Right Ankle Sprain

[dibblego]

Hello everyone. I am hoping to attract some advice regarding an ongoing condition I have since spraining my right ankle on July 21 2007. Although this has been going for a long time, my situation is now becoming more urgent and fast, hence this post. I have sprained this ankle 5 times and this last time was the most severe - the pain was much more intense and more widespread.

I saw Physiotherapists after the injury and have never been able to get any Dorsiflexion - achieving "0cm" when holding my big toe perpendicular to a vertical wall and bending my knee by keeping my foot flat. Around January 2008 the GP gave me a cortico-steroid injection. There was a very minor improvement (so minor that I may have been wishfully thinking and not noticing) but whatever improvement there was, disappeared a few weeks later.

I saw an orthopaedic surgeon who performed a Brostroem Repair and medial ligament repair on September 15 2008. My surgeon has stressed the importance of intense Physiotherapy and I have done everything I can to help this case. I see a Physio three times a week and after a visit to the surgeon on Friday 14 November, who advised even more aggressive Physio, I had an appointment on the next day where the Physio was indeed quite aggressive.

My situation is rapidly deteriorating and I can now barely walk. Not in a "oh this is just muscular pain" way, but I feel like my ankle is about to collapse. I am convinced I have a broken bone in my ankle that has gone undiagnosed. I am worried about my Physio visit tomorrow (Monday November 17) because of any further damage I am almost certainly doing.

I have googled about and Transchondral Talar Dome Fracture seems to ring some bells for me, but I honestly have no idea what I am doing. I also have an MRI tomorrow (Monday) where I am really hoping that whatever is going on is indicated, but what if it isn't? I seriously cannot walk. Two years ago, I was playing A-grade level squash and I consider myself to have a high pain threshold.

I now walk on my toes because it seems to put less stress on "the part orf my ankle that is about to collapse". I have less Dorsiflexion than I have ever had since the injury. My foot is swollen (not from the surgery - but because it always has been swollen ever since the injury).

My work is in research in computer science and mathematics. I am a university lecturer (who is having a hard time standing up on one leg for 2 hours).

I am sure my plea is a quite tasteless in its desperation, but I must admit my tendency for immediate advice and thoroughly appreciate any that can be provided.

Tony Morris.

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[thomas bibu]

dear tony,

at the outset let me reiterate that you have all rights to voice your tribulations whether in desperation or in ecstasy.

well, from your post I understand that you are going in for an MRI, hence let us wait for the results. kindly post the results, I am sure we (physio forum) will be able to help you out.

regards,

thomas

[dibblego]

Thanks Thomas for the heads-up. I strongly suspect medial malleolus fracture and possible lateral malleolus fracture. I decided this after I allowed a friend to prod around in my ankle. Very specific spots on my ankle are extremely sensitive and painful - they are less than a fingerprint in size. The medial side is extremely painful when pressure is applied to a specific spot forcing me to flinch.

However, the MRI does not indicate - I hope the surgeon finds something, because this pain is getting worse.

Here is the radiology report transcribed verbatim:

Clinical Details: Ongoing pain 3 months post-surgery. ? cause

Technique: Sagittal T1 sequence with STIR sequence, axial proton density and STIR sequence.

Oblique coronal proton density sequence.

Findings:
Metallic artefact is noted associated with the medial malleolus as well as the lateral malleolus.

The adjacent deltoid ligament appears slightly thickened and increased in signal. It appears to be intact.

Hyaline cartilage of the talar dome appears normal.

The anterior talofibular ligament is thickened and ill-defined. The calcaneofibular ligament is also thickened. The posterior talofibular ligament appears intact. The syndesmosis appears intact.

The tendons of the ankle appear intact including the peroneal tendons and both the medial anterior tendons. No significant joint effusion is seen. The subtalar joint appears normal. The sinus tarsi appears normal.

There is a separate bone fragment associated with the tip of the lateral malleolus visible on the sagittal PD sequence.

Impression:
Post-surgical ankle. There is thickening and increased signal involving what appears to be intact deltoid ligament. No other significant abnormality demonstrated.

Please, any clues? I'm sure it's getting worse the more I weight-bear (I've cancelled Physiotherapy for now).

[thomas bibu]

hi tony,

I am not very happy with the first sentence, outlined under findings;
metallic artefact is noted associated with the medial malleolus as well as the lateral malleolus.

although artefacts cannot be considered as a biological effect of the MR process, I should admit misinterpretation can yield devastating consequences. a metallic artifact can show up depending upon the size of the metallic implant, type of metal, the pulse sequence and the imaging parameters used.

in some cases even though there is no metal within the patient it can show up, this could indicate the presence of blood products most commonly a hemorrhagic lesion. The ferromagnetic properties of iron in the blood may create fluctuations in local magnetic field.

well, I am concerned as your pain presentation is "inappropriate", sorry to say so. for a person with otherwise normal post-surgical ankle the pain presentation is not as bad as yours (as per your post). so kindly get a specialist second opinion to rule out - presence of any metallic fragments in situ (? sequlae of surgical procedure) and or whether the separate bony fragment (outlined further down - report) is interfering while weight bearing etc.....

all the best and keep us (physio forum) posted.

cheers,

thomas

[linbin]

hi
i feel he might have had ligamentous injuries in the past-which is showing thickening.
i agree with the above post regardingmetal artefact

[dibblego]

I recently had a cortico-steroid injection which decreased swelling but did not improve range of motion or pain.

After spending months walking on my toes and persevering associated muscle atrophy, I believe I have it figured out. I hope to run my strong suspicion passed you guys.

I suspect a meniscoid lesion in the anterior/anteromedial area of the joint. This is causing pain, swelling and restricted ROM. My biggest question is, I wonder if it is possible to miss such a lesion on MR radiography?

[Canuck Physio]

I recently had a cortico-steroid injection which decreased swelling but did not improve range of motion or pain.

After spending months walking on my toes and persevering associated muscle atrophy, I believe I have it figured out. I hope to run my strong suspicion passed you guys.

I suspect a meniscoid lesion in the anterior/anteromedial area of the joint. This is causing pain, swelling and restricted ROM. My biggest question is, I wonder if it is possible to miss such a lesion on MR radiography?

Hello,

if this is the case, then it would be necessary to complete surgery. However, it would be difficult to make a diagnosis over the web with minimal results. Has someone actually palpated and confirmed this.

Probably best to see a specialist and mention this to them.

[dibblego]

Thanks. I am seeing another surgeon on Thursday 11 December. I just hope this nightmare is over soon. Thanks for the help from everyone and I'll post an update if one becomes available.

[dibblego]

An anteromedial lesion was found on arthroscopy. It was "the size of a finger" according to the surgeon. I still have the original (prior to any surgery) minor complaint of anterolateral impingement. I'm hoping this can be assisted by ultrasound-guided steroid injection and will pursue this course of treatment.

I have lost complete trust of the medical establishment and plan to self-diagnose conditions in the future, since while I am utterly incompetent, I have a higher strike rate (1/1) than doctors (1/5).

Thanks for the advice from you guys and I'll post any updates.

[rugby18]

I recently fractured my fibula and ruptured the AFTL and the syndesmosis. I went to hospital on the day that i was injured (15th of November) and was told to return on the 17th, on that day i was diagnosed with a weber c3 ankle fracture had surgery to fix a syndesmosis screw through the tibia and fibula and a plate fixed onto the break. After the ORIF surgery i was put into a back slab cast on the 17th untill the 1st of December.. I have since been since been in a non weight bearing cast. I was firstly wondering what the long term ramifications would be if any and also how soon would i be fit to play rugby(the doctors seem to stray away from answering this question when asked). Also would a patient normally be put into another cast after having the non weight bearing cast removed or would they be given some sort of support brace. Finally how long is a patient typically on crutches for after sustaining a pretty severe ligament damage injury such as mine. thanks very much.