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Painful ankle

Discussion in 'Biomechanics, Sports and Foot orthoses' started by gangrene1, Jun 12, 2008.

  1. gangrene1

    gangrene1 Active Member


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    Of recent, a male in his 50s attended the clinic with a complain of right lateral ankle pain without any trauma indicated

    Occupation: maintainence officer

    Medical Hx: Hypertension, hyperlipidemia, gout
    Pain mainly below the distal tip of R lateral malleolus upon palpation or when the foot is in plantarflexion on non -WB and WB only.Pain tends to increase with prolonged walking.

    Other findings: Unable to tip toe, full ROM of ankle joint, -ve anterior drawer's test, nil pain noted on peroneal tendons upon palpation, nil ligamentous laxity, ankle equinus. No tenderness along the peroneals.

    Seen an Orthopaedic Dr in April 07-diagnosed at Peroneal tendinopathy as confirmed with ultrasound report.

    Seen another Ortho Dr in May 07- diagnosed as recalcitrant of right P. longus tendinitis. Had an xray of R tib-fib done which it was reported as : No # or dislocation seen. Normal joint space and articular surfaces. No bone abnormalilty is demostrated.

    March 08: Had physiotherapy /NSAIDS/customised foot orthoses with- no improvement at all.

    *note: Xray of the right ankle (in "plantarflexion" view) as attached was ordered by the ortho doc in April 07.

    Could the patient be suffering from sinus tarsi syndrome instead?:sinking:
     

    Attached Files:

  2. drsarbes

    drsarbes Well-Known Member

    Hi Gangrene

    I read your post; one question.....when you state he is unable to tip toe, is that because of pain or muscle weakness or instability?

    I can't see the ankle joint on the lateral and the AP is somewhat rotated so I can't really make out the lateral gutter area. What I can see looks normal.

    Peroneal patholgy is normally fairly easy to Dx, especially if you have a linear tear. Given the fact that he has had two ortho exams and this was not mentioned I'll assume he does not have this. You mentioned Gout in his history but no mention of acute inflammatory findings. No history of repetative stress. Was it acute onset or insidious?

    Pain at the tip of the lat malleolus might be an impingement syndrome (where the distal fib abuts the lat surface of the os calcis or other soft tissue in the lateral gutter).

    Sinus Tarsi syndrome, as you probably know, normally starts with a Hx of truama (ankle sprain, etc....) and has increased pain on palpation of the opening laterally. I find this is confused frequently with common ankle synovitis in the lateral shoulder area (they are pretty close together).

    In order to Dx a Sinus Tarsi I usually inject 1/2 cc dexamethasone with 1/2 cc .5% marcaine into the sinus. If you haven't done this before it take a little practice to get the needle (1 1/4 inch) on the correct plane and into the sinus. If the pain is Sinus Tarsi in origin you will get at least 24 hours of relief (from the Marcaine)

    Otherwise, I doubt cal-fib ligament is a concern if he has no other symptoms (these RARELY are isolated injuries)


    Hope this helps

    Steve
     
  3. gangrene1

    gangrene1 Active Member

    Hi Steve,

    In regards to your question, the patient is not able to tiptoe due to pain from the ankle. The orthopaedic doc written 'gout' as part of his medical history. There wasn't any blood test results or medications for gout indicated after checking through the patient's notes.
    Will try and follow up with the ortho doc on that.

    Cheerios.
     
  4. drsarbes

    drsarbes Well-Known Member

    Hi Gangrene!
    Where exactly is the pain when your patient attempts to "tip toe"?
    Steve
     
  5. gangrene1

    gangrene1 Active Member

    Hi Steve,

    the pain is still at the distal tip of R lateral malleolus radiating to the sinus tarsi region as well.

    Cheerios,
     
  6. drsarbes

    drsarbes Well-Known Member

    "the pain is still at the distal tip of R lateral malleolus radiating to the sinus tarsi region as well"

    Hmmmmmmmmm........

    Sounds like the ant talofib ligament to me, with perhaps some residual inflammation within the sinus tarsi. If you are unsure whether it's JUST the sinus tarsi, as I mentioned, you can inject the sinus, however, there is no guarantee that this will not also effect the ant talofib area.

    Diagnostically you can inject 5-7 cc .5% marcaine intraarticular into the ankle joint. If the symptoms are originating from within the ankle this will give fairly good relief for at lease 20 hours. If it has no effect you can can conclude that the pain is extraarticlular and go from there.

    MRI or ULTRASOUND would also help in the diagnosis.

    Steve
     
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