Daily Mobility Exercises by Dr. Kelly Starrett Forums General Lateral Malleolus displaced after sprain

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    • #71211
      AvatarDaniel Lugn

      Hi all,

      I was really hoping to find a solution to this on my own,
      but up till now I have yet to find an for what is quickly becoming a chronic
      problem and I feel I have explored most avenues the medical system has to
      resolve this.

      Back in April I took a doozy of a inversion sprain to my
      left ankle while running (in a weighted vest I might add) accidentally stepping
      into a gopher hole. It ended up being a serious grade 2 with a mild High Ankle
      to make it extra nice. Four months later I found myself cleared of the injury
      by two different PTs and carefully began to return to running. The lateral
      malleolus remained very swollen or raised up, which I was told could be normal
      and may last several months. Fast forward to today and its just as raised as
      before and causing chronic problems with my peroneal.


      Because one of the peroneal tendons runs along a groove in the
      malleolus and my malleolus is basically raised out of its normal position, this
      tendon does not sit well in its groove. Instead it will gently slip out of the
      groove with no notice and snap back into it during certain ankle and foot
      movements. Neither of these events are painful to the tendon however if it
      happens enough the peroneal muscle goes into spasm, tightens like a guitar
      string and that in itself is uncomfortable. Over the last few months of this it
      eventually led to tendonitis and even a small tear in the muscle (confirmed by
      US) that occured during stretching.

      After a lot of investigation I have come to the conclusion
      that until I get the lateral malleolus back into a normal position, the
      peroneals will continue to be irritated and prone to injury.

      A couple more things to note is the Superior retnaculum is
      intact (MRI confirmed) and Peroneal tendons are in normal position, not
      switching places (MRI and US confirmed). So though it could be classified as a
      subluxing peroneal, it is not caused by the common categories that are
      medically documented.

      Question now is why is it raised up? The US/MRI mentioned
      fluid build up in the tendon sheath, but it was a small amount and noted as
      common in athletes. Outside of that I could only imagine that the fibula itself
      slightly rotated out of normal position, but I am not sure if that is feasible
      and it was not mentioned by the PT’s I saw or the ortho doc I am seeing now.

      I am considering seeing a chiropractor next, but I am not sure if thats the correct course of action.  Maybe I am looking at this entirely wrong or there are other causes I should be considering?

    • #75570

      What are you doing to address the fluid build up?
      What is causing the fluid in the area?
      Pro Episode # 35 – MWod Pro-User Request Friday: The IT Band Primer
      Take a Yoga Tune Up Ball and strip the outside of your calf from your knee to your ankle.
      Has anyone looked at your running technique?
      A deviation in foot strike may be a cause of the situation.

    • #75574
      AvatarDaniel Lugn

      I am thinking the fluid is due to the sprain or potentially the rubbing of the peroneal tendon as it slips in and out, but honestly those are guesses and may or may not be the cause.

      I have tried starting from before I was a suppling leopard – Icing, anti-inflammatory, prolonged rest. After I started suppling – Voodoo flossing, daily soft tissue work on the peroneals (this helps relax the muscle if it goes into spasm, utilizing a lacrosse ball or barbell), plus a prescription ankle support to aid in keeping the tendon from moving (that doesnt work to well, but its not a rigid support). Is there anything more I could be doing to try to remove the fluid?
      I have not had my technique looked at, but I have not run much since September. Its hard to say how my gait was pre-injury, but I was a ball striker logging hundreds of KMs each summer without any trouble. Post injury however, I am certain my gait is off now. The ankle does not feel like it moves naturally and I think I now have a subtle limp, but I think this goes hand-in-hand with the mallelous being out a bit forcing the ankle to not move naturally. At this point I feel like until I resolve the issue with the ankle not being aligned I am not going to be able to fix my gait. But maybe this is a chicken-egg scenario – My gait is bad because my ankle is out, my ankle is out because my gait it bad?
      I know this is a complex issue and one that needs to be addressed in person by professionals. I have seen two PTs and a orthopedic doctor and going to see a chiropractor in the new year. Is there any other options I should consider investigating should this fail?
      Thanks again
    • #75577

      From Gary Reinl’s work:
      Swelling is the accumulation
      of waste at the end of the inflammatory cycle that you didn’t evacuate
      because the muscles weren’t activated. You need to move the waste out of
      the system with muscle activation. With no muscle activation the waste
      isn’t moving. Shutting off the signal(icing) to the muscles and nerves
      waste can’t move.

      Active recovery/movement will get the waste moving out of the system. Stillness is the enemy.
      Email me [email protected] and we can look at it more.

    • #75591
      AvatarDaniel Lugn

      Thanks Kaitlin

      If I don’t have any luck with the Chiropractor I may hit you up for some advice.
      Happy New Year!
    • #75593

      sounds good Bradley
      Happy New Year

    • #75669
      AvatarDaniel Lugn

      So three sessions and several cracks later I am still in the same boat. Although he was able to get some movement in the ankle, I don’t think this is the right course of action anymore as there hasn’t been any change, even immediately after the adjustments.

      The malleolus remains elevated, but something that I recently became very aware of was home much more prominent my peroneal tubercle is on this foot (I noticed this before and have mentioned it to all the professionals I have seen so far, but it was passed off as unimportant). It’s difficult to judge if its always been this way on my left foot, or it became like this after the sprain, however it is clearly much larger then on the right. Based on some reading it seems that a prominent tubercle can be the cause of irritation and peroneal tenosynovitis (something that was noted in my MRI, though I do not remember if they mentioned the tubercle being enlarged and I do not have the report to review), but I don’t know if thats the case for me. This could simply be another red herring in my endless journey of ‘i dunno’ ankle syndrome. At any rate I think I am going to need to see the orthopedic doctor again for advice.

      I am trying not to let the hypochondriac in me burst forth again, but I am starting to wonder if surgery is back on the table as the only solution for this issue. To note I am not in any amount of pain (on the pain scale of 1 to 10, its a 0 to 1 most times, 2-3 on the rare days its flaring up), just irritation and the occasional spasm that I can manage with self massage. I am able to train without much, if any additional discomfort and I could easily live with this if I knew it did not leave me open to worse injuries from regular use. I really do not want to go under the knife, but I would rather be proactive then reactive.

    • #75673

      Yes, seeing a practitioner where you have been working on things and not seeing any improvement and its not a new situation.
      If you aren’t happy with the practitioners you have seen see if anyone has referrals for you.
      I’d see if you can get the results/report from the MRI so you can bring those with you to your appointment.
      Was anything done to address what was seen in the MRI?
      Are you doing any active recovery?
      Swimming would be one option. You’ll have movement without body weight.
      Active recovery gets your muscles pumping and helps clear the irritation.

    • #75674
      AvatarDaniel Lugn

      Hey Kaitlin

      Thank you for your reply. I got a referral to another chiro/physio from a coworker who said he helped him a lot so I am seeing him in February.

      The ortho I was seeing did try addressing the tenosynovitis from the MRI, however there wasn’t much, if any change over all. Just a lot of anti-flammatory creams and a brace which I did as per his instructions for a few months. I am going to see him again next week for my follow up which I will bring up the tubercle again and get his thoughts.

      As far as active recovery… I really just went back to my normal training, sans running and over the last couple weeks began to add more dynamic ankle movements (like skipping, jumping, lunging, TGU) without much change in the overall state of it. I spent a very large part of 2014 being inactive due to this and a separate shoulder issue (which is nearly 100% better now thanks to MobilityWoD and the Supple Leopard) and honestly had enough of it. I really got to the point of “If its not getting worse when I use it, I am going to use it”. I understand rest and caution are needed to heal, but I am also of the mind set that this issue is not crippling by any stretch, so why treat it that way. I know… I am stubborn.

      I recently started Yoga with my wife which really showed a lot of glaring holes in my overall fitness, including how weak my ankles still are. I am trying to address this now with more properception training and continuing with Yoga once a week. I also went semi-barefoot/minimalist to get my feet moving again, plus I stand most of the time for work now as well. None of these things make it any worse or better, but I know its strengthening my feet and ankles

      With all that said I am trying to be as cautious as possible and listen to my body. Nothing I have done has left me hobbling around, so I am figuring its safe to proceed. Running is still off the table for now though, at least until May when the snow clears. 

    • #75841
      AvatarDaniel Lugn

      The saga continues…

      In the past few months I have been to see the orthopedic again (gave me more meds), a sports medicine doctor (told me basically that nothing was really wrong, so just go back to physio) and an osteopath and someone for IMS treatment (both were able to give some temporary relief of the spasms and pain in the calf, but nothing long term). I have also had a couple bad flare ups, both of which left me unable to walk due to pain, both of which seemingly came out of nowhere (I think it had to do with my winter boots, but cannot be certain). Needless to say this has been a very frustrating few months.

      One very important thing to note is the ‘swelling’ I thought was causing the lateral malleolus to raise up isn’t swelling at all, its actually that the entire fibula is twisting clockwise giving it the appearance of being raised. If I screw my feet into the ground I am able to rotate the fib and lateral malleolus back into position, however as soon as I relax my leg it swings right back. I am not able to get this kind of movement in my good foot, everything seems basically locked in place. Top this up with a noticeable amount of inversion laxity in the bad foot when compared to the good foot I am starting to have serious doubts about the MRIs accuracy and my superior retinaculum being completely intact. And if it is, its likely very stretched and I have some serious muscle imbalances pulling my fibula out of line.

      Anyway, I am planning to show this to my family doctor this week and I am going to ask to get referred to a different orthopedic (I live in Canada and though medical is free, its a long process getting referrals to specialists for anything non-life threatening. It could be over a year before I even get to see someone after they give the referral). I will also show this to the osteopath this week as I have an appointment scheduled and hes helping with a hip problem that is likely brought on by the limping.

      On a side note I have completely stopped any and all high impact (jumping, skipping), have went back into my brace and have been strengthening my ankle as if I was recovering from a sprain as per the PT and Sports Doc, though I dont believe this is helping at all.

    • #75913
      AvatarDaniel Lugn

      And continues…

      Over the past month things haven’t changed much. I have been actively avoiding the ‘irritants’ (running, jumping and limiting my total amount of walking to under 1 hour a day) and the pain has mostly vanished, until I cross those thresholds and it immediately reminds me that things are still messed up in the ankle.

      Through what I imagine is sheer luck I was able to see a podiatrist almost immediately after my referral and was able to request another MRI which I did privately. The results came back yesterday and confirmed my retinaculum and peroneals are intact like the original MRI (sans some fluid around them likely caused by the constant subluxation of the tendons), but it also found a few things that were missed which leave me unsure of the root cause of this issue.

      The most concerning discoveries are what appeared to be a partial tear of the ATFL (described as ill-defined) and a sprain in the PTFL (fluid build up). These results are confusing to say the least; how could I still have a partial tear in my ATFL nearly a year after the original injury? Why is there fluid in the PTFL? What does it have to do with my ankles condition and the clearly over-mobile fibula? I am not sure what to think anymore about this injury. The podiatrist is going to call me back for a follow up on the MRI within the month, so hopefully he has some insight.

    • #75985
      AvatarDaniel Lugn

      And takes a turn for the worst…

      Several weeks of limiting my activity and avoiding impact exercises things were feeling good. During one of my morning walks I decide to try a short jog to see how it feels. Big mistake apparently. A short 800m jog and initially everything feels fine, except for some tightness in my in my hams and glute. I heat and massage the area thinking its a spasm or cramp, but as the day progresses it continues to get worse. By the end of my work day I am unable to bear weight on my leg the pain is so severe. Two days later bruising shows up around the hams and behind the knee confirming I tore my hamstring (bicep femoris).

      So here I am laid up again on my couch because of this issue with my leg and ankle. I feel its all related (the bicep femoris attaches to the fibula) and I am starting to lose hope that I am ever going to be able to get back to my normal self. Ever since the original ankle sprain a year ago I have been unable to go more then 3 months without some sort of serious set back. Every time I tear or injure the area it weakens it, throws off my gait, lays me up for 3-6 weeks and the cycle repeats itself several weeks later. There has to be something wrong with my leg causing me to injure so easily during certain activities, yet still allow me to do loaded exercises without any trouble.

      I still need to see the orthopedic doctor next week, but I am worried now that this new issue its going to overshadow the actual problem and I will be misdiagnosed or like with every other specialist I have seen, not bother to try diagnosing me at all. I guess I won’t know until I see him next week and I am just going to stay on my couch until then.

    • #76135
      AvatarBrian Sable

      I came across this in hopes of answers. I am going through the exact same thing and 5 months of drs, and nothing. My MRI showed everything intact and also states no swelling. Ha. The swelling is like someone with chf and I have been given water pills. Hello…..let me get dehydrated and lose all my sodium and potassium due to the real problem causing the edema. I am about to lose my job of 15 yrs due to can’t keep up then apace. Sad, I am a physical therapist that can get NO answers but I have the answers and no dr will look into it. An Mir keeps your foot and ankle in a fixed position and doesn’t show the real problem. Because things are intact doesn’t mean that their is not a problem.

      My right foot is affected and now it I causing so mNy other problems, hip pain on the left, back pain, tight hip flexors on the right, and on and on.

      The first ortho took one x Ray on my ankle and one on my back and immediate said it was coming from my back. I have no back problems, until now. It is coming from my back and the compensation is causing the posturL changes which is causing back and bio problems. I have no radioculpathy on the sciatic nerve and am getting so frustrated. It is a true problem with either the peronials, or the fibula.

      Bradley, I was hoping to see how you are doing? I am glad to know I am not the only one but I hate that there is someone else who appears to have gone through the same thing. Just hoping to see where you are at even with this being an older thread.

    • #76136
      AvatarDaniel Lugn


      Funny that I actually wrote a follow up to my last post a couple weeks back but trashed it because I didn’t think it had much value. Prepare for wall of text.

      So the main issue has mostly been resolved, however not entirely. I saw the othor and we reviewed the problem foot and leg in detail, along with my MRI’s and X-rays and the history of the injury. He told me that it was likely during the original sprain injury I like tore the peroneal along with the rest of the ligaments. He explained that tendons don’t always heal back nice and smooth like their original form and no longer glide during natural movements. As the for the additional laxity, he basically said he has seen many dancers with more laxity and no problems because they have the ankle strength and propreception to support it. The peroneals were probably very weak from the repeated injuries and long term tendonitis, so I had to restrengthen them. I was also noted to have hyper mobility in my knees so I had to be careful not to over stretch.

      I decided that if this was the case I needed to strength my ankles and all the supporting structures up the chain. I religiously worked inversion and eversion band work (like hundreds of reps per day), calf raises, hours on the wobble board (I stand at work, so I would take my board and stand on it for a couple hours. I also went to town on glute and ham redevelopment, as they had basically atrophied from all the sitting and moping around I had been doing the past year. I had actually developed a bad hip issue on the opposite leg from all the limping I was doing and literally had to relearn how to walk properly. This is now clearing up as well.

    • #76137
      AvatarDaniel Lugn

      So the finally results after months of rehabilitation –  In bullet form so its not such a wall of text
      –    I have been running for 4 months now and did my first 10km last weekend without any trouble
      –    I am squatting heavy, jumping, burpee’ing and everything else without pain
      –    The peroneal pain is mostly gone, though does occasionally flare up if I push myself to hard or over stretch the area
      –    The peroneal still clicks, but I have decided its something I will just need to live with
      My rehabilitation plan was sort of all over the place, but the most important things I did –
      –    Minimizing stretching and massaging of the peroneals. Poor guys were beat up and did not need it in my case. They needed strength.
      –    Doing 50 inversion and 50 eversion banded ankle on both legs every day (I can actually see the development of the peroneal muscles)
      –    Doing lots of hamstring strengthen, active stretching, etc (think Romanian Deadlifts, reverse lunges, etc)
      –    Glutes, glutes, glutes, glutes. Every day. Several times a day. Because you’re a PT you should know which ones to do. I am still working on these to get my glutes working correctly again (Bonus, my butt looks great now)
      Not sure if this helps you much, but for me the biggest help was making things stronger, not ignoring them. I clearly over complicated the issue, similar to what I did with my shoulder issue which I talk about in a different thread (now 100% fixed), seeing a much more serious problem that wasn’t actually there.
      I won’t be racing this summer, but my goal is to race next year in a half marathons which no longer seems a pipe dream.

    • #76524
      AvatarStephanie Lefferts

      Hi Bradley

      Thanks a lot for discussing your case here. I’ve been having a similar problem and couldnt figure out what exactly was happening. I sprained my ankle about a month ago and wasn’t a very painful one. I could walk immidiately with a slight pain. Now after a month I have absolutely no problem in walking, just experience a slight pain if I stand on my toes for long enough. My lateral malleolus aslo appears risen and it’s not swelling.

      So I was just trying to figure out if I’m in same condition as you. Since I don’t think mine was a high end sprain is it still possible for fibula to rotate?

    • #76526
      AvatarPatrick Thomas

      Sounds like a situation to see a practitioner.
      What did you do to address the ankle sprain?
      You can’t tell the degree of the sprain only on what it looks like.
      Muscles, fascia, tissue can have damage on the inside which you are able to see from the outside.

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