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The response to the question below was authored by Marc Mitnick DPM

random medial malleolus ankle pain

by Lauren
(Denver, Co)

tibialis posterior tendon

tibialis posterior tendon

I am a 23 year old female. I was very active in high school, but not so much since, until about a month ago. I began running/walking up to five miles a day, but that only lasted for about two weeks and I have not done so since. For the past month, I have woken up with random sharp pain on the medial malleolus of both my left and right ankles. The pain is the worst and begins on the very tip of the knobs, then fades back and if i move it or walk on it weird, a shooting pain will go back up my ankle. It is fairly uncomfortable to walk on. It is sharp on the tip of the knob on my ankle, but other than that, it it a consistent pain that almost feels like my bone and ankle are bruised. My left ankle and foot is not swollen, but my right foot is slightly swollen, especially under and the right of my medial malleolus. The past few times this has happened the pain has been random in left, right, or both ankles. The pain also would fade throughout the day but this morning the pain woke me up and has been consistent all day and is just as sore as it was this morning. I don't want to go to the doctor since its random, but the whole thing is so weird to me that I'm curious if I need to. Thanks!


RESPONSE

Hi Lauren,

If I understand your narrative correctly, your pain started after initiating a walking/running regimen about a month ago. You do not mention any history of trauma, so it is safe to say this new pain came about as a result of extended running and walking; something you have not done in a long time.

Since the problem is occurring on the same part of each ankle, in varying degrees and there is no rhyme nor reason as to which ankle is going to hurt on a given day it sounds like what we call a repetitive stress problem due to a common denominator. In other words, you are essentially having the same pain in the same area of each ankle so in my way of thinking there is a common denominator that is causing bilateral, similar pain and that is your new walking/running regimen.

The first thing that comes to mind is the possibility that you are excessively pronated, meaning your feet flatten out excessively. It has not been a problem in simple every day walking but as a result of the excesses caused by extended walking and running it is now causing a problem on the inside of your foot and ankle (medial malleolus).

What happens when you are
pronated is that you get a stretching
of the structures on the inside of your ankle (and a corresponding jamming on the outside of the ankle). This so called stretching that is occurring on the inside of the ankle can cause two problems, either of which may be giving you your symptoms.

The first would be a "stretching" of your medial ankle ligaments. These are the ligaments that attach from the medial malleolus to the foot. They are designed to help maintain the alignment of the foot relative to the ankle, but if you are excessively pronated and your foot is flattening out too much then in essence, you are over-stretching these ligaments and they can begin to hurt. These ligaments attach to the base of the medial malleolus and that is where you mention your pain is originating from.

The second possibility as a cause for your pain would be irritation of the tibialis posterior muscle. This is a muscle that originates in the back of the lower leg and its tendon comes down and passes under the medial malleolus. Its purpose is to help maintain the height of the arch, so as you can imagine, if your feet are flattening out too much, this too will put excessive tension on the tendon and could cause it to start to hurt in varying degrees.

Since you mention one ankle appears to be swollen below and in front of the medial malleolus I would be more inclined to think about posterior tibial dysfunction which is inflammation of tibialis posterior, as the source of your pain.

Now, the only way to get an accurate diagnosis is to see a local doctor in your area, however, if you wish to try something first before seeing a doctor to see if you can relieve your symptoms and continue to exercise, you might consider the following.

Purchase a good pair of arch supports for your sneakers, ones that actually raise your arch and prevent your feet from flattening out. This will remove the strain on the tibialis posterior tendon as well as the medial ankle ligaments.

If you can tolerate them, try a round of over the counter anti-inflammatory medication and take them for about 10-14 days, no longer, according to the recommended daily dosing in the package insert or on the box.

Ice the area regularly to bring down the inflammation and during this time, no exercising.

Assuming you feel better after two weeks, then you may try exercising again, I would recommend long walks, not running, and absolutely make sure you are wearing your arch supports. In fact, if you can wear sneakers regularly, I would recommend the arch supports be worn all the time.

If this regimen does not relieve your pain, then I would strongly suggest you see a local foot specialist.

Marc Mitnick DPM
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Dec 21, 2018
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Ultrasound just determined 2 tears on mine
by: Ema

Had injury to both arches in Nov ‘07 n suddenly last week this Nov, l felt intense pinching pain n some swollen to right foot same spot as mentioned here exactly. Today I got Xray & ultrasound results back but my referral GP has gone on Xmas break as his Clinic is at a Church Office, nearby.
Ultrasound’s result I got today, reads : chronic changes seen to the ATFL. Tearing & tendinitis appearance seem to the tibialis posterior tendon. CFL intact AITFL intact. There is thickening n heterogeneity of tibialis posterior tendon insertion w/partial-thickness tears a 5 x 3 x 4mm & 4 x 2 x 5mm near the naviculaa. Small trace of fluid in the sinus tarsi. Peroneal tendons normal. No tenosynovitis. No ankle joint effusion. Deltoid pigment is intact.
Xray result reads : Norma alignment of ankle mortise. No bony avulsion or fracture. Small planter calcaneal spur noted. Small amount of distal Achilles insertional enthesophytosis is present. There is soft tissue swelling esp over the medial aspect. No osteoarthritis or fracture or tibiotalar joint effusion. Can u pls help me w/a temp remedy until GP is back on in Jan’19. Thankyou so much
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Keep the foot and ankle immobilized with an Ace bandage or similar item. Limit your weightbearing to necessary tasks.

Marc Mitnick DPM

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