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medial malleolus pain

by Simone
(Australia)

Hi I fractured my ankle about 10 yrs ago the medial malleolus was screwed back into place with three screws I had them removed a year later but as long as I can remember I've always had pain since the accident I've had numerous X-rays bone scans and an ultrasound,which show up nothing ..... The pain is mainly located on the medial side of my foot it radiates from the medial malleolus down to the bottom arch of my foot the medial malleolus is also tender to touch at the top of the bone which is where the the fracture had occurred sometimes the pain goes up the inside of my leg to the knee but not very often, sometimes there is slight swelling around the medial malleolus usually at the end of the day, I find it very hard to sleep at night without strong pain killers and using pain relief creams, it seems to hurt more with rest and during humidity I also know when it will rain as the pain increases even more .... I'm having a MRI done tomorrow to see if they can find something that is causing the pain, thanks in advance your opinion and or guidance would be much appreciated.


RESPONSE

Hi Simone,

In general terms, many people who have had fractures that required surgical fixation end up with some degree of discomfort going forward. In our best efforts, surgeons cannot replicate the great job mother nature did when we were first created.
All musculo-skeletal surgery, actually all types of surgery results in some degree of scar formation. Scar tissue plain and simple, is not as healthy as original tissue.
That is one part of the problem. Additionally, there can be other issues as well. When you originally fractured your ankle, your doctor(s) immediately noticed the fracture and their goal was to go in and re-set the fracture. Apparently they did a fine job as the follow-up x-rays do not reveal any serious problems. But it goes beyond that.
Even with a great surgical result, the original fracture line may have some scar tissue in it which means although it looks pretty good on x-ray there may actually be parts of the fracture line that are not completely healed with new bone. The term in known as pseudo-arthrosis or false joint. In other words, if there are micro sized areas of fibrotic tissue (scar tissue) instead of real bone along the fracture line then the healed fracture is not as strong as it should be.
This "false joint" is one of the reasons why you have pain when it is going to rain. The increase in barometic pressure creates the same kind of swelling (and Pain) in this false joint as it does in normal arthritic joints in people who suffer from arthritis.
It is not surprising that nothing has shown up on x-ray or even a bone scan. The MRI might show something but there is a possibility the pathology will be so miniscule that the radiologist may not even consider worthy of mention.
The second problem to address is the soft tissue injury that occurred when you fractured your ankle. If the trauma was severe enough to break your bone, than one can assume there was damage to the medial ankle ligament, perhaps one of the tendons that passes below the medial malleolus or even some damage to one of the nerves which passes through that area.
As I said earlier, most of the soft tissue structures that may have been damaged possibly were just ignored while your surgeon fixated the broken bone.
So, what are your options?
Hopefully, the MRI will reveal something that will explain you ongoing pain such as a pseudoarthrosis or perhaps damage to a tendon or ligament and your doctor will be able to address that.
From a simple conservative standpoint (and I am making this suggestion without the luxury of examining you), a well constructed orthotic may help alleviate the stress on the inside of your foot and make your day (and night) more tolerable.
People who tend to be flat footed (pronated) will strain the structures on the inside of the ankle, so by wearing an orthotic, the structures will be relaxed and in theory should diminish pain.
If your pain is severe enough and the MRI reveals significant damage either to bone or soft tissue, you might have to consider an additional surgical procedure to remedy the problem.

Marc Mitnick DPM
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Aug 15, 2013
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UPDATED MRI RESULTS
by: SIMONE

help i dont know what this means MRI says # status post previous ORIF of a medial malleolar fracture , with sudsiquent bony union near anatomic alignment, with small bony spur at the lateral margin of the retro-malleolar sulcus of the posterior tibial tendon # small tubular focus of cystitc tendinopathy in the posterior tibial tendon at retromalleolar sulcus extendinglongutudinally up to 9mm measuring up to 2x1.5mm with additional small tubular focus of cystic tendinopathyat talar neck level, extending close to the deep surface, extending longitudinally over 10mm measuring up to 1mm in diameter, small amount of fluid in the posterior tibial tendon sheath , without evidence of marked peritendinitis, # small non acute crack in the chondral surface of the mid medialtalar dome at the superficial margin of the medialgutter articular facet, no associated subchondrial bone marrow oedema or cystic damage # focal central osteophyte formation at the postero-medial margin of the tibial plafond with overlying smooth chondral thinning # small fibrous bands on the anterior posterior recessof the ankle and mild synovial thinning

Hi Simone,
It is the job of your doctor to go over the results of the mri with you; that is what you pay him for.
It is apparent you have a lot of "stuff" going on here and you need someone to physically examine your ankle with the mri report in hand and determine what part of the report is significant and what part is just incidental findings.

Marc Mitnick DPM

Nov 30, 2012
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Results from MRI
by: Simone

Hi I got results back from the MRI today the conclusion is

Mild scarring of the deep layer of the deltoid ligament

Subcortical bony oedema at the fibular attachment of the posterior tall fibular ligament mild scarring of the ligament and
mild synovitis in the ankle joint

I have to make an appointment to dsee the doc on Monday but can you tell in simple English terms what that really means?


Hi,

As I suggested to you, there is damage to the ligaments that attach to the end of the medial malleolus. They were probably torn when you first sustained your injury and may or may not have been addressed during the surgery.

Subcortical bony edema is suggestive of a low grade fracture.

Marc Mitnick DPM

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