ankle (tendon?) problems

[Hinker]

Hi all,

I'm an avid hiker and have managed to do something unpleasant to my ankle. I understand that generally the best course of action is to go see a doctor. So far, I have been to my naturopath, my family doctor, and a sports medicine physician. My naturopath seems to think I have peroneal tendinitis, the family doc thinks I have achilles tendinitis, and the sports medicine physician was utterly unhelpful.

Here's what occurred: I was on a hike two months ago where I was sidehilling (e.g., walking across an incline with the now injured foot uphill the entire time) for several hours when the pain started. It has hurt to various degrees since then. The pain is present around the lateral malleolus, toward my calf muscle (on the outside), as well as just above my heel. Sometimes it is also present below the malleolus and even a little bit on the bottom of my foot. Pain is made worse by immobilization due to taping (especially posterior to the malleolus) - I have tried various taping methods. Pain is also made worse by hiking, particularly up and down inclines.

EDITED TO ADD: I have also gotten a weird bruise where the peroneus longus muscle attaches a little below and to the outside of the knee) and that area is very tender. I know it's not an impact bruise as it has occurred twice now since my ankle injury.

I have greatly reduced my activities, am icing, taking NSAIDs, using epsom salts baths, using a TENS (all these recommended by the various physicians I have seen thus far). I'm frustrated because at this point I don't really understand what's wrong, let alone how to go about recovering as efficiently as possible.

Anyone have any ideas about what might be going on?

I have a PT appointment for next week. Due to my prior fruitless experiences with various doctors and PTs, I am anxious that this appointment will not be as helpful as I am hoping. How should I approach my PT for the best results? I realize my appointment time is pretty limited, so I want to bring the most useful information to the table. What kind of information is the most relevant to share?

Ooops. Long post. Any input y'all might have would be greatly appreciated!

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[gcoe]

Hi Hinker

It sounds like it isn't a straightforward injury and it is a bit confusing with the various professional opinions. It is particularly disappointing that you didn't get a satisfactory response from the sports physician as this should be the most authoritative opinion.

I agree that it sounds like the diagnosis to date is inadequate. A good MSK PT should be able to help you. Just preempt the interview by stating it seems complex, you hve been given differing opinions and that you really are seeking a definitive diagnosis.


Things come to mind are:

Here's what occurred: I was on a hike two months ago where I was sidehilling (e.g., walking across an incline with the now injured foot uphill the entire time) for several hours when the pain started.

The injury maybe more an overuse type injury as there wasn't a sudden incident. This tends to suggest the musculo-tendonous units are the culprit not the ligament or joint. so one of the tendons that cross under the lateral maleolus might be the problem

lateral malleolus, toward my calf muscle (on the outside), as well as just above my heel. Sometimes it is also present below the malleolus and even a little bit on the bottom of my foot

The Peroneus Longus muscle may have been injured. Most likely sight of injury was at the distal tendon. This tendon is one of two that passes under the lateral malleoulus. This could explain all these symptoms. You may have developed trigger points (local sites of pain in the muscle) since then

An alternative structure to consider is if the Tibio-fibular complex is damaged. This complex has two components:

1. the distal tibiofibular ligament which binds the fibula and tibia bones together just above the ankle joint
2. the proximal tibio-fubular joint - this lies just above just below the knee on the lateral side. You can locate the head of the fibular as a bony prominance there and the joint lies deep to that part of the bone

While these two structures are at considerable distance they are biomechanically closely linked and disruption of one affects the other. Again this could explain at least many of your symptoms and can refer symptoms to the muscles that may try to stabilise the joints.

I have also gotten a weird bruise where the peroneus longus muscle attaches a little below and to the outside of the knee) and that area is very tender. I know it's not an impact bruise as it has occurred twice now since my ankle injury.

Tenderness is more likely to be a symptom of pain rather than a bleed as in a real bruise. The fact that it comes and goes is just part of the nature of the problem - some days it is better and some days it is worse. Again I would wonder if this is due to the involvement of peroneus longus and may be it was an overload injury.
Additional Comment I forgot:
Hi Hinker

It sounds like it isn't a straightforward injury and it is a bit confusing with the various professional opinions. It is particularly disappointing that you didn't get a satisfactory response from the sports physician as this should be the most authoritative opinion.

I agree that it sounds like the diagnosis to date is inadequate. A good MSK PT should be able to help you


Things come to mind are:

Here's what occurred: I was on a hike two months ago where I was sidehilling (e.g., walking across an incline with the now injured foot uphill the entire time) for several hours when the pain started.

The injury maybe more an overuse type injury as there wasn't a sudden incident. This tends to suggest the musculo-tendonous units are the culprit not the ligament or joint. so one of the tendons that cross under the lateral maleolus might be the problem

lateral malleolus, toward my calf muscle (on the outside), as well as just above my heel. Sometimes it is also present below the malleolus and even a little bit on the bottom of my foot

The Peroneus Longus muscle may have been injured. Most likely sight of injury was at the distal tendon. This could explain all these symptoms. So the naturopath maybe right about the injured structure, although it may not be a true tendonitis. You may have developed trigger points - local sights of pain in the muscle since then that give you the more widespread symptoms.

An alternative structure to consider is if the Tibio-fibular complex is damaged. This complex has two components:

1. the distal tibiofibular ligament which binds the fibula and tibia bones together just above the ankle joint
2. the proximal tibio-fubular joint - this lies just above just below the knee on the lateral side. You can locate the head of the fibular as a bony prominance there and the joint lies deep to that part of the bone

While these two structures are at considerable distance they are biomechanically closely linked and disruption of one affects the other. Again this could explain at least many of your symptoms and can refer symptoms to the muscles that may try to stabilise the joints.

I have also gotten a weird bruise where the peroneus longus muscle attaches a little below and to the outside of the knee) and that area is very tender. I know it's not an impact bruise as it has occurred twice now since my ankle injury.

Tenderness is more likely to be a symptom of pain rather than a bleed as in a real bruise. The fact that it comes and goes is just part of the nature of the problem - some days it is better and some days it is worse. Again I would wonder if this is due to the involvement of peroneus longus and may be it was an overload injury.

[Hinker]

Hi gcoe,

Thanks so much for your thoughtful reply. I will just have to be very focused on getting some sort of answer from the PT, I guess.

It just seems weird that it hasn't been getting better. I understand that tendon injuries tend to heal fairly slowly, but this seems a tad ridiculous.

I only have one question regarding your post, where you said:

Tenderness is more likely to be a symptom of pain rather than a bleed as in a real bruise. The fact that it comes and goes is just part of the nature of the problem - some days it is better and some days it is worse.

I'm not certain what you are trying to say? Perhaps I am misunderstanding your comments. There was a real bruise. The reason I am sure it wasn't from an impact is that appeared twice in the exact same spot, it didn't look like an impact bruise, and it's in a spot that I would be hard pressed to bruise by hitting/falling on anyway. The tenderness is just something I noticed when I was poking around in the area of the bruising.

Again, thanks so much for your response. I appreciate it.

[gcoe]

Hi Hinker

Glad you found it useful.

RE the bruise - Sorry I may not have understood what you said. Was there a discolouration indicating a real bruise or was it just tender to touch? Maybe it doesn't matter. Anyway you could discuss it with your PT.

Just in terms of times: you are right that tendons can take quite a while to heal so two months down the track is still within healing period. However if it is due to other things such as trigger points - these problems can be self sustaining so worth getting it all checked out.

[Hinker]

There was a real bruise, discoloration and all. I will definitely be mentioning it to my PT. I've just never had anything like that happen before and wasn't sure what could have caused it.

[Hinker]

Well, the PT seems to be of the opinion that it is my peroneus and achilles tendons that are acting up. She gave me some eccentric loading exercises last week for the peroneus which are going well (can't tell whether or not they're helping). This week she added eccentric loading for the achilles and it has resulted in the sorest calves I have ever experienced. Hopefully this is a sign that I just did too much too soon and not a symptom of something more being wrong.

[gcoe]

Hi Hinker

That sounds like a good way to proceed. You physio may well be onto it. The eccentric exercise takes time to improve matters so it will be a while before you will know if it is helping. The loading of the muscle stresses the muscle and tendon in a positive way so that the tendon remodels itself over time - it becomes more healthy and resilient. However tendon doesn't remodel quickly - it is much slower to adapt to the stress than muscle or bone is. So you are looking at several weeks to months. Even when you start feeling better you should keep on the regime as you are likely loose the pain before the tendon is in optimal condition.

Eccentric exercise (lengthening the muscle while you are loading it) produces the most delayed muscle soreness in the muscle of any type of exercise. This soreness is that typical soreness from a vigorous workout but can be quite marked when doing eccentric training. It usually comes on several hours after the exercise - often up to 24 hours. (When it is more sever it comes on earlier). If you made yourself really sore it will take several days to settle down. So don't worry - it is unlikely to be anything serious - probably just got stuck into it rather enthusiastically.

Your muscles should soon get conditioned to it and then you shouldn't get pain even when working them quite hard.

[Hinker]

Thanks, gcoe. I felt a lot better reading your post, and the soreness, as you predicted, has mostly faded. I've never done that to my muscles during any exercise before!

I understand that it'll take quite some time to recover, though I think my PT has unrealistic expectations about my recovery (she seems to think I'll be good to go in a couple of weeks).

I am trying to be patient and not do too much too soon, but I am not used to being so inactive and am looking for ways to exercise while I recover. So I've eliminated the following, either by logical reasoning or trial and error: running, walking more than a mile, swimming (freestyle, at least), stationary bike more than 20 minutes, indoor climbing.

My university gym has a hand bike which I haven't tried yet. I also have access to various swimming pools but not sure what to do that doesn't hurt my ankle. I've gone rowing a couple of times (in a boat, not with the rowing machine, which causes too much ankle motion), which is nicely gratifying but not very aerobic and only an upper body/back exercise.

Any thoughts on what else I can do. I am mainly interested in exercises that: (a) help me keep my hard earned leg muscles (especially the calves, but quads/hamstrings as well) and (b) something sufficient for reasonably aerobic fitness.