We see it ALL THE TIME. But sometimes it is nice to point out the obvious, just in case you are not looking for it. "Conclusions: Our subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantar-flexion range of motion on the involved sides. Clinicians should consider exercises to increase hip abduction strength when developing rehabilitation programs for patients with ankle sprains."-Friel et al Dr. Allen: if the hip abductors are weak, the leg will posture more adducted (ie, cross over type pattern) and this places the foot more directly below the body midline plumb, this will posture the foot in inversion and thus at greater risk for future inversion sprains.  This sets up the vicious cycle of hip abductor weakness, frontal plane drift of pelvis, inversion of the foot and more ankle sprain risks/events.  The cycle must be broken. The hip must be addressed. That lateral chain must be restored all the way up from the foot.  All stuff you likely already know, but good to find another study to validate.

Dr. Allen

This is what happens after getting an inversion sprain which caused a small bone fracture in the ankle bone where the lateral tendon joins with it.

When it happened it sounded like a "pop" and the next thing I knew I was writhing with pain and my foot instantly went numb with the pressure feeling like it was going to burst.

So thanks to this I can't make any videos for a solid week because I have to keep this elevated and rested, but I can make mobile videos of QnA's for example and upload them from my phone..

I hope you guys are doing well and I love you all. Please take the time out of your busy day to talk to me, if you want. I'm extremely bored and incapable of being productive...

Thank you everyone, and I do have a video coming right away which explains more of my situation.

Love you guys. 

A case of the non-resolving ankle sprain.  Things to think about when the ankle and foot just do not fully come around after a sprain.

Gait Guys,

A while back I had a severe ankle sprain while trail running.  As I stepped on a rock my toes pointed downward, my ankle was rolled in and I felt a pop. This was follow by a lot of swelling and bruising both on the inside and outside of my ankle.  Being experienced with ankle sprains, I jumped on the initial treatment immediately. The reduction in swelling and bruising lead me to believe that I was in for a 4-5 week recovery, then I would be back at what I love doing. I was proven wrong:  

1.       Initial treatment consisted of immobilization, icing, and a very high dose of Ibuprofen (3 days only). After a couple weeks of this I began stretching, massage and trying to get into some modified activities as the pain allowed me to. I was able to  do some hiking but running was too painful.

2.       After 6 weeks, I was still having pain in the posterior tibial tendon area as well as the deltoid ligament area. I tried running but, I was met with severe pain beginning in the middle of the gait cycle through  the push off. I saw a PA at this time and was told to give it more rest. For the next few weeks I wore a soft brace and spent most of my time in a chair.

3.       By week 9, there was no improvement. I could walk fine but, I had the same pain when I tried to run. I visited the PA again and was put in a walking cast and had an MRI. The MRI should a low grade deltoid and ATFL sprain as well as a bruised bone. I spent 2 weeks in the walking cast then returned to the soft cast for another week. During this time I did nothing besides give it rest.

4.       At week 11, I did not see a noticeable improvement. I still had a sharp pain in my posterior tibial tendon area and deltoid area during the middle of my gait (when trying to run). At this time, I had another visit with the PA. After looking at my MRI more closely, he saw fluid buildup behind my talus. He thinks that I had an impact injury to my Os Trigonum. He also noticed that I had very limited dorsiflexion.  He has advised me to stretch and give it a few more weeks. If it’s not going in a positive direction he recommended a cortisone shot.

As it stands today at week 12, in a dorsiflexion position, I have a sharp pain in what feels like my Achilles tendon and posterior tibial tendon area (the MRI shows these are intact). I also have a lot of tenderness in the deltoid area. Walking, I am almost pain free but as soon as I begin to run, the pain starts in the areas described above. This is the first injury I have ever had where I haven’t seen a steady improvement when recovering (maybe I am just getting old). The pain I am having now when trying to running is the same as it was at week 4. This really concerns me.

I guess my question is, where do I go from here? Do I keep doing what I am doing? Should I seek a second opinion?  Any help or guidance you could provide would be greatly appreciated.

On a side note, your blog has helped me to get though the last 12 run-less weeks without losing my mind or falling into a deep depression.  You guys do some great stuff.  Keep up the good work!

Best Regards,

MR

____________________

Dear MR:

Somehow we missed this email. Sorry about that.

Whenever things are not resolving with reasonable intervention one must think of two things: either the injury was severe or the diagnosis is incorrect.

Without seeing you we are unable to determine either. But here are our thoughts.

The Os Trigonum syndrome is a good thought. It seems to be in the correct area of your complaint. These "Os" bones can be embedded in tendon or soft tissue and they can be fixed to the posterior talus by either bone or a cartilagenous bridge. It is possible for this to be your problem if the inversion event was severe enough although it is not that common in this described mechanism.

One must also be suspect of osseous compression of the medial talus against the medial calcaneus, which will bring thoughts of a posterior subtalar facet fracture. We pulled up an article we read a few years ago on this issue (click here), the article is entitled, "Pseudo os trigonum sign: missed posteromedial talar facet fracture". Obviously this needs to be considered in your case since there are similar components in area and symptom of your complaints. Posteromedial talar facet fracture (PMTFF) is a rare injury, sparsely reported in the literature and it must be chased as a diagnosis of suspicion when all other clinical presentations have not panned out. Damage to the sustentaculum tali must also be assessed, as this too can be fractured.  Osteochondral defects are also always on the list in violent inversion events; they are classically seen anteromedially and posteriolaterally at the ankle mortise joint.

Something else that is often missed in ankle inversion sprains is avulsion or rupture of the extensor digitorum brevis on the lateral foot. As the rearfoot inverts and forefoot plantarflexes the EDB is tensioned to the point of tearing. Although you seem to have no symptoms in this area it can never be overlooked. These are easy to discern from the lateral ligamentous structure damage because the areas are clearly separate from eachother.  Look for tenderness down into the top of the metatarsals into the forefoot. Also test for weakness and pain of toe extension.

So, lots to consider here in this case. When things to not resolve you have to start looking for less common problems and damage.  We would love to hear how you are doing MR. Drop us a line.

Gait / Running Injury: Misdiagnosed Big Toe Extensor Hallucis Brevis tear in a distance runner from a simple ankle sprain.

* Sorry for the less than perfect video. Need some editing time.  Watch from 0:32 onwards for the topic at hand.

This young man, State caliber cross country runner, came in to see us after some unsuccessful treatment for an inversion ankle sprain several weeks prior. Although his swelling and range of motion had improved he was still having pain despite treatment. On examination it was revealed that there was no loss of integrity of the lateral ligamentous restraints, no joint gapping was noted and the ligaments were non-tender. There was no swelling. Balance was clean. Even the immediate local lateral ankle muscular restraints, largely peronei, were competent with skill, endurance and strength assessment. After further pointed discussion, after the ankle was cleared as a causative /symptomatic generator, we insisted the patient be more specific with his pain region. After requesting he palpate around to focalize the area of complaint this time he pointed not to his lateral ankle but rather pointed to the lateral dorsum of the foot over the fleshy mass of the short extensor muscle group just distal and anterior to the lateral malleolus. Inversion of the ankle was pain free but inversion of the forefoot on the rearfoot reproduced his pain pin point to the EHB (extensor hallucis origin area). Upon reassessing his gait it was now obvious that he was unable to engage the left hallux (big toe) extensors. You can clearly see his lack of toe extension (lift) on the video at 0:32 seconds. When consciously requested to do so it immediately reproduced his pain ! If you look very carefully, that the hallux was not extending during swing phase through midstance contact phases of gait. After specific muscle testing found only the EHB (extensor hallucis brevis) weak and not the EDB at all (extensor digitorum brevis) we began a few minutes of manual therapy to the EHB. Within ~5 -10 minutes the EHB was painfree and he could engage the muscle again actively. The muscle was clearly healed from it low grade strain, he was just unable to reactivate it during the gait cycle. Post treatment, he was able to walk immediately with much less pain and with ability to use the EHB in gait. We followed up a second visit with him but he was pain free and was discharged from care. There were no gait compensations and screens for functional sensory motor compensations were unremarkable. Case closed. Good results come from a precision diagnosis which can only come from a sound base of knowledge of anatomy, physiology and biomechanics .... when it comes to this kinda stuff.  Would you have picked this up on someone's gait ? We didn't at first.  Use your clinical examination to drive your suspicions in your gait analysis. What you see is not always what you get during gait analysis, this easily could have been a similar presentation of a hallux limitus.

Details, details, details. The devil is in the details, The proof is in the pudding....... etc.