Identifying A Dancer's Chronic Ankle Pain
A patient comes into the office with pain in the posterior aspect of her ankle. She doesn’t recall injuring the leg, but notes she has had the pain for over six months and that it is present at all times. An active dancer with the local ballet company, the patient adds that she experiences chronic pain when doing any form of dancing. She says the pain is far worse with high heels and ballet shoes en-pointe, but finds it more tolerable when wearing stable flat shoes. The pain is deeper than the superficial Achilles tendon region and does not radiate to any region. An examination of the patient reveals a normal vascular examination with biphasic pulses of both the dorsalis pedis and tibial arteries. The dermatologic exam shows minimal edema or erythema. There is a small effusion of edematous region medial to the Achilles tendon on the medial ankle region. This region is slightly erythematous, yet the erythema decreases with elevation of the leg. The medial ankle is also slightly painful to touch. Although there is no loss of sensation or positive Tinnel’s sign of the tibial nerve, the patient does have some localized burning in the region of the tibial nerve medial to the Achilles tendon. The musculoskeletal examination shows minimal pain in the Achilles insertion or central portion. There is some edema and pain medial to the Achilles just proximal to the insertion of the tendon on the calcaneus. There is pain with pressure on the posterior and medial aspect of the ankle joint. Range of motion of the hallux does not cause pain, yet the patient says she feels a “clicking of something” on the posterior ankle. Ranges of motion of the ankle and foot are within normal limits. The patient has a slight gastrocnemius equinus, but this is not severe or irritating to the patient. The ankle is more painful when it is placed in plantarflexion and range of motion of the hallux is being performed. Radiographs of the ankle and foot show no deformity or bony injury. There is no fracture and there are no signs of arthritic changes to the foot or ankle. What Is The Probable Diagnosis? 1. Achilles tendonitis/ tendinosis 2. Tarsal tunnel syndrome 3. Osteochondral lesion of the medial ankle 4. Shepard’s fracture of the posterior talus process 5. Flexor hallucis tenosynovitis/ stenosis Diagnostic Answers Achilles tendonitis and tendinosis are possible but in this case, it’s very rare. The patient’s pain is deep to the Achilles and she has no pain with pressure of the Achilles region. With Achilles pain, you’ll often see bulbous swelling of the tendon, usually in the central watershed area. Although Achilles tendonitis may present without a great deal of swelling, the pain the patient has with range of motion of the hallux is rare in Achilles tendonitis cases. This patient also notes some burning of the medial ankle, yet does not have any Tinnel’s signs. There is also no pain with compression of the tarsal tunnel region. If this were of great concern, you could obtain an MRI to rule out a foreign material in the tunnel and also perform a nerve conduction study to see if there are any signs of compression at the tunnel region. When it comes to tarsal tunnel cases, it’s important to rule out compression and disc injury to the lower back. An osteochondral lesion of the ankle is possible. There is edema and pain in the medial ankle region, but there is also pain with hallux range of motion, which is not in line with this ailment. Osteochondral lesions are also related to a twisting injury to the ankle, which this patient did not have. Obtaining an MRI or CT scan can be helpful in ruling out this ailment. The most common injury and cause of pain in this case would be either a Shepard’s fracture or a flexor dysfunction. Patients with flexor hallucis dysfunction commonly have chronic pain with an increase in pain after activity. They essentially have the pain all of the time but they don’t have any feeling of weakness. There is pain to dorsiflexion of the hallux and palpation of the posterior ankle. Often, these patients will also complain of a “sticking” or popping feeling in the posterior ankle. A Shepard’s fracture of the posterior process of the talus is also associated with an acute injury. In this case, it may be due to en-pointe dancing that causes compression of the posterior process of the talus at the ankle level.