Evaluation of Lateral Ankle Pain in Runners- Part 1 of 2
Ankle problems often occur in runners, and a review of the more common conditions that produce lateral, or outside, ankle pain is relevant. These include fibular stress fracture, lateral ankle sprain and its possible sequelae, synovial impingement, and peroneal tendinitis, among others. Although all of these can cause lateral pain, tenderness, swelling, weakness and/or instability, the causes and management of these problems varies greatly, and thus the determination of the precise diagnosis is extremely important.
The discussion will be presented from the standpoint of a clinicianís thought process during the presentation of a runner complaining of ankle pain. Knowing how a clinician thinks helps the patient prepare for an office visit and anticipate the question and answer "give and take" of the history-taking process.
The first, and most important, part of a medical evaluation is the history, or the story of the patientís problem. In 90+% of situations, a good history will reveal the diagnosis, or at least serve to eliminate possibilities and whittle the list of potential diagnoses to just a few: the "differential diagnosis". The best history taking technique is open-ended, that is, it allows the patient to ramble along at their own pace, telling their story in their own way. This requires a very patient clinician in some instances, and the process is facilitated by a well-prepared, organized, concise story, not always the case. Once the patient is finished, the relevant blanks can be filled in and more directed questions can be asked to complete the job.
With regard to lateral ankle pain, a history of injury or overuse is important. Inversion injury, such as rolling the ankle in the turf, can produce a sprain or initiate tendinitis. A history of training errors indicating rapid progression of mileage or intensity may suggest stress fracture. A story of a more remote sprain accompanied by persistent pain, swelling, and possibly catching sensation suggests impingement of the lining synovial tissues or scar tissue left over from the old sprain. With regard to pain, we need to know the precise location (on the bone, or in the soft tissue), any radiation (up the leg, or into the foot), chronology (timecourse), aggravating factors (footware, surface conditions), alleviating factors (mileage, medications, orthotics), associated symptoms and their relation to the pain (back pain, numbness, swelling, catching, locking, etc.).
The focus of the exam is on physical findings, so-called signs. These include swelling, range of motion, bruising, tenderness, weakness, and instability. Synovial impingement is usually accompanied by swelling and tenderness in the front of the ankle, as well as pain and limitation of upward motion (extension=dorsiflexion) of the foot at the ankle joint. Tendinitis of the lateral peroneal tendons usually is accompanied by boggy swelling and tenderness at the outside of the ankle just behind and beyond the lateral ankle "bump", or malleolus, as well as weakness of eversion of the foot (motion of the foot outward). A stress fracture of the fibula may have no findings whatsoever, or perhaps produce swelling or tenderness directly over the bone laterally.
Next time, a common sense and practical approach to the management of lateral ankle problems will be presented.
Lateral Ankle Pain in Runners- Part 2 of 2
Ankle problems often occur in runners, and last month we reviewed the more common conditions that produce lateral, or "outside", ankle pain. These included fibular stress fracture, lateral ankle sprain and its possible sequelae, synovial impingement, and peroneal tendinitis. The determination of the precise diagnosis is extremely important, and the subtle differences in history and physical findings were discussed, to give the runner an appreciation of the mechanics, and complexity, of the diagnostic process.
A common sense and practical approach to the management of lateral ankle problems will now be presented. To select a reasonable treatment plan, one needs to have a sense of the probable diagnosis, or likely alternative diagnoses. These ankle problems differ greatly in their management options, and therefore illustrate the supreme importance in knowing the likelihood of what one is dealing with when the ankle is painful and running is a problem.
For the runner, probably the worst of these possibilities is the fibular stress fracture, as the usual recommendation is the cessation, or at least significant restraint, of running activity, substituting non or low impact activities, such as cycling or pool running. Other alternatives include using a treadmill or stair climber, both of which are more forgiving. It is extremely difficult for a stress fracture to heal and hence, for pain to resolve, when running continues at levels which initiated the problem in the first place. On the other hand, there is often no reason to completely cease running when one is reasonably sure a stress fracture does not exist. Peroneal tendinitis can be treated with inversion stretching (such as walking the toes up the opposite shin), peroneal strengthening, lateral heal wedges, medication, an ankle sleeve, and ice. Usually running can continue, at least initially, while these conservative measures are undertaken. One may want to avoid running on a banked surface, especially on the right side of the road with involvement of the right ankle, and vice versa.
Similarly, the runner can often continue running with modifications if synovial ankle impingement is considered. Uphill runs may be painful with this condition, but flat surfaces may be tolerable. Even the slight incline of a treadmill may be a problem. Again, conservative measures, such as ice, medication, and plantar flexion stretches (pointing the toes downward) also are advisable with this problem, which usually resolves with time.
Finally, once a sprained ankle has begun to settle down, and straight-ahead, level walking is no longer painful, light jogging can be initiated. Again however, cambered, banked roadsides may aggravate the pain for awhile, and flat, soft surfaces are preferable. Medication to control swelling, post run ice massages, and an ankle sleeve can all alleviate pain and swelling following runs. Stretching, especially into dorsiflexion, or extension (typical calf stretches) are essential following a sprained ankle, and will usually facilitate uphill running. Peroneal strengthening exercises, such as with stretch tubing or a forefoot weight, are also necessary to compensate and reinforce the damaged lateral ligaments while they are healing. A lace up brace may prevent reinjury as running resumes, especially if off-road trail runs are selected.
Warning signs of a serious problem that merits immediate evaluation include the following: pain, which increases during the run, locking or catching sensations in the ankle, especially after an injury, recurrent sprains or instability of the ankle, swelling across the front of the ankle joint, and localized bone tenderness, among others. When in doubt, have it checked out!
Dan Wnorowski, M.D.
More on ankle sprains: www.genufix.com/ankle_sprains.htm