Beware mysterious ankle injury

Conway McLEAN, DPM

I’ll bet you knew a guy like Joe. He was one of those fellows who was sort of popular in school, though not really part of the “it” crowd. He was smart, but not that smart, not one of the brainy nerds. Joe liked sports, but wasn’t ever good enough to be a starter or even a back-up; instead he was perpetually a bench warmer. Nonetheless, he tried, and that was appreciated. Because he was a nice guy, and didn’t make waves, he was included in many activities. Did you know a “Joe” in school?

Even after college, Joe tried his best to stay active, and often participated in local pick-up games of softball or basketball. As the years passed, he found it difficult to muster the fortitude and endurance to be even moderately competitive in these good-natured events. The participants became younger, and strangely, he somehow grew older. He liked to think that he became wiser, but that wisdom didn’t seem to translate all that well to the hardcourt. Softball became his arena of choice, especially because many of the entrants were in much poorer shape than he, evidenced by the size of their beer bellies.

Softball seemed safer too, since it didn’t involve large bodies throwing themselves into the air, often in the same small space. This was a recipe for disaster, in Joe’s mind, so the change to softball was a wise one. If you played infield, you really didn’t have to run. With great forethought and consideration, the natural position for Joe was definitely catcher. Basically, he never had to run at all! Except for the minor detail of having to run the bases if he got a hit. And that’s where the trouble started.

Joe’s teammates were very excited about the next contest they were scheduled to play, since the winner would go on to the playoffs, while the loser would find it time to pack up and go home. After a spirited pep talk by the team captain, everyone was fired up. That is, until Joe attempted to reach second on a “bloop” single into the near outfield which just barely managed to make it over the head of the third baseman. In his enthusiasm, Joe attempted to turn this meager achievement into a double, whereby he stepped on the foot of the second baseman and twisted his ankle. Joe was done for the day.

Naturally, this is where the story gets interesting (medically). Like every ‘serious’ athlete, Joe had sprained his ankle several times before, but had either been able to walk it off, or had been told by the ER doc to keep it wrapped with an ace bandage and use crutches for a week. This injury didn’t seem all that severe, but the limp was obvious and pronounced, and the pain more than mild. With great relief, Joe learned from the technician at the emergency department his ankle was not broken. The usual treatment was recommended, with the added recommendation of some heavy-duty meds — ibuprofen.

Concern developed when the pain did not lessen in that long week of rest and inactivity. Besides, his arm pits were growing sorer by the hour. (At some point, getting off the crutches seemed the most important goal of all.) Still, the ankle continued to hurt, mostly when he walked, and less when he simply stood. With much insistence from his wife, Joe presented to his family doctor for some specific recommendations. These included icing, continued compression, as well as the use of an ankle brace. This simple device made a great difference in his pain, and allowed him to discontinue crutch use (thank goodness!), ambulating with a high-topped sneaker.

After 3 weeks with the brace, and little progress to show for it, he presented to my office. The fact that he continued to experience the dull, aching pain he had from the beginning was an important clue. A careful exam revealed that much of the pain Joe had from the outside of his ankle seemed to be experienced behind the ankle bone, rather than in front of it, as is typical for the prototypical sprain. Once again, ultrasound imaging proved its worth by revealing a small tear in one of the peroneal tendons. No doubt, at this point, many of you are exclaiming “I knew it!”

In nature, and consequently in the human body, balance is the rule. As it is in the distribution of muscles going into the foot, where you have muscles in front balanced (hopefully) by muscles in back. The same holds true for the muscle groups which run along the inner and outer sides of the ankle. The two peroneal tendons run down the outer side of the ankle, behind the ankle bone, and help to balance the muscles running along the inside of the lower leg and ankle. They help to stabilize the foot, as well as reduce excessive inward motion. Most ankle sprains involve this type of movement, and it is this that the peroneals attempt to minimize. In doing so, either of them can be injured. What makes this injury so interesting is how commonly it is missed. Because it is often in the same region as your average ankle sprain (whereby one or more of the ankle ligaments is damaged), differentiating one from the other can often be a diagnostic dilemma.

Magnetic resonance imaging, the well-known MRI, can provide an amazing amount of information. Unfortunately, in our current climate, getting insurance approval for an MRI study can be as difficult as breaking into Fort Knox. (But wait…do we still have a Fort Knox?!) This is where the ultrasound machine shines due its availability, sitting in the equipment room of my office, waiting and ready. In addition, it is easy to use, and is free of any deleterious effects whatsoever. The image quality has improved tremendously in recent years, though some training and practice are still required to interpret the image.

Joe was placed in a removal cast boot, with a course of physical therapy also utilized. He made steady progress (despite the ungainly and inconvenient boot) over the subsequent weeks, and was then able to progress to a more sophisticated ankle brace. Softball would have to wait until next year, so he headed to the gym, where he fortunately discovered pilates. Many with a torn peroneal tendon require surgical repair, so the degree of Joe’s recovery was fortunate. Although not a terribly difficult procedure, surgery is to be avoided when possible.

Are you ready for it? At this point, no doubt, you are looking for the “take home message”! Play basketball instead of softball! No, that’s not it. The key is to seek out a diagnosis and treatment plan that make sense. Internet research can often provide disparate answers, and create more confusion than solutions. If you are not making progress, maybe the treatment being provided is for a problem that you don’t have. The other message: just hit a home run!

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.