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While I’ve been away, I’ve been thinking of ways to make these segments more useful. For the next several segments, I’m going to review some real cases that I have seen in my clinics. Now, from my perspective and that of other orthopedic and podiatric surgeons, these are not the most interesting cases. In fact, just the opposite, they will be the common things that I see everyday (although with the names changed). These cases will not highlight fantastic surgical salvations; they will highlight the diagnostic approaches and typical methods of managing these very common problems.
Matt is a 32 year old IT professional who twisted his ankle four months ago while playing basketball. The ankle has not felt normal since then. While he can walk and do his job, he is unable to return to any running or sporting activities.
When I examined Matt, he had a great deal of tenderness along the inner front and back portion of the ankle joint. His ankle joint was stable, meaning that the ligaments that restrain the ankle joint and keep it from falling out of position are functioning. The radiographs are normal.
This is one of the most common problems that I see, the ankle sprain that won’t quite go away. The initial goal is to make sure that no other serious commonly missed injuries are present. These are usually easy to find if you know where to look—the front of the calcaneus or heel bone, along the outside midfoot at the fifth metatarsal, and the outside of the talus. They are usually suspected by the pattern of tenderness and careful inspection of the x-rays. Additional tenderness on the front of the calf or near the knee can suggest a high ankle sprain, an injury of the ligaments that bind the tibia and fibula, the main bones of the leg.
It is important to make sure that the ankle ligaments are still working, that they haven’t healed in a lengthened position so that they no longer work. Matt’s ligaments seem fine.
So Matt is left with a painful ankle joint without a fracture or ankle instability. This is very, very common. Causes for this are bone bruises, damage to the joint cartilage, or scarring problems within the joint. If you look at the position that ankle is in at the time of the injury, the joint surfaces are knocked against each other in peculiar ways. This causes these bone bruises and joint injuries. Many times, however, a specific diagnosis is not found. Many studies have looked at ankle sprains and how people recover from them. After six months, more than 30% of people will have some degree of pain. Certainly, recovery is not as predictable as many people believe.
The next step is to determine what to do next. The options are non-operative methods such as pain medication, therapy, bracing, and intra-articular injections, further radiographic evaluation, and surgical management. I feel uncomfortable considering surgery in the absence of a more definite diagnosis. Matt and I discussed what other methods of non-operative treatment had to offer and decided to get an MRI.
An MRI is a radiographic test that is slightly different than an x-ray (more about MRIs and when to get them). X-ray film image the body based on its ability to block x-rays. Bones that contain calcium are shown very well while soft tissues are only vaguely defined. MRIs image tissue based on its chemical composition, its water and fat content, using very strong magnets. The images can be displayed in two- and three-dimensions and can show damage in tendons, ligaments, and skin. While it is a very expensive test, it is appropriate when a problem does not respond to initial treatment like prolonged activity limitation and therapy and the diagnosis remains in question.
More to follow…
-Brett Fink, M.D., co-author of The Whole Foot Book, a comprehensive guide for anyone with foot pain.
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