied as links in the above text. if you wish me to send you the whole thing with working links and pics then i will email you, just let me know.

good luck, and it would be nice to hear an update on the ankle situation.

james.

ps i know there is a lot to read above, if you want me to send you the original i have faded out the irrellavent text and bolded the stuff that is important.