Anterior ankle pain (Full Version)

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Alex Brenner PT MPT OCS -> Anterior ankle pain (February 7, 2005 12:52:00 AM)

38 year old male who has a long history of running complains of recent anterior ankle pain during running and has noticed recent loss of dorsiflexion due to pain. No history of trauma, pain was of insidious onset 3 weeks ago.

What are the findings?

(All images obtained and used with permission)
[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle1.jpg[/IMG]

[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle2.jpg[/IMG]



SJBird55 -> Re: Anterior ankle pain (February 7, 2005 1:28:00 AM)

I'm not seeing anything that looks to be the culprit in anterior ankle pain. His toes crack me up though. His calcaneous looks like it has some spurring. He's kind of flatfooted too, isn't he?



FLAOrthoPT -> Re: Anterior ankle pain (February 7, 2005 2:20:00 AM)

symptoms make be believ that something going on with Talo/crural joint. Is it as simple as OA?



jma -> Re: Anterior ankle pain (February 7, 2005 4:27:00 AM)

Hello,
I too see what looks like a small spur in the lateral view. However, in the plantar view, I see what looks like an oblique line, running diagnonally from the distal to proximal cuboid. It does not look like a joint line space. Perhaps this could have been a stress fracture at one point? Just my observation. And yes, the last three digits show metatarsus adductus.

JMA



JLS_PT_OCS -> Re: Anterior ankle pain (February 7, 2005 9:53:00 AM)

Anterior osteophytes at the talocrural joint.

A suboptimal lateral view, as you should see a nice curve for the top of the talus (maybe it's just my screen).
Time for some ankle mobs!



steve -> Re: Anterior ankle pain (February 8, 2005 10:25:00 AM)

? osteochondrial lesion of the anterior talar dome.

Steve



Alex Brenner PT MPT OCS -> Re: Anterior ankle pain (February 13, 2005 9:24:00 PM)

Anterior osteophytes at the talocrural joint and at the talonavicular joint. He also incidently has a calcaneal bone spur.

[IMG]http://img.photobucket.com/albums/v85/brennerak/ankle3.jpg[/IMG]

Good job Florida and Jason for correctly identifying the pathology.



Alex Brenner PT MPT OCS -> Re: Anterior ankle pain (February 14, 2005 10:42:00 AM)

So no one really liked the anterior ankle case. Thats ok.

Well then, let me at least show you some of my pictures from my short trip to Tuscany yesterday (only 2 hours south of my house).

Nice view of the rolling Tuscan hills showing some of the Chianti vineyards and olive trees.
[IMG]http://img.photobucket.com/albums/v85/brennerak/TuscanySiena026.jpg[/IMG]

From the small Tuscan town of San Gimignano, I climbed a 700 year old tower to capture this picture of part of the city and the Tuscan hill side. Enjoy!
[IMG]http://img.photobucket.com/albums/v85/brennerak/TuscanySiena014.jpg[/IMG]



Synergy -> Re: Anterior ankle pain (February 14, 2005 1:38:00 PM)

Those pictures are great Army! I'm jealous of one of my best friends. He's a minister and while working on his M.Div., he did a 1 1/2 year stint over in Europe (specifically Zurich, Switzerland) as an interim pastor. He traveled everywhere and sent pictures to everyone. He backpacked all across Europe. I do believe he made a pitstop in Tuscany. :)

Is that a bell tower in the bottom picture on the right?



jma -> Re: Anterior ankle pain (February 14, 2005 2:24:00 PM)

Hello ArmyPT,
I liked the x-rays. It helped point things out that I was not able to see, at least with the old screen I had. Now with a 20 inch flatscreen. It is much more clearer to see. Keep up the good work.

JMA



Jon Newman -> Re: Anterior ankle pain (February 14, 2005 2:53:00 PM)

Hi Army,

Nice pics. The Giro d'Italia is May 7 to 29th this year. Maybe you'll get a chance to catch some of it.

jon



Shill -> Re: Anterior ankle pain (February 15, 2005 7:23:00 AM)

Army,
To round out the topic, can you now give us some further symptom behavior characteristics, along with your pertintent objective findings and treatment for this patient? You mentioned the "incidental" calcaneal and infracalcaneal spurs already, so these are potentially asymptomatic, right? Do we know for sure (relative certainty of course) if the anterior spurs had anything to do with the pain? Perhaps include how you decided that these spurs did or did not cause him symptoms. From the brief history you gave, certainly the spurs could be responsible for the decreased DF. See if you think we could learn a bit from his findings, treatment or outcome. I realize the films are the reason for this forum section, but if you have an extra minute, we can potentially learn a bit more from your expertise.
Thanks,
Steve Hill PT



Alex Brenner PT MPT OCS -> Re: Anterior ankle pain (February 15, 2005 8:50:00 AM)

Thanks Steve. I will try and incorporate these in the next case studies.



Dr.Wagner -> Re: Anterior ankle pain (February 15, 2005 6:16:00 PM)

Just took a quick peek...so you are saying these osteophytes caused the pain? I see these incidentally all the time and they are asymptomatic...hell I see worse, way worse.
I guess the next question is why would an osteophyte (chronic) cause acute ankle pain?

I am NOT (repeat NOT) trying to cause any problems, but just sounds like an "over read". Perhaps the radiologist would comment, but man, those things are so common (ie all arthritic joints don't produce symptoms).

Or maybe this is really just an exercise to identify osteophytes...and the history is made up? If that is the case, just ignore the guy with the beard (me).



Alex Brenner PT MPT OCS -> Re: Anterior ankle pain (February 15, 2005 6:26:00 PM)

Hi Dr. Wagner. This particular guy did have anterior ankle pain but it wasn't acute. The title of the case was anterior ankle pain not acute ankle pain.

The goal of this case was to be able to recognize the osteophytes on the ankle radiograph. It would be hard to tell if these findings were the culprit for the pain but I think it is reasonable to think that anterior osteopytes could cause some impingment of the ankle synovium during end range dorsiflexion. This patient had anterior pain with dorsiflexion.

If I remember correctly, I think he responded well to some ankle joint mobilizations.

Thanks for the input.



Dr.Wagner -> Re: Anterior ankle pain (February 16, 2005 2:17:00 AM)

Ok, that seems reasonable. Recognizing osteophytes.



Jeep -> Re: Anterior ankle pain (February 16, 2005 3:13:00 AM)

This is a possibility(IMO) of the mechanism and the role the osteophytyes in this pain profile:

I would consider the pes planus primary(and of longstanding, and directly responsible for the heel spur- due to tension on the attachment of the plantar fascia). This secondarily leads to a fault in the tarsal arch, thereby leading to the osteophyte formation seen. Upon certain/or a certain activity or motion, an irritation is created, with attending inflammatory sequences, with are space occupying. This in turn can cascade into a anterior tarsal tunnel syndrome.

So in essence, osteophytes can indeed be a source of pain.

Orthotics would be an esstential treatment component in this patient.



Dr.Wagner -> Re: Anterior ankle pain (February 16, 2005 5:21:00 PM)

I guess my original point was that osteophytic lesions may coexist asymptomatically (especially ones that small) and may not be the source..just simply "there". As I have seen this to occur on literally hundreds of occasions (get ankle films on enough people and you see all kinds of asymptomatic stuff). But I understand the point and educational information he was sharing. Absolutely right about orthotics, I used to be our clinic's "orthotics guy"...casting was fun.



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