On-Going Tendon or Joint Pain in Ankle

Background:

Ankle broken in early June, surgery 2 weeks later to remove some large bone fragments. OS said injury was one of the worse he's seen in 20+ years.
NWB for a total of 9 weeks, then was allowed to walk towards the end of August.
PT for 3 months
Pain in peroneal tendon area when going up on my toes, going up and down stairs, attempting to jog... starting when allowed to go weight bearing. PT was a bit concerned but not majorly.

MRI showed no tear, however pain continued to get worse. Currently it is painful to walk, not so much that I can't walk, but still noticeably painful. It generally is quite a bit more painful after sitting down or not walking on it, but the pain never goes away completely. It's a sharp pain that is right along the peroneal tendon (from what we can tell). OS said it may also be from the joint, just feels like around the tendon due to compensation.

I've also gotten a snapping feeling, usually about 1x a day that feels like a rubber band has snapped... and it hurts horribly.

Follow-ups with OS every 4-6 weeks... OS is at a loss right now and after trying multiple things that have not helped, he has put me back in a walking boot until my next follow-up to see if that helps.

He also wants me to get a second opinion with another OS foot/ankle specialist at Johns Hopkins to see if he can find anything. Surgical options were brought up (one to see if we can find something that's going on, another to help with arthritis if that was the cause)... but we are trying to avoid that and that would be a last option...

Do you have any ideas on what would cause the pain I'm describing? We are really at a loss and it will be a couple of months until the doc he wants me to see for a second opinion has an opening...

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Jul 09, 2010
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by: Carroll

I took a severe fall several years ago and fractured my talus and was told I had a grade 4 sprain and put first in a plaster cast then a walking boot. It never seemed to really heal. One day about 2 years ago I woke up and could not walk. There was a rather large bone in the center of my foot that had broken and fallen in on itself...had surgery to repair that. Unfortunately, the ankle started to fuse, so was placed in external fixator for 3 monthes. Still, extreme pain and swelling on lateral ankle - but I could walk. PT convinced it was torn tendon, but x-ray and CT showed nothing and I can't have MRIs. So, went to surgery and found tear in 1 peroneal tendon. Followed usual course, after about 2 months was able to wear a shoe for the first time and while at work 350 lb. co-worker stepped on my ankle. This time both peroneal tendons torn...still never saw it on CT, only in surgery after many months of debate and cortisone shots. Never completely healed from that surgery, still excessive pain and swelling. Decided it was probably torn again. This time, both peroneals torn through and through and were corrected by using allograft and remains of my tendons to create one tendon sewn together with Kevlar suture. Fell twice during recovery stage and after 3 repairs, feeling is there is no viable tendon left, so will be removing the tendons in December (I can't do any more damage than already done, so I decided to suck it up and deal with the pain and swelling and finish it all on my schedule).

Moral of story is...CT and plain films don't necessarily give the whole picture. My tears were quite severe but never showed up on CT, even with contrast. Only through clinical, hands-on examination did my doctor determine it was probably the best thing to do surgery. I probably would have healed pretty well had it not been for some terrible luck.

Dec 23, 2008
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Thanks for the input!
by: Shannon A

Oh man... I really don't remember where he said the fracture was. I want to say either the Talus or Fibula, but I'm not sure which of the two.

My ROM is almost as "good" as my unfractured ankle... which isn't really saying much beccause I have never had very good ROM. Doc was originally disappointed with the ROM, but when he saw the ROM on my good ankle, they were pretty close.

How would it be determined if the peroneal tendon is subluxing? Are there any tests to determine that or do you just have to go by the symptoms?

The OS said the next step would probably be surgery to see if he can find anything inside that tests aren't showing, but he doesn't want to do that before I get a second opinion with this doc at Johns Hopkins. He also said there might be a possibility of some bad arthritis that would require surgery (I'm assuming x-rays could determine that?)... It's really frustrating to not know why I'm having all the issues that I am!

Dec 23, 2008
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peroneal pain
by: Bart - SII

Where was your fracture? Fibula, Tibia, Talus?

My first thought would be to look very closely at the mobility of your ankle and surrounding joints. With a serious fracture, 9 weeks NWB, and the immobilization, you likely have some changes in the normal motions of the joints in and around the ankle. Any restrictions can cause a significant amount of abnormal stress on the joints and surrounding soft tissue.

These issues can sometimes be fixed with aggressive (and sometimes creative) joint mobilizations of the ankle and foot. That is something your PT should be able to evaluate and correct.

The other idea, from what you are describing, is whether your peroneal tendon is subluxing out of its normal groove behind the lateral malleolus. Subluxing (which could possibly be the snapping sensation you are getting) would place a significant amount of stress on the tendon and cause inflammation and irritation. Even if it is not subluxing regularly, if it is out of the groove or moving abnormally (or perhaps not moving because it is stuck), that could be contributing to the pain as well.

I know none of this is very definite, but some things to consider and perhaps talk to your OS or PT about.

Bart

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