Just looking for ideas/input in case anyone has dealt with this. I have seen an orthopedic surgeon, had an MRI, and did PT and dry needling, but I’m still hurting. (the ultimate answer is going to be to get back to the ortho office, but like I said, looking for ideas)
Have had anterior ankle pain at least 18 months, going on 2 years. It ‘feels like’ anterior impingement, but MRI didn’t show significant degenerative change. It did show lots of fluid around the extensor tendons (anterior, lateral). When I run or walk or hike, particularly uphill, I get sharp pain at the front of my ankle, sometimes more lateral, sometimes more medial. Like stop me in my tracks pain. Ankle is swollen where the extensor tendons are most of the time. I had switched from motion control running shoes to neutral shoes at one point-- switching back didn’t help.
Had an unpleasant visit the last time I went to PT (several months ago) because she kept calling it ‘soreness’ and for me to not do any repetitive motion. Not sure how I’m supposed to get even to the mail box without walking (other than driving 1/2 mile which is silly). I told her that after 20 years of triathlon including long distance, I know the difference between sharp pain and soreness. Also, what other cardio besides swimming (not my fave) would I even do? Not like tennis or pickleball or aerobics isn’t going to keep stressing my ankle. Even just going hiking or a walk around the neighborhood is getting uncomfortable. The mental hurt of being told, “just don’t walk, run or bike” was brutal.
I was a gymnast in my much younger days-- so I’m sure there are underlying chronic ligament issues, but I’m getting frustrated not being able to at least jog a little or enjoy a hike that might involve a hill.
So I just wanted to check the ST collective brain before I schedule another ortho visit (would be a different doctor, as the other ankle doc moved). Or could see a PMR doctor.
I’m a sports doc, but don’t take this as medical advice.
To summarize the key points:
Former gymnast
Anterior ankle pain
xrays and MRI show pretty normal joint
Maybe some extensor tenosynovitis (they can be innocent bystanders in the setting of anterior impingement).
In my head, anterior ankle pain in a (former) gymnast is anterior impingement until proven otherwise. It is just so crazy common in that population.
If I were your doc, I’d do this:
Diagnostic injection (just anesthetic) into the ankle joint than have you go do something that would normally recreate the pain.
If dramatically better, I’m blaming impingement despite what the imaging shows. Then steroid injections into the joint are usually first line. If that works for a while, but not enough, decompression surgery makes sense.
If no better, then I’m thinking the extensor tendons are the problem. That is crazy good news because that is super easy to treat. Topical NSAIDs (like diclofenac creams or patches) work really well. One is cheap (OTC voltaren) the other is a bit more expensive (flector patches), but I think the patches might work a bit better. Probably not better enough if your insurance won’t cover them because they are like $250/month.
The other counter intuitive thing that can actually help either problem is a bit of a heel lift. Lifting the heel decreases the impingement (obviously). Less obviously, it can also help with the extensor tendons because giving them a slightly straighter path across the joint gives them more mechanical advantage.
Anyway, that’s how I think about it in the clinic room. Hope that helps.
I’ve had numerous repetitive use injuries over the years. PT for them has always been some variation on: 1) heal the injury such that you can regain functional use of the joint through rest, and various methods of reducing inflammation, 2) gradual, progressive strengthening/stabilizing of the affected area (based on root cause) 3) gradual, progressive reintroduction to activity, as limited by pain.
These repetitive stress injuries have typically taken 3+ months to recover from, and some much, much longer. Typically, for me the time away from the affected activity is 4-6 weeks, before phase 3 and the gradual reintroduction of sport. However, I’ve also had a couple of injuries that took 6+ months, and one that took many years (I actually had given up ever coming back).
I’m not a doctor, so…I could be wrong. But, my own personal experience is that every repetitive stress injury I’ve had required weeks, months, and in one case years to recover from.
ETA: I was composing my response at the same time as Andy. Obviously, his response over-rides anything I had to say above.
Thank you so very much!
I’m right on the same page with your assessment based on what you have seen clinically. I’m in health care, too, but this is out of my lane; though I know what pain is vs. ‘soreness’ in reading my own body’s signals.
I haven’t been taking NSAIDs, but will do so and look into topicals.
Great idea on the heel lift-- it makes perfect sense, as when I hike uphill, I end up weightbearing on toes on that foot to alleviate discomfort. Downhills are fine.
Will get back into the sports med office and see if the PMR doc will do an injection. The first doc did one, without much relief, but I never got to follow up with him because he moved.
Part of what got me so frustrated with the physical therapist was that, after several months of work, some strengthening, and dry needling, was that she all of a sudden said, ‘oh, it could be ankle impingement.’ Um… yeah, exactly why I saw the ortho in the first place, and right there on the indication for the MRI. Ugh. I knew that.
