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ankle My left ankle

Discussion in 'Other joint replacements' started by Celle, Apr 4, 2016.

  1. Celle

    Celle Forum Advisor
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    I have been having pain and swelling intermittently ever since I sprained my left ankle, in October 2006. Following the sprain, I had physiotherapy, followed by orthotics, to prevent overpronation of my foot and ankle.

    For a while, I developed peroneal tendinitis, which eventually subsided. I persevered with the orthotics for some time, but they never really seemed to help, so I gave up wearing them (they were hot, uncomfortable and ugly).

    My ankle pain and swelling have increased over the past couple of years, to the extent that I decided to find out what was really going on. Much of my pain and swelling is inferior and slightly anterior to the lateral malleolus, with a very tender lump over the malleolus.
    Symptomatically, I also feel that I am developing arthritis in both feet.

    Following an inconclusive X-ray of my left ankle, my GP referred me back to my OS, who ordered an MRI, which I had last Thursday. (The radiologist reported nothing significant, but my OS showed me several places where he could see narrowed joint spaces, indicating arthritis.)

    I saw my OS this afternoon. He discussed my X-ray and MRI with me, showing me various things on his screen. I could see narrowed joint spaces and that there is some deterioration of the talus and navicular bones – on the MRI pictures, part of them looked white, with small cysts, instead of the clear black of the rest of the bones.

    This is the MRI report (I don’t have pictures, unfortunately):

    MRI Left Ankle 31 March 2016
    Indication
    : Painful swollen left ankle. Probable arthrosis. Confirm severity of chondral changes.
    Technique: Standard MRI ankle protocol.
    Findings: There is a generalised ankle oedema, slightly more pronounced laterally and anteriorly.

    There is thinning of articular cartilage of the tibiotalar joint with resulting joint space loss and subchondral oedema medial talar dome. There is also mild subchondral oedema of the distal fibula and more pronounced subchondral oedema with cyst formation around the intertarsal articulations, particularly medial facet of the subtalar joint which also shows thinning of articular cartilage and resulting joint space loss.

    There is osteophytic lipping of the talonavicular joint associated with capsular hypertrophy. Further osteophytic lipping is also noted between the remaining intertarsal articulations. Appearances are consistent with arthrosis.

    Lesser amount of subchondral oedema and subchondral cyst formation is noted of the first, second and third tarsal-metatarsal joints associated with osteophytic lipping and moderate chondral thinning and joint space loss.

    The ligament and tendons of the left ankle are grossly intact except for the anterior and posterior talofibular ligaments which are attenuated and indistinct, suggestive of partial tearing if there has been a history of trauma.

    There is a 12 x 9 x 11 mm. fluid signal intensity structure anterolateral to the talus (7/8) which may represent a small ganglion cyst.

    The very distal peroneus brevis and longus tendons are suboptimally visualised, likely related to magic angle artefact rather than pathology. Clinically correlate.

    The sinus tarsi demonstrates normal fat signal intensity.

    There is a small calcaneal plantar spur but no evidence of plantar fasciitis.

    Fluid is noted around the flexor halluces longus tendon, of doubtful clinical relevance.

    Impression: Significant arthrosis of the left ankle with thinning of articular cartilage and joint space loss, osteophytic lipping and significant subchondral bone marrow oedema and cyst formation. Indistinct and attenuated anterior and posterior talofibular ligaments are suggestive of partial clearing if there is a history of trauma.

    Generalised soft tissues oedema of the left ankle which is more pronounced laterally.

    Underlying inflammatory arthropathy not excluded.

    Small ganglion cyst.


    At this appointment, I was only wanting to establish the cause of my continuing pain – not expecting that there would be any immediate treatment. I admit that I suspected some mild degree of arthritis, but I thought my intermittent but recurring pain was probably tendinitis. I was wrong.

    The ganglion probably accounts for the painful lump over the malleolus.

    My OS has suggested that, as this degree of pain is currently “liveable”, no surgical treatment is warranted right now. We discussed having a steroid injection into the sinus tarsi, but he said this would only give temporary relief and probably wasn’t worth-while. I can’t have NSAIDS, because of my bleeding disorder.

    If the pain persists and gets much worse, the surgical option would be a subtalar fusion (including talo-navicular fusion) which would eliminate lateral movement of my ankle, but would not restrict dorsiflexion or plantar flexion.

    Meanwhile, my OS has recommended a UCBL type orthotic (rigid heel cup with medial arch support), to restrict lateral movement of my ankle. On the request form for the orthotic, he has put the diagnosis as “Post traumatic arthrosis left subtalar joint.”

    We’re sticking with “post traumatic" for now, as I still have a claim with ACC (Accident Compensation Corporation) relating to the original accident and ACC has covered my costs so far.

    My OS said “Try the orthotic for a while. It may help. If it doesn’t, come back and see me and I’ll refer you to my colleague for the fusion.” He specialises in knees and hips, could do the fusion but prefers it to be done by someone whose specialty it is.

    @Josephine , @Orthodoc , I’d welcome your opinion here, particularly with reference to the recovery period and success rate of subtalar fusions. I know that non-union is sometimes a problem.
    Thank you.
     
  2. Jaycey

    Jaycey Moderator

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    @Celle So sorry you are suffering with this. I don't have any answers but I too have a bad ankle (tore all the ligaments in a running accident years ago) and must wear orthotics. They do take awhile to get used to but they certainly work for me. Only problem is that I literally have to wear shoes as walking bare foot without the orthotic support is quite painful.

    I hope you can get some relief soon!
     
  3. Josephine

    Josephine NURSE DIRECTOR, BONESMART Administrator

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    You poor ol' thing! I'm so sorry you're suffering this.
    Recovery period is generally about 4-8 months and the success rate is not recorded though it's usually pretty good.
    It really depends what kind of fixation is used. If done well and post-op protocols are followed - limited weight bearing until after bony union is clearly established - then that shouldn't be a problem.
     
  4. Pumpkln

    Pumpkln Forum Advisor

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    Celle,
    Sorry to hear you are going though troubles with your ankle. Hope the orthotic works and your ankle starts to feel better.
     
  5. Celle

    Celle Forum Advisor
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    Thank you all for your replies.

    At the moment, I'm still getting over my surprise that I actually have a valid reason for the ankle pain. Because it has been coming and going for so long, I really thought it was a soft tissue problem and I was mentally prepared for PT and gentle exercises. I'll certainly give the orthotic a good try, although not being able to go barefoot in the summer will be irksome.

    I did know that I'm one of those "fortunate" people who get OA in multiple joints and I had felt its twinges in my feet, but somehow I hadn't related this current pain to OA.
    So far, I know I have OA in fingers, thumbs, right elbow, neck, and now, my feet. Thankfully, my hips are still OK! :fingersx:
    Not being able to take NSAIDS is a bit of a nuisance, too.

    I won't be rushing into the surgery.
     
  6. Celle

    Celle Forum Advisor
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    I went to the orthotic department at the hospital this morning, to have a plaster mould of my foot taken, so that a custom orthotic can be made. The orthotist was very thorough, taking a history, examining my foot and ankle, and having me walk around the room barefooted. After that, he made the mould.

    I was a little surprised to find that the plaster mould encompassed my entire foot and ankle, not just the ankle, sole and heel. He first put on some stockinette, then marked it with a felt pen, to show where my ankle bones and other landmarks were situated. He inserted a plastic ruler down the front of my foot and ankle, then he wrapped the wet, plaster bandage around.

    When the plaster was dry, he cut it down the length of the ruler, so he could remove it. He used an open blade, like a Stanley knife. I held my breath, hoping that the knife wouldn't slip. It didn't.

    This orthotic is going to be quite big, as he intends to extend it to cradle my big toe joint as well. I hope it fits in my current shoes! It will look a bit like these:
    UCBL orthotoc 1.jpg UCBL orthotoc 2.jpg
    They're made of polyethylene. Mine is to be coloured pale blue-grey, with small yellow daisies on it. The orthotist said that they started colouring them to make them more acceptable to children. This big kid likes the idea, but will be more impressed if it is comfortable and fits my shoes! It should be ready in 2-3 weeks.
     
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  7. KarriB

    KarriB Forum Advisor

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    Last summer I tried Vionic ortho heel flip flops because of the pain in my heel, but I've read of some who wear them for over pronation. I'm sure your custom orthodic will provide better support, but if you're looking for something different you can check them out on zappos. It did take about a week for me to get used to them and they did bother my knees and back at first, so I wore them for short periods of time. But my Vionic flip flops sit right beside my bed so I can slip into them as soon as I get up and I always wear them when driving long distances, even in the middle of winter!
     
  8. Celle

    Celle Forum Advisor
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    Thanks for the suggestion, @KarriB . I've located a store in my town that sells Vionic shoes. The orthotist has told me "No more sandals or bare feet", but I know I would hate wearing closed in shoes in hot weather.
     
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  9. kneeper

    kneeper Forum Advisor

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    I hope the orthotic helps. They can be hot, but if they relieve the pain...
     
  10. KarriB

    KarriB Forum Advisor

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    @Celle are you in fall now and going into winter? I know your winter isn't like ours, but it will be better weather for closed in shoes.
     
  11. Celle

    Celle Forum Advisor
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    Yes, Karri, it is early autumn/fall here.

    We live on the coast and we don't get very cold winters - probably only about two mild frosts a year.
    I do wear Mary-Jane type shoes in the winter and I have several pairs by Ziera, whose last suits my feet. They have the facility to remove the insole and replace it with an orthotic, so I'm hoping the new orthotic will fit. It does look rather bulky, though, so I might have to buy a larger size. We shall see, when I get the orthotic.

    I'm going to England in 8 weeks' time, to spend several months there, based with our daughter and her family. I'll need some summer shoes there and I'll also need a pair of slip-ons to waer around her house. She usually asks for no shoes indoors, but I'll keep this pair for indoors alone.

    I've located a store in our town that stocks Vionc shoes and I'm going there tomorrow, to have a look.
     
  12. KarriB

    KarriB Forum Advisor

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    Yep, I'm usually a no shoes in my house person, until plantar fasciitis. Now I keep one pair of Vionic flip flops for just inside the house. They also sell slippers which I have, but the flip flops are better for me.
     
  13. Celle

    Celle Forum Advisor
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    Hi @KarriB - I bought a pair of Vionic slides this morning. Thanks for the suggestion. We'll see how they go.

    The orthotist phoned this afternoon, to say that my orthotic has arrived. I'm going to have it fitted next Wednesday morning.
     
  14. KarriB

    KarriB Forum Advisor

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    I had to break them in over a few days because my knees, legs and feet were hurting. That's the advice from the company also, because they line everything up correctly. Hope they help!
     
  15. Celle

    Celle Forum Advisor
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    I picked up my orthotic this morning.
    DSC04092 - Copy.JPG DSC04093 - Copy.JPG DSC04094 - Copy.JPG It's rigid and it only fits in one pair of shoes - my new sandals.
    The wedge under the big toe is so thick that there's no room for my foot to go into my Mary-Jane shoes.

    I'll have to wear socks with it. Socks with sandals - Ugh!

    I will give it a good try but, at the moment, "I do not like it, Sam-I-Am!"
     
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  16. KarriB

    KarriB Forum Advisor

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    Oh my goodness! I can't imagine that fitting into any shoe.
     
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  17. Celle

    Celle Forum Advisor
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    I wore the prosthetic for about an hour and then I had to take it off. I'll give it another try tomorrow.

    I think I'll be going back to have it adjusted - that wedge under the front of the foot is going to have to go! The orthotist put it there to try and correct the over-pronation but, as I understand it, the purpose of the prosthetic was to stabilise the large foot bones that have arthritis. I've over-pronated for many years, but the arthritis is relatively new.
     
  18. Pumpkln

    Pumpkln Forum Advisor

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    Overkill on those orthotics, they should give you the least that you need, not the maximum correction for non existent problems.
     
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  19. Celle

    Celle Forum Advisor
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    Unless the orthotic is modified until I'm happy with it, it will be $900-worth of useless junk.
    I won't wear it if it won't fit in other shoes. With winter approaching, I can't wear sandals. I love those sandals and I don't want the orthotic and the weather to ruin them.
     
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  20. Celle

    Celle Forum Advisor
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    I've made an appointment to see the orthotist again - next Wednesday at 1 p.m. I'll keep trying the orthotic for short periods. That way, I'll be able to pinpoint exactly where it needs to be adjusted. I think that having it for a week is a fair trial to establish obvious problem areas, although one day was enough to find the most obvious ones.

    I don't want to correct the over-pronation. I've had it for more than 10 years and my body is used to it. Trying to correct it now would mean my body would have to adjust to all sorts of different angles and stresses. I'm 74 now and don't want to have perfect gait, but just to walk without pain.
     
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