Two years ago I got a real bad pain in my very lower outer shin (slightly above the ankle - peroneal brevis area, I think) during the bike portion of a long distance tri. It was very painful - felt like muscle pulling off the bone but I ran through it and finished the race. After 2-3 weeks the swelling went down and I thought it was behind me. I ran alot over the next 6 months with no issues. When I started riding more (about 6 months after the injury) I started having upper hamstring/sciatica type issues. Stupidly, I trained through pain for 3 months and and did an IM that summer (never again) which I think really destroyed the hamstring at its attachment. Since that time (over 16 months ago) I have been battling unsuccessfully to get back to health including sustaining a calcaneal stress fracture and plantar fasciitis in that same heel (left foot).
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This fall I started PRP treatments for the upper hamstring/adductor problems and they have helped alot. Recently the doctor who is treating me looked at my feet and found that the ligaments in the bad foot (left) were, in his words, incredibly loose, relative to the right foot, making the foot unstable, which in turn very possibly led to the stress fracture and plantar fascitis in my heel. I have noticed this myself, that the right foot is alot looser at the ankle joint than the left, but never thought much of it I’d rolled it quite a few times throughout my life playing baseball, football and rugby (at least twice pretty badly years ago). He also pressed on the ligaments on the top/outside of my foot (calcaneo-fibular ligament, I think) and it was very painful compare to when he did so on the other foot. He said that the ligaments could be stretched from a previous injury and that this could cause looseness/instability in the foot that he has often see associated with heel pain and/or plantar fascitis. He though it also could be a cause of my upper hamstring problems.
The doctor said this can sometimes be treated by PRP or prolotherapy but that he thought it best to first get an MRI of my heel and ankle to confirm what he was feeling so I got and MRI of my ankle and heel and it had the following findings:
-mild edema at the insertion of the plantar fascia and mild calcaneal spurring. These features ae consistent with plantar fasciitis. A complete fascial tear is not identified
-lack of continuity and definition of the anterior talofibular ligament consistent with a previous injury
-thickening of the anterior syndesmotic ligament that may also relate to a previous injury.
I am now really thinking that this ankle instability has been the cause of all my hip/upper hamstring/glute/adductor problems. It seems maybe my foot has not provided a stable platform when I pedal causing overstress to the muscles in my lower shin and causing the angle of my femur into my hip to be off an causing pain in my upper hamstring/adductors/glutes when I pedal for a long period of time.
Other factoids: ankle and shin do not hurt at all when I run. Ankle does not hurt when I ride but brevis area of lower shin can get very sore sometimes when I ride. Most significantly, whenever I get a massage of that area (brevis lower outer shin) it hurts like crazy in one area near the bone - feels like a nerve is trapped or something against the bone. Bone scan I got for heel fracture showed no fracture in that area however.
My doctor is planning to try PRP this week to strengthen the loose ligament in the ankle. I’d really appreciate hearing from anyone who has had or given such treatment and whether it helped as well as any other suggestions given the above history.
There is no data to support using platelet rich plasma injection to “strengthen” an attenuated ligament (in your case, the anterior talo-fibular (ATF) ligament). Perhaps if it was ruptured (a common occurrence and the very definition of a typical inversion ankle sprain) and didn’t heal, the PRP injection could “stimulate” healing? As for strengthening? No. If the ligament is healed (i.e. intact), but attenuated (think “healed too loose”), PRP won’t likely be helpful.
I have similar issues to you - common hamstring tendonosis/tendonopathy at the attachment point. I tried PRP - but it had little effect. Another year down the road, I think I know why.
Previous treatments (and I’ve tried everything) did not include a full complement of therapies. E.g. PT on its own. Chiro on its own. PRP on its own. ARP Wave on its own. etc, etc. All these did something, but did not fix the problem, it would just go back to doing what it was doing before.
I currently have a good chiro (not necessary in my opinion), a great rolfer (Very useful, ART or similar will work) and now an exercise physiologist (PT, massage, dry needle, scraping, gait, etc). It is the inclusion of the last one that is finally making a difference. Having someone one-on-one, looking at how I do things, and responding immediately with treatment or exercises to counter is HUGE. I am currently retraining the muscles to fire correctly, strengthen ones that are weak, and retrain ones that are too strong. The rolfing and chiro keep everything in order while the muscles are learning new things.
If I had PRP now, I think it would probably add to the healing. All I can say, is that 6 treatments did nothing for the injury in the absence of the other things (I was doing PT at the time, but shitty couch potato PT).
Its worth a shot if your insurance covers it, mine doesnt, and it cost a fortune for nothing. Consistent and expert treatment did a lot more for me…
Rroof, Thanks alot for your reply. If there is no data to support PRP for such a situation (healed too loose) what would you suggest as a course of treatment? Also, does the fact that I had the previous injury to the brevis area of my shin and get a sharp never on bone pain there at times after riding mean anything other than my ankle is not holding in place and thus overstressing that muscle? One other fact I forgot: at times I get a electric-like feeling on top of my foot when I curl my toes up - its usually after being on feet for awhile. THanks again for all your advice
If lots of PT/strengthening does not improve/resolve to your satisfaction, primary anatomical repair (ie Brostrum procedure) is an option. If very unstable, a peroneal tendon harvest type procedure can be employed ( ie Cristman-Snook).
Three of the most common reasons for ankle sprains and pains are the following: Abnormally Loose Ankles
Ligaments are the connective tissue that attaches one bone to another, and they help to support and stabilize our joints. Each of us are genetically predisposed to have a certain amount of tightness (or lack there of) in our ligaments. If you have a history of twisting your ankle from childhood to today, it could be an indication that you lack a sufficient support structure of ligaments around the joint. One Sprain Leads to More Sprains
In addition to being born with loose ankles, you can also develop them due to a past ankle injury that never healed properly. When this happens, the ankle loses some of its original stability or soundness. The next time you land on it wrong and twist it, the joint snaps much easier than the first time it was injured. Compounding the problem is the healing process: When swelling occurs in a joint, the neural network that controls your muscles has a harder time doing its job. People often re-injure their ankle while tripping over something seemingly mundane, like stepping off a curb. Poor Coordination A good number of ankle injuries occur to people with the bumbling coordination of Inspector Clouseau. This clumsiness is due to, of all things, lack of practice. All your joints are wired with receptors that help sense your ankle’s position and rally the muscles that control the joint to hold it in place. If you don’t use this wiring system on a regular basis through, say, a regular game of hoops or soccer that involves plenty of cuts, stops, and quick changes in direction, the systems grows weak and unstable. Create a Firm and Lasting Foundation Fortunately, by fine-tuning your senses so they fire more rapidly and by strengthening the muscles that surround the ankle, you can reduce the chances of future or recurring ankle injuries. The following exercises are designed for this purpose and should only be performed if all movements are pain free. Try doing them two times per week to keep your ankles strong. Recovering from an ankle injury, or think you have loose ankles? Do them three times a week. 1. Single leg balance: Without any support, stand on one leg for 30 seconds. Repeat six times with each leg. Begin with your eyes open, then progress to standing with your eyes closed. Once your master that, move on to standing on a slightly bent knee. 2. Toe-Heel: Sit in a high chair so that your foot comfortably hangs approximately two inches off the ground (use a stack of books on a chair to get the height set). Rhythmically tap your toe and then heel on the ground, trying to isolate all movement in the ankle. Start slow and build up speed to produce a fast but rhythmical tapping. Do 3 sets of 50 reps. 3. Side-to-Side: In the same sitting position and rhythm as Toe-Heel above, touch the outside edge of your foot on the ground and then your foot’s inside edge for one rep. Again, start slow and isolate the moment in the ankle as best your can. Speed up the rhythm as your coordination improves. Do three sets of 50 reps. 4. Wobble Board: Sit in a chair and place one foot in the center of a wobble board or Bosu platform with 360 degrees of rotation. Rotate the foot in a circle so the edge of the wobble board comes close to the floor but doesn’t touch. As your balance and coordination improves try standing on the wobble board with one leg. Do two sets of ten of the following motions for each foot: a. Forward-Backward, b. Side-to-Side c. clock-wise and counter-clockwise http://www.arthroscopysurgeryindia.com/Articles.aspx?id=14
Ligaments are tough bands of tissue that connect bones to each other. They provide strength and support to joints. In the ankle, injuries to the ligaments, called sprains, are usually caused by unexpected twists of the joint. A sprain can be a stretch, tear, or complete rupture of one or more of the ligaments that hold the bones of the ankle joint together. Sprains are classified according to the severity of the ligament tear.
With a first degree sprain, stretching and minimal tearing cause mild pain, difficulty walking, tenderness, and swelling. There is no bruising or loss of function. Recovery time is 4 to 6 weeks.
With a second degree sprain, a tearing sensation, or a pop or snap is felt. There is swelling and tenderness in the ankle. Bruising begins 3 to 4 days after the injury. Walking may be moderately difficult. Recovery time is 4 to 8 weeks.
At the time of the injury in a third degree sprain, the joint may slip out of place and then back in. There is massive swelling, severe tenderness, and instability in the joint. Walking may not be possible. Surgery is sometimes necessary. Recovery time is 6 to 12 weeks.
Severe ankle sprains need medical care. It’s a good idea to be evaluated for a possible fracture. Then use RICE therapy: rest, ice, compression, and elevation.
Ice the injury as soon as possible. Cover your ankle with a WET towel and place a plastic bag full of ice over it. A one or two pound package of frozen corn or peas makes an excellent ice pack. They mold to the ankle and can be refrozen for repeated use. Ice should be applied for 10 to 30 minutes on and off for 48 to 72 hours. Stay off your feet. Recline and elevate the hurt ankle slightly higher than your hips. Compress the injury with an elastic bandage. For the first few days crutches are advised, even with mild sprains. http://www.arthroscopysurgeryindia.com/Articles.aspx?id=14
out of curiosity… what kind of doctor are you seeing?
agree with above. there is no literature to support prp as a for ligament regeneration or “tightening”. it has been anecdotally effective in treating tendonitis and ruptures of the hamstrings, achilles, patellar tendon, and lat/med epicondylitis, as well as augmenting repairs of the achilles and rotator cuff. it has been investigated in ACL studies as well, though those are mostly in animals. the literature for prp at this time is weak at best, but this would be a novel use of this particular therapy. if your ankle is loose enough to inhibit you, reconstruction is an option. however, if your ankle doesn’t hurt, biomechanically it is unlikely to have been the cause of your upstream problems (although it may contribute.)