Persistent right ankle pain: mine

History

Over the years I have sprained my ankles many times. All requiring significant force.

In 1967 at high school (age 17), I was running downstairs, missed a step, and my full body weight pushed my ankle into severe inversion with immediate severe and mobilising pain, followed by a rapid swelling within an hour. I was taken to the local hospital A & E department, and an X-ray revealed that I had not fractured my ankle. That event terminated my career in the 1st 15 rugby team.

I did recover, and at age 19, while at physiotherapy school, I injured my ankle again. It was at the end of a day in the clinic after the patients had left, and we were doing high kicks to see if we could touch the upper rail holding the curtains in the cubicles with a foot. Of course I overdid it and came down on my ankle with the same ankle sprain result. I recovered well from that too. At age 23 or 24, I was doing a full arm handspring over my home boundary fence which was too low for my height (I was once an average gymnast). I did not get fully vertical before landing, and one foot was forced into severe plantarflexion. Although this was a lateral ankle sprain again, probably affecting the lateral and anterior talofibular ligaments, I had obviously damaged the posterior ankle as well. The ligament sprain settled well, but I was left with persistent posterior ankle pain that was clearly not a heel or TA injury. The most telling “test” was if I was walking downstairs and caught my heel on the edge of a step, I would get a very severe posterior ankle pain that would immobilise me for a minute or two. I had received very high-quality treatment from a colleague, but she had no answer for this posterior pain. On looking up Dr James Cyriax’s textbook, my condition was very similar to what he described as “dancer’s heel”. This is where the posterior talus and calcaneus impinge on the lower end of the posterior tibia, causing a persistent inflammatory periostitis. Ballerinas and other dancers put their whole body weight through the point of their toes, and the heel is tucked into the posterior tibial region. Cyriax’s treatment was a steroid injection done using a peppering technique across the posterior tibia, guided by pain response to needle probing. At about the same time as reading Cyriax’s texts, I was having a conversation with an orthopaedic surgeon who had been trained by Dr Cyriax, and worked well with physiotherapists and musculoskeletal specialists who used Dr Cyriax’s diagnostic and therapeutic methodologies. He agreed with me that although I am not a dancer, and did not have an excessive range of ankle plantarflexion, the injury and consequent posterior ankle pain were likely a residue from a posterior periostitis and posterior capsulitis. He offered to inject the area with local anaesthetic and corticosteroid in the Cyriax fashion. By this time, I had experienced persistent pain after full recovery of the anterior and lateral ankle swelling and pain for over three months with no evidence or suggestion of improvement. The injection was painful as he probed for the tender spots with a needle tip, injecting a mixture of hydrocortisone and lidocaine in little droplets. The whole procedure took perhaps 3 minutes. I got off the bed, and the pain was absent. In fact, the pain never returned until I re-injured my ankle again some five years later.

During the 1970s and 80s, I was working closely with orthopaedic surgeons and GPs with an interest in musculoskeletal medicine and sports injuries. We had found that perhaps 15% of all severe ankle sprains seemed to have some residue of slow-to -settle posterior ankle pain similar to my own experience. As a consequence, I did write an article which was published in the New Zealand Physiotherapy Journal in 1988.

The pdf of this publications mat be downloaded from this website, too.

To this day, the diagnosis and treatment of what we might now call posterior ankle impingement syndrome has not really changed or needed much improvement, just more sophisticated nuance. What we do have is better technology. We now have excellent quality X-rays, CT scans, MRI, and diagnostic ultrasound, which can give us excellent images of the pathology that was only implied and inferred at the time of my first experience of the problem. That paper may be downloaded from this website as an historical record of our understanding of this problem, which I believe was a slight advance on Cyriax’s original descriptions of “dancer’s heel”.

I have sprained my ankle perhaps 8 times in my life. The last serious sprain was in 1998 (age 48) during a ride down the “flying fox” skyline recreational fun ride on Mt. Ngongamata in Rotorua, New Zealand. The maximum weight recommended for this ride was 80 kg. I was about 95 kg and ignored the advice. The reason for the limitation on weight is that the heavier you are, the faster you go. For me, it was very, very fast! There were 7 stages down the mountain, and I managed 3. The owners and operators of the fun ride did not weigh their customers, or teach them how to slow down at the end of each ride section. What I now know is that you have to trust the braking mechanism in the machinery. I instead used my feet to come to a juddering halt before the ride section reached its endpoint. On the 3rd ride, my ankle gave way. Instantaneous severe mobilising pain within seconds, and the ankle turned black and swelled within seconds before my eyes. I was utterly convinced I had broken either the tibia or the fibula. I was stretchered off the mountain and taken to the emergency medicine clinic in Rotorua. My ankle was X-rayed and no fracture was seen. By this time my ankle was enormous, and exquisitely painful. Because there was no fracture, I asked the doctor to aspirate the haemarthrotic joint. He refused. We had an argument. I asked him if he would aspirate the knee of a haemophiliac with a haemarthrosis as consequence of his blood condition. He confirmed that he would. I asked why he wouldn't do that for my ankle, when it is very clear that I have a parallel problem in my ankle. He used the lame excuse that there was a risk of infection. I argued that the same risk exists for the haemophiliac with knee haemarthrosis, and proper sterile technique minimizes the risk significantly. I might add that by this time. I had been working with doctors doing these procedures for over 20 years, and had been doing injections on occasions myself for over 15 years. He would not change his mind. As a consequence, rehabilitation took about three months, although, being an experienced physiotherapist, I was able to progress myself along the way probably more quickly than most.

In 2010 and 11, we had major earthquakes here in Christchurch. About 30,000 residents (about 10%) left the city, some permanently. I live up a right-of-way driveway, and one of my neighbours had left the city out of concern for his safety. One evening I heard some noise in his backyard, so I walked down the right-of-way drive, stood up on the curb and jumped to look over the two metre fence. It appears that the problem was a cat and not a burglar or other criminal. As I came down and landed back on the curbstone, I felt something click in my right ankle. This was completely different from my previous experience of ankle sprains. Although it was painful inside the ankle joint, at no time was there ever any swelling or evidence of a haemarthrosis. From that time, I started experiencing severe twinges of pain in the ankle that were completely uncontrollable and would make my leg give way. These were not random, but related to slight variations of angle in weight bearing in various parts of the normal gait. Any twisting action would cause a nasty twinge of pain and giving way of the leg. This did not seem to get better over many months. This was very disturbing to me because I am a keen freshwater angler. Wading in streams and walking riverbanks has always been a great pleasure for me and my main recreation. I found that I was becoming less and less confident because I could never predict when my ankle would produce a severe twinge of pain, and my leg would give way.

I consulted a good friend and sports medicine physician colleague who arranged an MRI. The MRI from 2011 shows what we suspected right from the beginning, which is a talar dome fracture.

I consulted the local orthopaedic surgeon expert on ankles, and he said that he was able to do a repair of the defect. I asked him what the odds were for a good outcome, in his experience. He said about 50%. I asked him if I did not have the defect surgically repaired, would my ankle necessarily deteriorate into a condition that would require future surgical fusion. He said “not necessarily”, noting that some do rather well with conservative approaches. I opted for the conservative non-surgical course of action. I further chose to push the ankle to the limit. Part of my fishing habit was to walk along shingle beaches to the mouths of some major rivers in the South Island during the salmon-spawning season. We catch salmon and other species of fish as they enter the rivers during the salmon spawning run. These shingle beaches are physically challenging, and walking a kilometre in waders with fishing gear is a good workout even for a younger, fitter person. By this time, I was in my early 60s and still quite fit, so I continued to walk on the shingle beaches, in agony at times, but persisted cause I was either going to get better or I was going to have to give up my fishing. Not a good choice to have to make. Remarkably, over that summer and the next, the pain diminished. Between about 2013 and 2023, I was able to do a lot of fishing with mild pain, but most importantly, I was not fearful for my safety while wading slippery streams and navigating uneven surfaces.

Obviously, as I age, there is a higher risk of osteoarthritis in both of my ankles, given my history of multiple ankle sprains. The depression fracture in the dome of the talus is obviously not helpful. Nonetheless, I have had a good run. The conservative management option seemed to have been a good one. However, over the last two years, the right ankle has become progressively more disabling. I have found that walking even 500 meters along a level stable surface, can be a challenge. I have had to limit my fishing ventures to only very simple and easy fishing locations, and I stopped wading streams unless I am accompanied by much fitter and younger people.

The pain I experience is not really the sharp twinges inside the ankle, although I do get that at times. The most significant pain is felt somewhat deep and posteriorly, especially on the push-off phase in walking. At times, I have had pain in the instep, which I suspect is the old talar dome fracture playing up. The length of my stride is dramatically reduced, and I limp as a consequence. These symptoms wax and wane as is common, but in the end, I decided to have a follow-up consultation with my sports medicine colleague, and we have had the ankle X-rayed again, followed by a 3 Tesla MRI. The deterioration in the injury to the talar dome is plain to see.

However,  given my knowledge and experience of the pain in the first 10 years following the injury, it did not seem to me that this may not be the main problem. As is common, the radiology report focused on the old fracture and its development over time. Perfectly reasonable. However, in discussion with the sports physician after the MRI, it was clear that there was an effusion at the back of the ankle joint that surrounded and included the spaces around the flexor digitorum longus and flexor hallucis longus. This seemed to me to be a more likely cause of much of my complaint.

Only the diagnostic component of a targeted injection could hope to sort that out. As a consequence, ultrasound-guided injection into the ankle joint using an anterior approach, followed by a guided infiltration of the posterior part of the ankle and tendon sheaths, was undertaken. The anterior ankle injection was slightly uncomfortable. Very minor problem. The posterior injection was undertaken using a posterolateral approach. A medial approach is not appropriate because of the neurovascular bundle that traverses that region. The posterolateral injection was more uncomfortable. I did feel that the needle impacted a superficial sensory nerve, as there was a brief, severe twinge of pain down the lateral border of my foot to the little toe. This did not last. The rest of the injection was essentially painless. A peppering technique was not used, rather, a bolus type of procedure that radiologists use to infiltrate joint and bursal spaces.

During the immediate post-injection period of about four hours, I would have put my pain relief at about 50%. Not impressive. Normally, we would use an 80% pain reduction standard to infer a positive anaesthetic response. However, by the evening after the injection, long after any anaesthetic effect must have worn off, I was essentially pain-free. It has been 3 days since the injection, and I have not experienced any pain at all. My gait is more normal, and I do not get the pain during the push-off phase of my stepping.

We will see what happens..