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clouth 04-21-2008 06:37 PM

Inner Ankle Pain: Struggling to get a diagnosis
I've had inner ankle pain since November. It came on strong, burning and throbbing while I worked out and about 6 weeks after.

In December I got diagnosed with posterior tibular tendonitis. I did the ice/rest/NSAIDS routine until early january and it didn't help. The ortho put me in a walking boot but when it didn't help after 10 days he send me to another ortho.

That ortho did a bone scan and a CT. Both showed some healing activity in the joint, and a little fluid back by the heel. The ortho didn't know what to make of that, so he suggested cortisone shots or a visit to a foot/ankle ortho.

In Feb I went to the foot ankle ortho. He diagnosed flexor hallicus longus tendonitis, which is right next to the posterior tibular tendon and it goes to the big toe.

For six weeks I did physical therapy, ice, stretching, advil. It lessened but still would ache and swell with activity. When we tried strengthening it got much worse and the burning pain came back, still in the inner ankle.

A few weeks ago I went back to the foot/ankle ortho and he suggested casting it for six weeks, or surgery (or cast followed by surgery). He said he thought the tendon might be torn.

I went for a second opinion tonight to my aunt's podiatrist, who does the platelet-rich plasma injections for tendons. I thought that kind of injection might heal my tendon and help me avoid surgery.

He and his partner instead completely disagreed with my diagnosis. They said they don't think it's a tendon at all. They think that the joint itself is irritated (because when they push on the lateral side it's very sore). They suggested cortisone shots followed by NWB for 7-10 days, then the cam walker for another week.

I'm feeling like a should give cortisone a shot (ha ha) at this point, but I'm so confused about this. Why would the joint itself be sore?

Does or did anyone else have inner ankle pain that was alternatively burning, scratchy, achy? Did you get a diagnosis?

emmie54 04-21-2008 07:44 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Welcome to the board. I would get a second opinion from a foot and ankle orthopaedic surgeon. There is a risk of rupture any time you inject directly into a tendon. Your symptoms sound classic posterior tibial tendon. With mine, my pain was just as much lateral (outside ankle) as medial (inside ankle). This is caused by the bones impinging on themselves because the tendon on the inside is not supporting the foot and the foot is leaning inwards. Think of two stirrups. One being the PTT and the other being the peroneal tendons. They both support the ankle. When one breaks down the other bears the load. The joint is affected because the tendons are not doing their job supporting things and it is overloaded. In my opinion you need an MRI if you haven't had one. That will give a clearer picture of the tendons..hopefully. It's not unusual for conservative methods to be tried first, in fact it almost always happens that way unless there was a traumatic event causing the injury. You've already gone the conservative route and nothing has worked. You definitely need answers and it sounds like you haven't gotten the same answer twice. Just my opinion! If you have any questions you think I might can help you with please ask. If I don't know then someone else will.. There are a lot of knowledgeable people on this board who are willing to help.

maggietaz 04-21-2008 07:48 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
This sounds a lot like what I have been going thorugh. Started last May or June after working out, it was a soreness, and an achiness, no burning - progressed to MRI's, walking boot, PT and a bone scan , showed some type of healing - at the time my pain was more towards my calf, but he said it was posterior tibial tendonitis. Anyway, long story short, It has never gotten very much better, I am working out again and the pain is coming back.
When I had problems with my peroneal tendon, the foot and ankle specialist tried nitro-glycerin patches, I put the patch in the spot where the pain was the worst and it worked. They had to call the doctors that has done the trial with it,to get the dosage, but I put a half a patch on a day and within a few weeks it felt better, the only success I have ever had healing a tendon without surgery. The next step was going to be the plasma route. My doc did give me an injection of cortisone in Dec. that did help for a little while. Good luck and let us know wha happens.

clouth 04-22-2008 04:49 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Thanks for your replies!

Emmie: Thanks for your description of PTD. Now when I have a follow up I can ask about that specifically. The podiatrist wants to put a little (ha) cortisone on each side of my ankle joint, not in the the tendon. He is actually the third doctor in a row to suggest cortisone, the one thing they all agree on! I have another appointment May 13 with the foot/ankle ortho at Mass General. I did have a MRI in January. The only thing it showed was some fluid above my heel. One thing I've realized is I haven't yet done two things: immobilization (I'm told 10 days is nothing) or cortisone. So I'm thinking of doing those two things while I wait for my May 13 appt. Does that make sense to you? Did you ever have cortisone?

Maggie: thanks to you too. I'm sorry to hear both of you are having problems too, because this sucks. I honestly go to sleep and wake up close to tears every day. Which sounds crazy because this could be worse, but there it is. I'm glad you're looking into ***. My aunt had amazing success with it in her achilles tendon, which had lots of tears in it. The podiatrist said if *** will work in the large achilles, it should certainly help smaller tendons like the PT.

emmie54 04-22-2008 07:25 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Oh, I'm glad they aren't injecting the tendon! Yes, I've had cortisone and it will definitely help with inflammation. I was four weeks in a walking boot and when that didn't work four weeks in a NWB cast. I agree, ten days is not enough to do anything. I would definitely try those two things. Just a note: my MRI did not specifically say my PTT was torn and in fact it wasn't. My doctor based my diagnosis on clinical exam and the fact that I had inflammation in the area on the MRI. When he got in there my tendon was total "mush" and had to be thrown away and replaced. Also, a determining factor in the diagnosis was the fact that I could not do a single heel raise. Can you?

clouth 04-22-2008 08:09 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Hi Emmie,
Yes, I can do a heel raise, and all the docs have had me do that. I spoke with the pod on the phone this morning and he said he thought my pt tendon is strong.

I have an appt. with the foot/ankle guy at Mass General, like I mentioned. Now I'm deciding, do I just do the walker for three weeks until I see him? Or do I go ahead and get the cortisone in the meantime. Seems there's always something new for me to wonder about with this.

Thank you so much, you're comments are really so helpful. :angel:

emmie54 04-22-2008 10:54 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Well, you would have a good idea if the cortisone was helpful before your appointment if you had it now. Just a thought. By the way, the heel rise thing isn't a deal breaker. You can have early stage PTT and still be able to do one. It's later on that you can't. I was probably a stage II-III.

I hate walkers! I find them sooo difficult to get around with. I found crutches easier and since I've had multiple surgeries I went ahead and purchased a wheelchair which I used around the house because it freed up my hands. My house looks like a rehab hospital. I have an ASO brace, two post op sandals, two different kinds of boots, a walker, crutches, wheelchair, toilet seat, shower chair, about 50 ace bandages, thera-bands in every color. :=). Thankfully the only thing I am using right now (knock on wood) is the post op sandal.

clouth 04-22-2008 02:20 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
I ended up calling the mass general doctor's office. The medical assistant checked with him, and he said to hold off on the cortisone. It could interfere with him evaluating the ankle.

I will defininitely keep the PTTD in mind, and I'll mention it when I go to see the next doctor. for now I'm holding on to what this podiatrist said, that based on his clinical exam that's not what this is. The only question is, what is it?

My cam walker is actually like a boot, sorry for the confusion. It's not bad, fairly comfortable. I have a heel lift inside which made it more comfortable too. I'll be in it for three weeks now, I'm sure it will smell wonderful by the time I get in to mass general. :D

I have a rubbermaid bucket full of stuff for my ankle: liniments, gels, heat pad, a book on muscular trigger points, a weight that hangs off my toes for exercises (not doing those right now), etc. etc. Can't wait to put the whole lot away. Maybe I'll have a bonfire one day.

best wishes for your continued recovery,

emmie54 04-22-2008 04:02 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Keep us posted, Kris. I like the bonfire idea 8=]

janewhite1 04-22-2008 06:21 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Definitely, bonfire, Emmie. I'll toss in my crutches, cane, walking boot, 2 lace up braces, 2 types of ointment, ice packs, vitamin E and band-aids (for my scar) collection of leg weights, rocker board, wobble board, and exercise bands.

emmie54 04-22-2008 10:19 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
hahahahaha.... I forgot about my cane..must throw that in too. :=)

kristim06 04-23-2008 06:28 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Just like emmie said it sounds like pttd. I just had surgery in jan after 9 months of non surgical treatments that did not make it any better. My doc (which is in Boston, one of the best out of Brigham and Womens & the Faulkner hospital) (a side note my surgeon minimized the incision he had to make which is great!) We did not do the cortisone injections because of the rupture risk. The only thing I can say is that I was still able to raise up on my toes and the mri showed severe tendonitis that did not get better. When I actually had the surgery done I had a lateral tear of my post tib tendon. which is hard to see on an mri due to normal lateral striations in the tendon itself. I wish we had known that earlier and I would be so far past post op. Right now I am 3 months and it is already starting to feel better other than normal swelling (due to using it more and more) and I am looking at being able to start jogging in a few weeks. (I am a runner so this is huge for me) I hope everything goes well at your appointment! Let me know if you have any questions.


emmie54 04-23-2008 07:43 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
I'm certainly no doctor but it bothered me that the pod "threw away" the diagnosis of PTT just because the joint had tenderness. As I said earlier, my lateral joint pain was my primary symptom - NOT the PTT. It was barely even sore which he found hard to believe because he could feel the thickness in it upon examination. But the lateral pain was evidently masking the PTT pain. The fluid around the heel also fits as it runs right above the heel. May not be PTT, but sure sounds like it. I'm curious as to how the next appt. turns out, Clouth. Inquiring minds want to know!

clouth 04-23-2008 08:22 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Thanks so much for your input Kristin. Best of luck with the return to running!

I just wanted to clarify, Emmie that I never got diagnosed with PTTD. My very first ortho diagnosed PT tendonitis. Then decided he had no idea what it was. Then the next ortho ordered a bunch of tests then suggested cortisone or go to foot/ankle ortho.

The foot/ankle ortho diagnosed flexor hallicus longus tendonitis. After physical therapy didn't work he suggested walking cast for 6 weeks followed possibly by surgery on the FHL.

The podiatrist diagnosed subtalar joint irritation of unknown origin with "varicosities" on the inner ankle. He thought the FHL tendonitis diagnosis was not logical. The FHL tendonitis diagnosis was partly based on my big toe being "tethered." But the podiatrist said its like that because of the big toe joint (flexor hallicus limitus sp?) not the tendon.

The idea of having PTTD is really bumming me out. :(

I'm in the process of making sure I'm seeing the right guy at mass general . One specializes in sports injuries, the other in sports injuries and "adult deformity."

emmie54 04-23-2008 09:13 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Oh, sorry if I misunderstood. Just trying to help, didn't mean to bum you out at all. You may NOT have PTTD. Several foot conditions mimic each other in presentation. I just hope, for your sake, you get a proper diagnosis since there seems to be a lot of different opinions going on which I am sure is frustrating. Best of luck to you.

p.s. Another name for PTTD, which you may know already, is "Adult Acquired Flatfoot" which the "adult deformity" guy probably deals with.

clouth 04-23-2008 10:04 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Oh, please don't be sorry, really. I know you're trying to help, and I appreciate it very much. Knowledge is power, in my opinion.

Also wanted to add that I've never had a weight bearing xray. And the podiatrist thought that was strange, said having xray nwb was like having an eye exam with the eyes closed. So maybe I'll be able to get that done before I go to boston.

I figure either guy at Mass General will end up being fine, and they probably consult with and refer to each other also.

this ankle thing though is taking a toll on me emotionally. When I feel like I know what's going on and have a plan, it's better. But at times like this, it gets overwhelming.

I'm also chasing around three kids (8, 6 and 2 1/2) and wondering what my summer will be like. Also had wanted a fourth baby and now maybe that won't happen (I'm 38 - getting old!).

I'm trying to stay positive and look at the blessings. (e.g., as of now I can walk in the brace, I'm not in excruciating pain, I'm not dying, etc. etc.)

Again, please don't apologize. All thoughts are really helpful, and I'm glad I found you all.


janewhite1 04-23-2008 10:39 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Absolutely, not knowing is the worst.

One productive thing you can do for now is try to make sure you have all records, films, etc in order when you go to the surgeon, and make a list of things you want to tell or ask him.

clouth 04-23-2008 10:55 AM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Thanks Jane. Funny you should mention that. I constantly have an index card and a pen in my pocket, and I was just going over the questions I have when I stopped to read this. :)

BTW, I spent some time reading your history, and I know you've been through it yourself. I hope that you are continuing to heal and do well.


clouth 04-23-2008 03:59 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
I double checked with the doctor at Mass General, to make sure he's the right guy to see. He said that he's the best for surgery, and his other recommendation would be the foot/ankle guy at Brigham and Women's.

Anyway, tomorrow morning I'm going to schedule with the B&W guy, that way, if I see the mass general guy and he doesn't think he can help me, I'll already have the appointment.

Regarding PTTD: I did the wet foot print test, and I have a band along the outside of my foot that is thin near the heel, but thicker toward the ball of the foot. Not sure what that means! I certainly will make sure that I'm thoroughly evaluated for PTTD though.

kristim06 04-23-2008 06:14 PM

Re: Inner Ankle Pain: Struggling to get a diagnosis
Clouth, I went to the guy at the Brigham because saved my father's foot from being amputated when every other doctor thought that it would have to be.

The best thing about him is even if he doesn't have time to call you back in the office he calls on his way home. Thats probably smart to have both appointments and hey maybe getting two opinions from 2 of the best isn't such a bad thing??

Good luck with all you appointments and like I said any questions feel free to ask. I am exactly 3 months out of surgery tomorrow. My only down side is I think it is happening to my other foot which is not good.

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