Anyone have experience with this? If so, how long does it typically take to heal?
Short Story:
I sustained the injury nearly 18 months ago in July of 07, however it just got diagnosed within the last month via MRI. I have been taking it easy since the injury in July of 07. Doc is surprised it hasn’t healed yet, but advised to take it easy. “Try easing into exercise after about a month off, if it hurts back-off”. I’m worried that it’s been nearly 18 months – will one more month help? Maybe some more aggressive treatment is necessary besides rest and calcium supplements? If I feel pain when I ease into activity, am I setting myself back too far?
Long Story:
For those willing to read the saga, here it is. I’ve been dealing with this injury for nearly 18 months now. I sustained this injury in July of 07 due to being an idiot (overtraining/hiking/new track workouts in regimen). I treated as a sprain with RICE and swimming only. After 2 months, went for a run but still felt pain. First doctor I went to diagnosed it as scar tissue and I treated it with PT accordingly, also suggested I continue easy exercise (ie run 5 min / walk 5 min). I got Mono in spring of ’08 (yes, its been a bad year) which took me completely out of commission. I thought maybe this was a blessing in disguise to really help my ankle heal. 2 months later, I was cutting the lawn when I felt a sharp pain in the ankle. Thought that was inline with scar tissue, since my muscles were tight. After another couple months of only swimming, tried running/biking again, but the pain was still there. Finally went to a different, very respected foot/ankle specialist who issued a higher quality MRI and saw that there was still evidence of trauma in the medial malleolus, likely from a stress fracture. There is currently bone marrow edema in that location. Looking back, its been 3 months since I stopped all activity except swimming, and its been 9 months since I’ve really been taking it easy. In fact, since the injury 18 months ago, I’ve been primarily swimming except for a total of about 3 months where I tried biking on it, and about 1 month of easy run/walk (this is when I thought it was only scar tissue).
I’ve gotten to the point where this injury is having a negative impact on my mental health, and I can’t even chase my kids around the backyard for fear of it not healing. Any ideas whether doctors course of treatment is a good approach? He feels it is far enough along in the healing process that I don’t need to do anything more aggressive, such as a soft cast or walking boot.
For any doctors out there, here are the MRI results…
“Nonspecific bone marrow edema within the medial melleolus. This may reflect a stress response or posttraumatic contusion. Alternatively, this may reflect edema related to an occult fissure involving the articular surface of distal tibia. No discrete osteochrondral lesion of the talar dome is visible and there is no evidence of tibiotalar loose body or joint effusion”
“Nonspecific bone marrow edema within the medial melleolus. This may reflect a stress response or posttraumatic contusion. Alternatively, this may reflect edema related to an occult fissure involving the articular surface of distal tibia. No discrete osteochrondral lesion of the talar dome is visible and there is no evidence of tibiotalar loose body or joint effusion”
Tibiotalar refers to the joint between the tibia and the talus bones (talus sits above the calcaneus, which is like your “heel bone”)
Bone marrow edema, edema means fluid accumulation, right? or is it more bone marrow stuffed in there than should be?
My experience with sfx, though I’ve never fractured that particular spot, is that the first couple times your run bike or walk for awhile you do feel some pain but it goes away. I don’t have any answers for you, but I’m wildly interested in bone things and am curious to read some responses from others.
Sending you a PM with the name of a doctor in my area who is a bone specialist… and a runner.
Very rarely a stress fracture that’s not healing can have a couple of screws placed across the fracture. Obviously a last resort and that assumes the specialist thinks this is a stress fracture. One concern about the MRI is the lack of signal consistent with an actual fracture line which indicates an actual fracture.
Hmmm … pretty odd. MRI is pretty vague though and that is not a very common place for a chronic, non-healing stress fx to occur. Occasionally, as jayhawk mentioned, a couple of compression screws can be placed across a stress fx in commonly poor healing areas (like the navicular), but you really want to see some sort of fracture line for orientation of the screws.
I good CT scan can show some more fine bony detail over an MRI and might be another option. Also, surprised no one has mentioned an external bone stimulator to you. Have no idea if it will help (and your insurance will likely balk with your paucity of evidence).
Thanks for the input! I’ve only had 2 appointments with the new doctor - pre/post MRI, so maybe we haven’t had to opportunity to explore other avenues. These are some good suggestions, so I’ll ask him about these options. I already have another follow-up appt scheduled in early January, and just wanted to be well armed with ideas.
I never rely solely on an MRI report. However, in this instance, I do not have your actual images to look at (or for that matter a physical exam). There are no findings on the MRI report to suggest utilizing bone screws. I’m am not certain if the “occult fissure involving the articular surface of distal tibia” was actually seen or is being referred to hypothetically. Regardless, the best fit diagnosis based on your symptoms and the MRI alone (no physical exam) is stress fracture.
Using 18 months of symptoms and the MRI findings, your doc might be able to make a case for delayed union and attempt to get you the bone stim unit.
Of the few cases of medial malleolar stress fracture (remember that they are not too common) that I’ve treated, I can recall that delayed pain resolution can be a problem in some. In fact, some patients may retain joint line tenderness once the bone tenderness is resolved, meaning that as the stress fracture resolves, the adjacent joint (ankle) may continue to have synovitis. In the case of your MRI report, there was some suggestion of a breach “involving the articular surface of distal tibia”. This could account for residual ankle synovitis, although the MRI report notes no joint effusion.
In my patients with medial malleolar stress fracture that is slow to heal, I use a bone stim and at least a removable walking cast. In the case of an athlete, depending of the films and exam, I would consider allowing the boot to be removed for swimming, stationary cycling at low resistance (L1-2 watts), but no running other than pool running with a floatation vest. Furthermore, if the patient’s bony tenderness was resolving and ankle joint tenderness remained, then I would perform a diagnostic local anesthetic injection into the ankle joint to see if the pain source was intra-articular (the pain from the stress fracture itself should not resolve, while the pain from ankle joint synovitis or other intra-articular derangements should). Upon ultimate resolution of symptoms, some consideration should be given to appropriate footwear, orthoses, and avoidance of training errors as the athlete is reintroduced to their sport.
Calcium supplementation will not accelerate the healing of the stress fracture.
YMMV
Sounds like your doc is on point. My discourse above is not made to cast doubts, but merely made to provide you with topics of discussion with your doc.
One more question for you all. In regards to the potential occult fissure, further detail in the MRI report states the following.
… “Alternatively, while there there is no discrete cartilage defect, this may reflect the presence of an occult chondral fissure and subsequent subchondral edema and cystic change.”
Since this injury happened after I ran (not hiked) down a mountain, from 13K to 10K elevation and a subsequent 10 mile run, it is very likely that it was an acute injury that also caused damage to my cartilage, as well as my bone.
What is the treatment for a fissure of the cartilage? Does cartilage regenerate? My guess is that it would involve some R&R, but would swimming be OK? I found that I generally did not feel pain with swimming, however if I did kicking sets I would start to feel a little pain.
There is no confirmation, based on the MRI, that you, in fact, have cartilage pathology. One way of helping sort things out, as I mentioned before, would be an intra-articular injection (into the ankle joint) of local anesthetic. If it does not resolve your symptoms for the duration of the local anesthetic effect, then it is unlikely that you have a problem within the joint. Depending on the location of the injury on MRI, arthroscopy is another way of investigating the joint (some locations in the joint may be harder to inspect vs other locations). However, I personally would not recommend the arthroscopy without first performing the local anesthetic test.
Cartilage does not typically regenerate or heal on it’s own accord. Furthermore, it has no nerve endings. The pain felt from cartilage injury is typically due to injury of the underlying bone (which is innervated), or from the resultant synovitis that can follow a cartilage injury (the subsynovial tissues are innervated).
Treatment of cartilage injuries is an advancing area. The range of treatments is growing, and the application of the various treatments is somewhat dependent on the location and size/extent of injury, among other parameters. It is best to discuss these kind of options with your treating doc, since the doc has the benefit of knowing your exam and MRI details.
WRT exercising, I would direct you back to point 4 in my post above. Remember, until you’ve had an intra-articular local anesthetic test, you have to respect the possibility that the pain is associated with a stress fracture.
I don’t practice internet medicine, but it is always worth seeking another opinion, especially in a case as long and protracted as yours. Have you seen a sports doc?