Prognosis - Right Ankle?

[dibblego]

Hello everyone,
I have quite a detailed and somewhat remarkable story, so I apologise for the verbosity.

I suffered an inversion sprain of the right ankle on 29 July 2007. I was kicking a football when I came down incorrectly. I was a very committed squash player at the time of the injury and I continued playing a few weeks after my injury right up to May 2008. This seems to have been a big mistake. I first approached doctors around December 2007 after the pain (which I found difficult to localise, but pointed to the medial area as the most prominent) refused to go away and was given a cortico-steroid injection. This gave a very minor improvement for a few days before returning to its previous state of pain and dysfunction.

I was never diagnosed as to the grade of the sprain, however, I have sprained my right ankle 5 times (4 previous to 29 July 2007) and my left ankle 4 times. I can say that without a doubt the pain on this last occasion was significantly higher than the other 8 times. To give a measurement, I think it was slightly more painful than having a ruptured appendix (if you've had that before, you'll know it is painful).

This short story may or may not be relevant, but during the few months after the injury, I became very sick as I pushed myself to quite silly limits. Eventually I landed in the emergency department after losing my vision (I had extremely tight muscles) and drifting in and out of consciousness. I was never treated for that, except for painkillers, but a comment en passant about magnesium supplements by a friend saw my symptoms - that I'd had for many weeks - alleviated quite a lot and within a few days (but never fully fixed to this day). I told this little part of the story because my intuition is that it had something to do with my ankle injury (Mg deficiency means?).

My continual complaining over the weeks and months to doctors about my ankle eventually saw me at an orthopaedic specialist who determined that I need a Brostroem Repair and a medial ligament repair. This occurred on 15 September 2008. After I started FWB a few weeks later I had incredible pain that had been exaggerated by the surgery. I could not localise the pain at all and my entire foot was on fire. I complained to the surgeon to this extent who ordered another MRI but could find no abnormality.

I approached another surgeon in Sydney (I live 1000km north of Sydney) who determined that an arthroscopic debridement of tissue in the medial, anterior and lateral area would help. It did - my foot is no longer on fire, but I am back to the point where I was before the September surgery (kind of).

This is where it gets interesting. In fact, my tissue impingement is better than it was before the September surgery, but my painful limp and "bent leg" is much worse since the September surgery. It is now very exaggerated.

Importantly, I have recently been able to localise an intense pain to a very precise point through my skin. This point is about 80mm proximal to my lateral malleolus. I recognise this pain very clearly as "bone pain" rather than tissue pain. Applying pressure to it gives me that sickening feeling and a slight sweat (if you've had bone pain, you'll know what I mean). The pain continues down from this point tapering off slowly until I get to the lateral malleolus where I have a dull pain. Moving up toward the knee, the pain tapers off quite quickly where I feel no pain at all after about 50mm.

After much reading and prodding my leg, I believe I fractured my fibula on 29 July 2007 and that this fact is the cause of my ongoing problems. That is, poor healing as expected given that I continued to train on the injury for months after. I also think the fracture is toward the front and behind (based solely on the pain) of the bone. I am going to see the Sydney surgeon on Thursday, but I am quite worried. Let us accept that my prediction is right (and that it can be indicated on an MRI) - what are my chances of a full recovery, with corrective surgery (I expect is the treatment?) 17 months later? Will I ever walk properly again? What are my chances? I was once a professional athlete (it's depressing).

I have some interesting links on this matter below for anyone interested. I have no idea how to read an MRI, but there appears to be some white discolouration on an image taken on 29 January 2008 (6 months after the injury) in the area that I feel pain. Maybe it's just normal - I don't know.

I should point out that I am not a medical professional and that my knowledge of the ankle anatomy and conditions of the ankle comes only from reading a lot of material over the months and medical journals (my partner is a midwife in a large hospital so I can get access). Thanks for any advice.

In this image, the black dot is the centre of my bone pain. The MRI is part of a set of images taken 29 January 2008.
http://public.tmorris.net/image/ankl...omparison1.png

Here are all the images taken 29 January 2008 in DICOM and PNG format. I have an MRI taken in October 2008 but not in electronic form.
Index of /image/MRI-20080129/DICOM/ST000000

Here is a measurement taken of one of the images using the DICOM software.
http://public.tmorris.net/image/ankle/wtf/measured2.png

Again, any advice is appreciated. Thanks.

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[physiobob]

Here's a bit more info on that proceedure. In general a bone scan would be the best first investigation to look for any "hot" spots. This will rule out any stress fracture or confirm the value of further investigation.

You also have a nerve exit point, for memory of the superficial peroneal nerve about where you dot is. This is a common site of pain post ankle injury and one which if treated locally to that point with things like soft tissue massage release techniques and neural mobilization works rather well.

Please let us know how you get on.

BROSTROM/Brostroem/Brostrom-Gould repair

Recurrent sprains tend to stretch out or tear the lateral ligaments (on the outside of the ankle) resulting in further ankle instability. Pain is another symptom, especially when squatting is attempted. Ankle sprains can be stabilised by strengthening the peronei muscles and propioceptive training. If surgery is needed, the Brostrom-Gould repair plicates the torn ligament and uses a periosteal flap to further strengthen the repair. Athletes do return to sports after such procedures without loss of motion.

There is more information on this and modified proceedures here:

Modified Brostrom Procedure - Wheeless' Textbook of Orthopaedics

BROSTROM REPAIR: REHABILITATION PROTOCOL

FOR CHRONIC ANKLE INSTABILITY

General Considerations:

• Time frames mentioned in this article should be considered approximate with actual progression based upon clinical presentation. Careful observation and ongoing assessments will dictate progress. - No passive inversion or forceful eversion for 6 weeks.
• Avoid plantar flexion greater than resting position for 4 weeks.
• Carefully monitor the incisions and surrounding structures for mobility and signs of scar tissue formation. Regular soft tissue treatments (i.e. scar mobilization) to decrease fibrosis.
• No running, jumping, or ballistic activities for 3 months.
• Aerobic and general conditioning throughout rehabilitation process.
• M.D. appointments at day 1, day 8-10, 1 month, 2 months, 4 months, 6 months, and 1 year post-operatively.

0 – 3 Weeks:

• 90° immobilizer for 3 weeks. - Nonweightbearing for 3 weeks--no push off or
toe-touch walking.
• Progress from posterior splint to pneumatic walker once most of swelling is gone.
• Pain and edema control / modalities as needed (i.e. cryotherapy, electrical stim, soft tissue treatments).
• Toe curls, toe spreads / extension, gentle foot movements in boot, hip and knee strengthening exercises.
• Well-leg cycling (bilateral once in walker with light resistance), weight training, and swimming in posterior splint after 10-12 days post-op.

3 – 6 Weeks:

• Progress to full weight bearing in walking boot. Walking boot weight bearing for 3-6 weeks post-op. Aircast splint for day-to-day activities for 6-12 weeks post-op. - Immobilizer for sleeping for 4weeks, then Aircast splint for 4-6 weeks.
• Isometrics in multiple planes and progress to active exercises in protected ranges.
• Proprioception exercises, intrinsic muscle strengthening, manual resisted exercises.
• Soft tissue treatments daily and regular mobilization of intermetatarsal and midtarsal joints. Cautious with talocrural and subtalar mobilization.
• Cycling, aerobic machines in splint as tolerated, and pool workouts in splint.

6 – 12 Weeks:

• Gradually increase intensity of exercises focusing on closed-chain and balance / proprioception. - Passive and active range of motion exercises into inversion and eversion cautiously.

3 – 6 Months:

• Progress back into athletics based upon functional status. - Wear a lace-up ankle support for athletics.

[dibblego]

Thanks physiobob for the reply.

I should point out that currently, I can barely walk, so I am not following the rehabilitation for a Broestrom Repair. It is not so much pain (though it is incredibly painful) but a mechanical limitation - I simply have no dorsiflexion at all and if I tried, it just won't happen no matter what I do.

[physiobob]

Best get a good set of physio hands on you to see why there's a mechanical block. If in Sydney for a weekend I'd suggest the gang as the NSW Academy of Sport in Narrabean. But for someone 1000km North you must be close to the border? There's some good physio's in Byron and the surrounding area.

[dibblego]

Just an update.

I saw an orthopaedic surgeon today who has ordered an MRI of the very specific areas of intense pain along my fibula (there are two very specific spots - about 25mm apart). I will do this on Tuesday 13 January. I have had friends and family confirm that there is certainly an abnormality along the bone as if someone has broken a rod in half then glued it but the surfaces didn't mate correctly. This can be felt at the two spots along my fibula (about 80mm and 105mm above the tip of lateral malleolus).

While I am on the verge of a diagnosis (529 days after the injury!), the condition is now so bad that I cannot walk without a brace (orthodic boot) and even then it is painful. This means I only do essential weight-bearing such as going to see a doctor. i.e. I am in jail for good now.

Thanks for the advice from this forum so far.

[Quickstart]

Just interested in asking a few questions, dibblego.

Have you had any changes to the skin around the foot or lower leg. Skin look glossy? Any hair growing around that area? Boiling hot or freezing cold at times? Skin super sensitive to the touch? Often red or purple? I tried to view on the photos but you didn't compare to the other side and the resolution quality isn't great.

Keen to hear back from you.

[dibblego]

Hello QuickStart,
"Have you had any changes to the skin around the foot or lower leg."

There is some very mild swelling. I think this swelling has always been there - just that the tissue debridement on 11 December 2008 has made the surrounding swelling subside a little.

"Skin look glossy?"

Maybe just a little around the area of pain, but then maybe I am biasing. If it is, it is barely noticeable.

"Any hair growing around that area?"

No more than everywhere else on my leg.

"Boiling hot or freezing cold at times?"

My leg feels cold at all times ever since recovering from the injury in 2007. I have also lost an enormous amount of muscle on the right side of my body - right up to my shoulders.

"Skin super sensitive to the touch?"

If you touch the area of pain, then I will make a noise - the pain is that gut wrenching type. Otherwise, no other sensitivity.

"Often red or purple?"

No.

Sorry about the photo. I might try to take another one.

What might be interesting to note is that I am finding it increasingly difficult to breath - I suspect due to the muscle atrophy. Twice now my breathing has been so difficult that I started to panic.

[dibblego]

I am booked for an MRI of my broken fibula on Tuesday 13 January and I have long maintained to doctors that whatever-it-is, it is deteriorating. I have only recently discovered I have a broken fibula since a tissue debridement on December 11 alleviated a lot of my general pain and swelling - I can feel it through the skin - it is most obvious.

However, my leg is cold and I keep getting sweaty flushes. I am worried about the potential for further complications - my body feels like it is in crisis.

Should I be worried?

[dibblego]

How is a malunioned fibula diagnosed 18 months after the injury?

[physiobob]

Basically look at the x-ray and see that the two ends where the fracture occurred do not meet. i.e. Are not joined back together

[dibblego]

Like this?
http://public.tmorris.net/image/ankl...4/MR000009.png

or this?
http://public.tmorris.net/image/ankl...4/MR000010.png

[physiobob]

Yep, but those are only two slices of an MRI. we would need to look at each slice so we can see the fibula. In the screen images you have referenced we can only see the distal end of the fibula which looks fine. Lateral ligament structures also look intact

p.s. I worked out if you change the ending on your links you can in fact see other slices but it is unclear to me actually the history and area of your problem. Your legs do seem somewhat large in both calves. Do you have any other physical issues/abnormalities. I think you had best give us a summary of your health and issues if you wish to have further informed comments.

[dibblego]

Hello, thank you for the response. How likely is it that I am looking at a broken bone in that picture? I really wish I could read an MRI. Also, in this image, am I looking at a fracture in the tibia or fibula (or a fracture at all)? It looks to me to be in the position of the tibia but I cannot expect a clean break in my tibia like that according to my intuition and feeling (I have pain along my tibia but I cannot feel a clean break).

Here is a history:

29/07/2007 Inversion Sprain while kicking a football - landed incorrectly. Hospital emergency department performs an XRay and finds no break.

01/01/2008 Complain to doctor about ongoing pain in right ankle and lack of ROM (dorsiflexion specifically).

29/01/2008 MRI reveals no abnormality.

11/05/2008 Muscle atrophy and deformity cause me to discontinue playing sport - specifically squash (I was training 1-2 hours per day up until now)

15/09/2008 Broestrom Repair + medial ligament repair performed under GA

15/10/2008 Ouch! There is now significantly higher pain and less ROM.

20/10/2008 MRI reveals no abnormality. However, the images do not go very high above the malleolus.

01/12/2008 Anaesthetic + Cortico-steroid injection with ultrasonic guidance. Pain eases temporarily.

11/12/2008 Arthroscopic Debridement of joint performed under GA. Large lesion removed.

29/12/2008 I can now notice very localised pain from fibula and tibia. Holy crap I can move my fibula! Image of fibula and tibia.

13/01/2009 MRI performed.

Today I cannot walk without a splint. My ankle is totally "the wrong shape" - even if I do walk only a small part of the underside can contact the ground. I often walk on my toes in my right leg. I can move my fibula at the at the top dot in this picture. The bottom dot also has irregularity and pain.

[physiobob]

Firstly you can attach the images and they will be viewable in the post. This is more efficient as they will be reduced to load faster.

Secondly, your MRI does show the full fibula if you change the sequential numbers at the end of the image reference in your first post. It does not show any major non-union to the right fibula although there is some trauma to the lateral ligament complex so it's nice to have seen that and have it comfirmed with your latest posting.

I believe the Surgery you have had uses the peroneus tendon (peroneus brevis - see attached image) to harvest a graft. From what I have seen and what you're describing your pain is probably related to the tendon graft healing and you need to give it more time.

Here's some bunf on the Modified Brostrom Proceedure.

- Surgical Technique:
- curvilinear incision is made over distal anterior border of lateral malleolus;
- if peroneal tendon exploration is necessary, then consider a posterolateral longitudinal incision;
- beware of peroneal tendons inferiorly, sural nerve (which lies over the peroneal tendons), lesser saphenous vein
(which can be ligated), and branches of the superficial peroneal nerve (intermediate dorsal cutaneous nerve);
- after dissection procedes thru subQ tissue, identify and preserve the inferior extensor retinaculum, which runs parallel to the CFL;
- this is mobilized for later attachment to the anterior edge of the fibula;
- identify the ATFL, which appears as a thickening in the anterior joint capsule;
- if it is torn, it is usually torn from the fibula;
- make anterior capsular incision along anterior margin of fibula down to its, distal tip, leaving a small cuff of tissue
attached to the fibula (to facilitate later repair);
- identify the CFL at the inferior tip of the fibula;
- ankle is then placed in valgus and dorsiflexion, and the redundency of the ligament is assessed;
- sutures are passed thru the proximal edges of the ATFL and CFL;
- drill holes are made in the distal fibula;
- sutures are passed thru the drill holes, and are tied;
- the posterior edge of the extensor retinaculum is then opposed to the anterior edge of the fibula;
- this advancement of the retinaculum will help re-enforce the repair, limites the inversion, and addresses associated subtal instability;
- modified procedure using peroneus brevis:
- procedure results in significant loss of eversion and inversion;
- tendon harvest:
- procedure involves exposure of the peroneus brevis, while maintaining the integrity of the superior peroneal retinaculum;
- anterior third of the tendon is isolated distally and split from the distal position to the musculoskeletal junction;
- this tendon portion is transected at its proximal aspect;
- tendon anchorage:
- a drill hole is made through the distal fibula, and the split portion of the peroneus brevis is passed thru this hole;
- tendon is tensioned with the foot in mild plantar flexion and eversion;
- post op care:
- standard involves 6 weeks of casting, but there is some evidence that there are better functional results with
3 weeks of casting;

[dibblego]

I can definitely move my fibula. I accidentally moved it into a position that was continuous the night before the MRI. I spent all morning before the MRI to try to get it back to its usual position where the discontinuity is more obvious when feeling through the skin. I am convinced that this is a bone fracture and that images have been missing it for the last 535 days.

The only part I am not convinced of is whether or not my tibia is also fractured since there is clearly a discontinuity is one of those images, but is this my tibia? I certainly have pain along my tibia in that area.

My condition has been significantly worsening since the Broestrom Repair 4 months ago. My ankle is deformed and I can barely walk. This is not a soft tissue problem.

[physiobob]

Suggest you discuss this further with your orthopaedic surgeon

[dibblego]

I just found this story which sounds remarkably like mine.

[physiobob]

First rule as a patient. NEVER diagnose yourself based on someone else's problem. Secondly you have your MRI. If the report says there is NO fracture then basically there is NO fracture. Please go back and consult your orthopod (or a second opinion). The appearance of your ankle is nothing like CPRS so forget about that one. We cannot provide any more advice without a physical examination. Sorry but that's the limitation of internet based forums at this time

[dibblego]

Please be assured that I am not diagnosing myself - merely observing some similarities (I have also seen many dissimilarities). Nevertheless, I still sit here, 535 days after the injury, without a diagnosis and finding it difficult to walk after seeing:

2 Orthopaedic Surgeons
2 Physiotherapists
2 GPs
1 Sports Physician
1 Podiatrist
1 Occupational Therapist

I am going to write a document detailing full history, symptoms, images, etc. Hopefully then I can present a fuller picture.

Thanks for your help so far - I expect to hear from the Orthopaedic Surgeon tomorrow when he receives the films from the latest MRI.

[dibblego]

The surgeon says "Nothing indicated on MRI. Bye." What now? I'm trapped in my house for the remaining years of my life? I had no idea I would get to 18 months without a diagnosis - please excuse my frustration but this is ridiculous. Help?

Given that many doctors have said "no sign of fracture" according to all images, despite my insistence that "the pain is coming from the bone", then is it possible that I have had a syndesmotic injury with diastasis that has been missed? Especially since it was 6 months after the injury before I even approached doctors (I used to be invincible!). I have no idea what this might feel like or what symptoms I should have, but I can pin-point my pain and you can see that my foot is the wrong shape - I walk with it pointed outward and have no dorsiflexion (if I attempt it I get pain then a physical limitation - like a bone hitting a bone).

I still plan to document a full history of this condition properly so as to pursue a diagnosis and possible treatment.

[physiobob]

If ortho is done with you, then they are done with you. You now need to see a neurologist to look at the nerve potentials in the leg (EMG) to see if that could be an issue. I would also try to get a bone scan. Nothing more we can do until you get the results of those investigations. I think you best take an approach of ruling out things one by one.

[dibblego]

I had a bone scan on 06 January and although the picture has a lot of emphasis around the area of my ankle joint, the radiographer report reads nothing remarkable and nobody else who has seen it seems too concerned. The report is below.

I'd love to rule things out one by one, but I've no idea where to start. Can you provide any tips besides nerves (which I will do although I am a little sceptical)?

One other thing; is there such a condition where the ligaments are damaged so that upon dorsiflexion, the talus cannot move backwards since it is hitting the tibia and/or fibula? If so, what is it called and how is it diagnosed (I have determined that in general, doctors are significantly more prone to confirmation bias than I am)? Is it known to drive people crazy so that they post all over internet message boards because NWB images have failed to show up a diagnosis? Just an intuitive thought.

I really need a diagnosis but I'm struggling to determine what to do next. All I can do is try to provide a full picture of my history and provide a comprehensive explanation of my symptoms but this has so far proved fruitless. Help!

BONE SCAN

HISTORY
Acute localised pain lower third fibula

TECHNIQUE
Three phase 99m Tc - HDP bone scan of both ankles and feet including
delayed images of both knees. Correlation is made with prior MRI right
ankle of 17/11/2008. 15/09/2008 - Broestrom Repair and medial ligament
repair.

REPORT
The early images show moderate increased vascularity in the right
ankle medially and laterally, especially medially.In the delayed
images, there is moderate to intense uptake adjacent right ankle,
especially in the right medial malleolus and distal tibia anteriorly.
There is mild to moderate uptake in the right subtalar joint.

There is mild periarticular uptake in the small joints of both feet
including the first MTP joint in keeping with mild degenerative
change. No intense focal increased vascularity is identified in the
distal third of the right fibula.

OPINION
1. Moderate to intense bone reaction adjacent right ankle, especially
medial malleolus and distal tibia anteriorly with increased
vascularity. This is presumed to be due to recent post surgical change
and there is history of corticosteroid injection. On its own, this can
be seen with synovitis. More intensse bone reaction in right medial
malleolus is presumably related to medial ligament repair.
2. No intense bone reaction identified in distal third of either
fibula to account for patient's presentation.

[physiobob]

An anterior impingement will prevent or cause pain on dorsiflexion. This is rather common though not often diagnosed as such. Suggest going to see a foot specialist who work with the ballet and athletic population. I would not be skeptical about EMG tests as your muscles don't appear to be behaving normally.

[dibblego]

Thanks for your patience.
By foot specialist, do you mean an orthopaedic surgeon specialising in lower limb or something else? Excuse my ignorance.

[dibblego]

Update.

Sorry but I take it all back. There is without a doubt a bone irregularity/discontinuity in both my tibia and fibula that is incredibly, immediately and unwaveringly obvious. It feels like a previous fracture though I am not qualified to say. I have had two registered nurses (one also a practising midwife) confirm this observation with absolute confidence. It can be felt through the skin and I am no longer open to any other suggestion besides a bone problem. I suspect that this also explains my bone impingement upon dorsiflexion since the joint is out of shape.

Question: why can I only sometimes feel this? It seems as if there is a tissue/fluid build up and if I spend the effort pushing it all away I can finally find it and then others can come along and easily confirm it. An hour later it is all gone and it is then difficult to locate (making me look silly when I say it is obvious). Does fluid build up in these areas or something? I really need a doctor's confirmation so that I can put an end to this perpetual hell. I'm afraid that my next doctor visit will be another unsuccessful attempt to locate this obvious problem that has gone undetected by 3 MRIs.

Sorry about the emotionalism. Why am I apologising to a text box? Send