This active 25-year-old has presented with marked “ankle pain” following all activities.
He remembers a severe inversion sprain when he was a child and informs me he has had a corticosteroid injection into the ankle joint with no success.
There are 3 very specific regions of pain:
- the anterior lateral ankle
- the posterior “ankle”
- deep in the rearfoot.
Pain is marked and lasts for days after exercise.
The radiographic assessment shows a large avulsed lateral malleolus ossicle and os trigonum. These correspond well with the described pain, which is palpated at both locations. However, on MRI, a significant osteochondral defect was noted in the posterior facet of the subtalar joint with bone marrow oedema in the talus. This is an unfortunate observation for a 25-year-old.
The main point to mention is that the patient has a problem with the ankle joint arising from the avulsed painful lateral ossicle and the os trigonum. However, his main concern is not in the ankle, yet in the subtalar joint.
Options for the patient could be:
- very controlling devices to reduce subtalar joint motion
- an US-guided corticosteroid injection into the subtalar joint
- surgery to remove the avulsed bone and os trigonum, with the possibility of PRP injection following this surgery.
It is a hard location to access if we were to consider cartilage grafting.
It must be noted that the above will not deal with all of his pain. However, if the patient has been adequately informed and the possibilities, fully explained, including perhaps little improvement in the deep joint pain, he may want to attempt the surgery to deal with the lateral ossicle and the os trigonum. But he must be fully informed that exact outcomes cannot be guaranteed, yet surgery can reduce symptoms and postpone fusion.
If you have any specific questions or would like to discuss similar cases, feel free to contact me.
Also read:
Posterior “ankle pain” (intra-operative images)
Anterior Ankle Impingement Syndrome
Platelet Rich Plasma (PRP)
(This content is intended for healthcare professionals only)