Dear ST community resident foot/ankle specialists,
Ten months ago back on November 2009 I severely sprained my right ankle, it rolled inward and my body weight came crashing down on it. There were no fractures per x-ray. The ankle was swollen for the first few days, then only residue swelling (puffiness) remained at the outer ankle bone until the present day. Besides the swelling, I was also no longer able to flop my sprained ankle up and down like fins when swimming, so when I swim I just hold that ankle rigid throughout the swim while my other perfectly good ankle flopped up and down like fins in good form while swimming. Even though I am able to perform the single heel rise on the bad ankle, the arch does not “lock in “ and rise as high as compared to when I perform the single heel rise on the other, normal, and good ankle.
My MRI showed “bone contusion in ankle,… minimal posterior tibial tendonitis bone of the ankle joint,… minimal thickening of the peroneous brevis tendon without definite focal tearing,… edema along the anterior talofibular ligament near the fibular attachment with mild thickening consistent with a moderate sprain,… and intact calcaneal fibular ligament appears with disruption.” My orthopedic surgeon who is a foot and ankle specialist sent me for 4 weeks of physical therapy. I have been swimming religiously since then because it lessens the swelling/stiffness/tightness of the ankle especially after a long day’s work of being on my feet all day. I was able to restart bicycling few months ago, and I gently restarted very light running a month ago.
Over the course of the ten months since I sprained my right ankle, I have noticed that my right foot gait has been changing. I have been pointing the toes of my right foot a little bit outward away from my body when walking; I felt that my ankle feel more “stable” this way. In addition, I noticed a painful soreness when I press on side of the base of the big right toe. Alas, after ten months, I still have to keep my bad right ankle rigid and stiff throughout the swim, or otherwise, it would flop up and down uncontrollably, and it would hurt. Last month, after reading on ST posts on posterior tibial tendons and peroneal tendons, I went back to my foot and ankle orthopedic surgeon, and told him that I thought that I might have stage II posterior tibial tendon dysfunction. However, he observed “nice inversion” when I performed the single heel rise test. **However, as before, I cannot FULLY extend my arch when doing the single heel rise. There is something missing which does not allow my arch to “lock-in” when I rise up on my heel, my arch does not rise as high as my other arch when I perform the single heel rise on the other good ankle. **My ortho seemed to consider this as a minor difference. He ordered a follow-up MRI with a “disclaimer” that he is not expecting to find something in this follow-up MRI.
This follow-up MRI showed “partial tearing of the peroneus brevis and longus tendons which is not particularly changed from the prior MRI examination,… some thickening of the anterior talofibular ligament compatible with prior injury,… and a small amount of fluid in the tendon sheath of the posterior tibialis tendon.”
Next week I will be meeting with my orthopedic surgeon to discuss the result of this follow-up MRI. Since I feel that my foot and ankle orthopedic surgeon is not really actively managing my ankle sprain, I also made an appointment to see a podiatrist who is himself a marathon runner & triathlete next week. He does running video gait analysis and custom molded orthotics, so I thought that I ought to at the very least get some kind of foot orthotic, especially since my insurance will cover 80% of the cost. I also noticed weakness and some tingling around the front of the ankle in the past 2 months. Just read about platelet rich plasma injections and Topaz coblation on ST. Do they have relevance on my case? I am a 38 year old female who have been swimming a minimum of 3 times a week, biking around 40 miles a week, and running 3 miles once a week. Any thoughts, suggestions, or directions that I ought to think about? Thanks.
Jean.
MRI of right ankle on 8/6/2010:
“Examination of the lateral aspect of the joint demonstrates partial tearing of the peroneus brevis and longus tendons which is not particularly changed from the prior examination. The lateral ankle ligaments are intact anteriorly and posteriorly. There remains some thickening of the anterior talofibular ligament compatible with prior injury. The tarlar dome is intact. The Achilles tendon and plantar fascia are normal in appearance. The previously noted focus of bone marrow edema in the posterior lateral talus is no longer identified.
Medially the posterior tibialis, flexor digitorum longus and flexor hallucis longus tendons are relatively normal. There is a small amount of fluid in the tendon sheath of the posterior tibialis tendon. There is no fracture identified. The sinus tarsi is normal in appearance. The previously noted joint effusion again is no longer identified. There is a physiologic amount of joint fluid.”
MRI of right ankle on 12/17/2009:
“There is a focal marrow edema seen within the posterior aspect of the talus near the dome. There is no corresponding discrete fracture line identified. Findings consistent with a bone contusion. The remaining marrow signal is unremarkable. The tarlar dome and tibial plafond are intact as is the overlying articular cartilage. There is no evidence for an osteochondral injury. Subtalar and calcaneal cuboid articulations are intact as well.
Achilles tendon and plantar fascia are intact. The posterior tibial, flexor digitorum and flexor hallucis longus tendons are intact. There is minimal posterior tibial tendonitis bone of the ankle joint.
Laterally, there is minimal thickening of the peroneous brevis tendon without definite focal tearing. Anteriorly the extensor tendons are intact.
There is edema along the anterior talofibular ligament near the fibular attachment with mild thickening consistent with a moderate sprain. There is no focal tearing. Posterior talofibular ligament is intact. The calcaneal fibular ligament appears intact with disruption. The medial deltoid ligament is intact. Anterior and posterior tibiofibular ligaments and distal ankle syndesmosis are intact.
There is a small joint effusion seen at the ankle joint with fluid in both the anterior tibiotalar and posterior tibiotarlar articulations**.** Normal fat signal is preserved in the sinus tarsi. There is no mass in the tarsal tunnel. Para-articular musculature is normal in signal and bulk.
