ankle injury & MRI speak and what next?

[Lothlorien]

Dear FSU,

I’m hoping someone on here might have the knowledge (and patience) to help me translate MRI findings to everyday speak and maybe someone has experience with this type of injury and its management...

Here is what happened:

early July – impact injury to right ankle
This was from a downward fall of about 3-4 feet, all my weight ended up on the outside of my right ankle and it kind of bent outwards and started swelling immediately; however, it didn’t hurt much and I was able to walk almost normally the following day; there was a lot of purple bruising which went away within days, but the swelling persisted.
I was concerned that the impact force might have done some internal damage to my ankle or that there might be hairline or stress fracture. I went to my GP a few days later to get the foot checked out and just in case I needed an xray. The GP decided that nothing was broken as I was able to walk normally, but did give me a referral to see a physio upon my request (note: this is Australia – physiotherapists are the practitioners of choice with most injuries). I saw a physio, he gave me some strengthening exercises to do, and recommended massage and a bit of tight bandaging for the swelling.

July to October – I gradually resumed some of my usual activities, though at a very reduced intensity. Some movements caused a bit of tenderness in the ankle. There was no pain, but the ankle stayed visibly puffy and seemed to give me a bit of a niggle at times. I had this strange feeling of it not being quite there – like if it would take a second or two for the ankle to get ‘activated’ and recognize the rest of my body and do what I was asking it to do.

October – by this point I felt that the ankle had recovered to about 90%. Still puffy, and some movements would cause a bit of a reaction – not pain, not tenderness, but just a reaction of sorts, which I wasn’t having in the other foot.
late October - I wanted to get back into long distance running, and wanted to make sure it would be okay, so I went to see my sports physician (he had helped me with a weird impingement in my other ankle a couple of years ago by means of a cortisone injection).
Sports physician ordered xray just in case, which came out fine, so he gave me a cortisone injection and said I should be good within 2-3 weeks.
Two days later I woke up at night in agony and unable to walk – I could not bear to stand on my foot (it would bear weight, but it would be incredibly achy). The foot felt extremely stiff and sore.
I called the doctor who said a flare up can happen from time to time and to give it a couple of days. And indeed three days later my foot seemed back to normal. Except the following night I once again woke up in immense pain (the worst pain of my life which would not lessen even with a maximum dose of over the counter painkillers). I called the doctor again, who said that the foot wasn’t behaving the way it was supposed to and recommended a MRI if the pain didn’t settle. I had a couple more (though slightly less intense) flare ups, and eventually booked the MRI.

mid-November – MRI
I can copy the full report separately, but here are the conclusions:
“transchondral lesion of the medial talar dome with a focal chondral defect and quite extensive bone oedema extending through the medial half of the talus”

This was 3 weeks after the cortisone injection. And over 4 months following my initial injury and nearly 4 months of using the foot with it being about 90% ok. I had had NO pain and NO difficulty with walking for most of those 4 months, until after the cortisone injection.
My sports physician had a look at the MRI results and said I’d given the ankle a nasty bash and that he was concerned about a bit of bone which seemed to have come detached. Diagnosed bone bruising and advised time, but told me to keep being active if I wanted to.
In the month after the MRI, the flare ups subsided to an extent, but only to an extent. They became shorter in duration but very unpredictable. Sometimes, it would flare up for a 20 minute period - very randomly.

One weekend, I went on an outdoors trip and found myself unable to walk upon arrival (this time, the ankle felt painful and tender when deployed over uneven terrain, there was no stiffness). However, the following morning it felt fine and I was able to do a few hours of (very easy) rock climbing and then walk over rocky terrain with no problem. Similar thing happened a couple of weeks later on a beach weekend – the first day walking over uneven, moving sand was hurting, the following day it was fine.

I saw the sports physician again, who was puzzled, and told me that he could not justify sending me to a surgeon because I was not in pain and able to do whatever I wanted most of the time. He reckoned the ankle needed more time. He could not explain why the flare up happened after the cortisone injection and why it was so severe when I’d been ok for 4 months.

Today:
It’s 10 weeks since the cortisone injection, 7 weeks since the MRI and exactly 6 months since the injury.
The flare ups are still happening, but their nature has changed – now it’s just intense stiffness which does not respond to pain killers or to anti-inflammatory medication. Taping the ankle doesn’t do anything. Sometimes the stiffness develops after activity (like gentle hiking), sometimes for no apparent reason at all – and hangs about for about 16 hours, then goes away quite suddenly. I can be limping badly and then walking almost normally 5 minutes later, until the next flare up. Any sort of hopping/jumping up and down causes dull but strong pain.
I’m trying to get another appointment with my sports physician, but he’s booked out for a few weeks.

What I’d like to know:
- what does the MRI mean (i.e. what is actually wrong with my ankle in non medical speak???)
- how can it be that it was 90% fine for 4 months and then became pretty much unusable immediately after the cortisone injection (I could understand a gradual worsening over the last 6 months if there is a damage inside my ankle, but the suddenness and intensity of the pain is puzzling)
- what now? wait more and do nothing in the meantime? investigate surgery options?
- is surgery the only way?
- if I need to have surgery, how long will I be out of activity? how long will it take before I can head out for a cruisy casual 30+ km run? will I ever be able to do that again?

It is pretty clear that the injury is affecting me and getting in the way of what I want to do. It would be fine if I lived a more sedentary lifestyle. But I don’t. I am a very active person (long distance running, trail running, hiking, rock climbing, bike and other activities in the outdoors – has to be outdoors and in nature). The added complication is that I’m a full time student and very pressed financially – and only have basic health insurance which has a restricted level of cover for things such as arthroscopy and surgery (it might cover the investigation, but not any actual repair work). I don’t have the means to pay for surgery.
Not being able to do things is killing me and I’m really struggling on a mental/emotional level. Activity, especially long distance running, is my way to inner peace and a means of working through stress and bad days etc.. I’m dealing with some personal stuff at the moment also, and it’s been quite uphill. I’ve been crying every day and really struggling. I can’t bear the thought of not being able to run and climb for months.



I hope someone here will be able to shed some light. Thank you so much in advance.


Full MRI findings
There is a discrete osteochondral lesion seen over the medial side of the talar dome. There is a focal 2mm area of chondral deficiency associated with a transchondral cleft. There is intense high signal seen through the talus.
In addition, there is a second osteochondral lesion seen over the lateral side of the talar dome. There is a focal area of chondral loss with subcortical cystic change and a moderate amount of bone oedema.
In addition, there is a large ankle joint effusion with a synovitis. The subtalar and talonavicular joints are intact. I note an accessory os navicularis and this distorts the talonavicular joint ligament. The anterior process of the calcaneus is preserved.
The Achilles tendon and plantar fascia are preserved. The ligaments of the distal syndesmosis are intact. The has been high-grade tearing of the anterior talofibular ligament with a disorganized frayed ligament. There is scarring of the extensor retinaculum and there is marked thickening and fraying of the calcaneofibular ligament. I note an intrasubstance split within peroneous brevis at the level of the fibula and indeed there is high signal seen within the fibula itself.
The flexor tendons are normal. There is increased fluid in the tibialis posterior tendon sheath.

[pingu]

Full MRI findings

There is a discrete osteochondral lesion seen over the medial side of the talar dome.
There is a lesion on the upper-inside part of the bone which is under the tibia, on the cartilage and part of the bone that is attached to it

There is a focal 2mm area of chondral deficiency associated with a transchondral cleft.
There is a lack of cartilage in that area, and near that the cartilage is split

There is intense high signal seen through the talus.
The area within that bone is more visible in the MRI, it means that there is an inflammation

In addition, there is a second osteochondral lesion seen over the lateral side of the talar dome.
There is another lesion on the upper-outside part of that bone

There is a focal area of chondral loss with subcortical cystic change and a moderate amount of bone oedema.
There is an area with less cartilage; and a cyst in the bone, which is swelling

In addition, there is a large ankle joint effusion with a synovitis.
There is liquid in your ankle, and the synovia, the membrane which is around the ankle joint, is inflamed

The subtalar and talonavicular joints are intact.
The other joints of the anke are fine

I note an accessory os navicularis and this distorts the talonavicular joint ligament.
There is an additional part of bone, on a bone which is inside your foot, and of course it affects the ligment between this bone and the bone you injured

The anterior process of the calcaneus is preserved.
The area between the calcaneus and the injured bone is fine

The Achilles tendon and plantar fascia are preserved.
the achilles tendon and the sole of your foot are fine

The ligaments of the distal syndesmosis are intact.
Same for the ligaments on the midfoot

The has been high-grade tearing of the anterior talofibular ligament with a disorganized frayed ligament.
There is a severe tearing of the legament between fibula (calf bone) and the injured bone. It is worn at edges and its fibers are not aligned anymore

There is scarring of the extensor retinaculum and there is marked thickening and fraying of the calcaneofibular ligament.
There is a scar on some ligaments on the top of the foot, and the ligament between calcaneus and fibula is thick and worn at edges

I note an intrasubstance split within peroneous brevis at the level of the fibula and indeed there is high signal seen within the fibula itself.
A muscle that runs along your calf bone is torn, and there is an inflammation in that bone too

The flexor tendons are normal.
The tendons of the muscles that bend your foot down are fine

There is increased fluid in the tibialis posterior tendon sheath.
There is some liquid in the membrane that covers a muscle that is in the back of your leg

English is not my mothertongue, so I know that I may not be the best person to explain to you the MRI. I hope you understood at least the general meaning

IMO you should get checked by an orthopedist.
Also, it is strange that your physio didn't give to you any proprioceptive excercises for your ankle, they are very important when you have a sprained anlke. That's why you had that strange feeling of not really feeling immediately the ankle.

Let me know if you have any other questions

[rfisher]

Essentially, you bruised the bones that are the top of the foot and tore several ligaments. Torn ligaments can take 6 months to a year to heal--you'd have been better to have just broken the fibula. You really should have seen an orthodedic surgeon. I'd still want to see one although they may not be able to help at this point.

[*Jen*]

I did a very similar thing and was treated in Australia as well. IME surgery isn't done, and a surgical consult isn't even done, unless it's really, really bad. They prefer the wait and see approach.

I didn't do exactly the same as you, but here's what I did: 3 severely torn ligaments and bone bruising. Treatment = physio 3 x week for 12 weeks. After 6 months, there was no way I could run. It was 9-12 months. Rfisher is right, it's better just to break it than do ligaments!

Anyway, 15 months later, I did it again while running, which the physio wasn't happy about since he'd spent so long treating me and doing strengthening exercises etc, but I rolled it freakishly when I stepped onto a little ball by accident. With no ligaments left to tear, I just had very severe bone bruising and ligaments trapped into the joint on top. Curiously, I had to wear high heels for ages to get it right! And more physio.

Moral: Rfisher is right. Ligament injuries take a long, long time feel better. I had pain on and off for years, but not as bad as yours. You'll have to keep it strapped while exercising for a long time, and make sure you get a long course of treatment with the physio to strengthen it.

Also, you ARE in pain, so insist on the surgical consult if you want it.

[Aceon6]

"there was a lot of purple bruising which went away within days"

The ortho at my former hospital taught me that swelling+purple always means that something is bruised, broken or torn. He'd do xrays first to check for damage to the small bones of the foot (most common), then an MRI if he suspected a tear. He'd immobilize immediately, either with a wrap or soft boot.

Unfortunately, Jen and rfisher are right. Your physio should be able to recommend some sort of program to reduce the intensity of the flare ups and and prevent additional damage.

[*Jen*]

Oh yes. It's all coming back to me now. I saw a doctor first who x-rayed and ruled out a break and said I'd be fine if I stayed off it for a week. I wasn't. I went to the physio and the first thing she said when I told her it was purple and took my sock off was "oh yes, something's torn"

[Lothlorien]

Aaaaargh. Neither the GP nor the physio were concerned about the purple bruising. I did say to them all that the force of the impact on my ankle was quite strong and that I was concerned that something might have happened inside even though it wasn't obvious.
Yep, I have been thinking that breaking something would have been a better outcome... I'd be likely to be on the way to recovery 6 months later. Sigh. :-(
Now it's going to be a few weeks before I can have it looked into and then aaaaaages to recover.

The physio kind of should have known better, especially since he told me about his own ankle injury, but most disappointing is the fact that the sports physician didn't pick up on it when I showed him a picture of what my foot had looked like after the injury.


I've had two doctors (specialists) look at the report and the MRI images, and they didn't bring up the ligaments - they were concerned about cartilage damage (which I think is different from the ligaments, right?). It was a mostly up ---> down impact, and my ankle rolled to the outside only slightly. I actually do have a full range of motion in the foot and no problems with balance. Unless it's flaring up, when it stiffens and freezes a bit - I can still move it in all ways etc. but the dull ache gets in the way of that a bit.


Thanks a lot for your replies. I mostly wanted to get the MRI findings translated to something simpler. :-) Nonnative speaker here as well, so it's all pretty complex terminology for me. Thank you so much pingu!

Thanks for sharing your story Jen.

rfisher - why do you reckon a surgeon might not be able to help at this point?

[*Jen*]

Cartilage damage is more worrying than ligaments, because it never grows back. Neither do ligaments, but you can at least strengthen the muscles to help that. The cartilage prevents the bones from rubbing together, so you miss it when it's gone! My mother has very little cartilage in one of her knees.

The bruising alone isn't necessarily indicative of anything that serious. A serious sprain will give you bruising, because tearing ligaments IS a serious sprain. There's really nothing that can be done about it except rest, ice, compression and elevation.

I assume they would have tested your movement and reflexes, and if they were fine, then the bruising and tearing isn't a worry. If the tear is so severe that you can't move your toes, for example, then it's something to worry about. You've said you have full range of motion and balance, so your doctors are right - the cartilage is definitely more of an issue than the ligaments. It will just take time to feel normal again, that's all

[rfisher]

Aaaaargh. Neither the GP nor the physio were concerned about the purple bruising. I did say to them all that the force of the impact on my ankle was quite strong and that I was concerned that something might have happened inside even though it wasn't obvious.
Yep, I have been thinking that breaking something would have been a better outcome... I'd be likely to be on the way to recovery 6 months later. Sigh. :-(
Now it's going to be a few weeks before I can have it looked into and then aaaaaages to recover.

The physio kind of should have known better, especially since he told me about his own ankle injury, but most disappointing is the fact that the sports physician didn't pick up on it when I showed him a picture of what my foot had looked like after the injury.


I've had two doctors (specialists) look at the report and the MRI images, and they didn't bring up the ligaments - they were concerned about cartilage damage (which I think is different from the ligaments, right?). It was a mostly up ---> down impact, and my ankle rolled to the outside only slightly. I actually do have a full range of motion in the foot and no problems with balance. Unless it's flaring up, when it stiffens and freezes a bit - I can still move it in all ways etc. but the dull ache gets in the way of that a bit.


Thanks a lot for your replies. I mostly wanted to get the MRI findings translated to something simpler. :-) Nonnative speaker here as well, so it's all pretty complex terminology for me. Thank you so much pingu!

Thanks for sharing your story Jen.

rfisher - why do you reckon a surgeon might not be able to help at this point?

A lot of healing with associated scar tissue formation and callus have occurred which complicate matters regarding doing reparative surgery. I'd still see one just in case. Cartilage and ligaments simply don't heal well once damaged. They don't get good blood supply to bring in nutrients. Sometimes the damaged areas can be scraped down and reattached or be replaced, but only a surgeon can make that assessment and that would be much more successful immediately after the injury. It's likely you'll just have to learn to live with this and modify your activities. Sorry. Again, if it were me, I'd still get a consult just so you'll know. And, unless your specialist physician is a radiologist (who interprets MRI) or an ortho, they probably have only a rudimentary knowledge of the MRI report. Moreover, an ortheopod is going to want to actually see the images.

[*Jen*]

Actually my understanding of sports physicians in Australia is that they are trained to read MRIs etc since they specialise in the treatment of sports injuries. I might be wrong, but I saw one of those throughout my very active childhood. Also, I had a physiotherapist with a much better understanding of x-rays and MRIs than the orthopedic surgeons my brother and I were referred to.

The surgeon told my brother he had no option but to have surgery or he'd never get full movement of his arm back. It was back to normal through physiotherapy. I was told that I had extra sesamoid bones in my feet, but that was no reason for pain. Yeah. Turns out I BROKE both sesamoid bones in both feet, I wasn't born with extra

By all means, get a consult, but I wouldn't take the fact that the physio and sports physician aren't orthopedic surgeons to mean they can't read scans. In my experience of Australian medicine, they're far more up to date and comprehensive than surgeons.

[Lothlorien]

Thanks. :-)

Yes, both sports physicians I saw are specialists and read MRIs and assist with surgeries, so that's not an issue. My main one didn't even need to see the report - he just looked at the images and interpreted them. Some physios can be good as well, I think, especially ones at sports/ortho clinics and those who work with athletes. But not necessarily the physio down the road. Physios in Australia are a bit different than in the US/Canada.


In Australia it is necessary to have a doctor's referral to see an orthopedic surgeon, so I have to wait till I can get an appointment my sports physician (who usually had plenty of free appointments and now he suddenly doesn't...). He was concerned about the cartilage damage and a small bit of bone which seemed chipped/broken off when first examining the MRI. Then I'll have to see what the surgeon says. I'm hoping to eventually find an answer as to why the ankle seemed fine for 4 months and then started flaring up like that after the cortisone shot.

I'm just a quite down a bit bitter about this whole thing, and the circumstances of the injury. I won't go into details, but around the same time, two good friends who participate in similar activities got ankle injuries as a result of ill-considered choices and risky actions. Both injuries seemed far worse than mine, yet 6 months later they're fine, and I'm not - and the circumstances of my injury were more a case of bad luck in a controlled situation. Sigh. But I'm not ready to give up - and won't. :-)

[rfisher]

As a radiographer who teaches MRI, I will tell you flat out it takes a radiologist 2-3 years to learn to make accurate diagnosis of MRI scans. Other physicians and physical therapists don't have nearly the same training. They think they do, but they don't. Physical therapy programs in the US are doctoral programs requiring 8-9 years of post-secondary education and they have exactly one class on medical imaging. One. I know because I help our PT program teach it. Lots of specialists think they can interpret MRI or CT scans and they really cannot. The sectional anatomy alone is difficult enough, but understanding the principles of an MRI image are an entirely different ballgame. Depending on how the scan is done, high vs low intensity signals indicate very different pathologic conditions.

[*Jen*]

Yes, but the whole system of training in Australia is very different. You really can't compare

I don't know the ins and outs, but I will ask my physio friend how much time was spent on radiography. She has a 5 year undergraduate degree plus a master's, all in physiotherapy, and about 40% of the training was practical. I'm positive they do much more than 1 class on reading MRIs but I'll have to ask her to find out just how much.