ankle clicking lateral malleolus

[angeloftheuk]

Dear all,
This is actually a new problem addition to the 'problematic ankle' thread, and apologies since I am not actually a physio (I am a community nurse) since this is to do with my 12 year old daughter (13 in December). I am asking you all out there since she seems to be getting nowhere at present!

Like one of the other patients she is a dancer and a very serious one (has been offered a place at a vocational full time school). 3 years ago had a right lateral malleolus fracture and an MUA to correct it, in cast for 3 weeks then weeks of traditional physio - ankle turns, strengthening with thera bands, balancing exercises then gradually weight bearing. She seemed to recover fully then 6 months later appeared to have a bad sprain. Repeated all of recovery regime except for cast.

Nothing after that till January when had fall on mini-trampette (purchase of which advised by last physios!) She had been doing a lot of dancing prior to this, some on pointe. Was startled at hospital to hear she might have a non-union of distal fibula from original fracture. Was worried re this so got second opinion. The second consultant has a special interest in non-unions and is a paediatric orthopaedic surgeon. He was not sure if if was a non-union or a kind of malformation of fibula, malformation meaning that the distal part of the fibula had never united properly with the rest. Have only just got him the original xrays and have not had a definitive diagnosis out of him 3 weeks after my daughter has come out of her cast.

Have commenced physio - therabands again, balances etc but when she does double rises there is a clicking sound in her right ankle and a brief pain when she rises up. The pain she describes as a 1 on a 1-10 pain scale. Because of this it is difficult to strengthen the ankles more. She says she tends to rise quicker and not develop control because of trying to get past the pain. The pain has not got any worse and only occurs in rises. She does not experience pain in any other situation - she walks to school forty minutes a day and is very healthy in every other way. I am worried because I do not want to cause any more damage to her ankle. But as a dancer she certainly cannot progress without resolving this problem. she has just taken (for those ballet fans out there) her rad intermediate foundation with a distinction and had commenced her intermediate training.
Even if she cannot do dance, athletics are her other great love and I am worried about her ankle in this respect also!

Any physio advice very greatly appreciated. sorry for long post.
am petrified of surgery she may have to undergo. she has already spent so much time in a cast!

[linbin]

hi
i feel she should take an MRI,to know exactly what's happening there.also stengthening wise ,peroneal group should be given more emphasis.

[angeloftheuk]

Thankyou so much.
I am worried sick about this due to extent of history regarding it.
have really horrible feeling that whatever the fracture status, she may have a sublux of peroneal tendons.
this has not been confirmed yet but i just have a gut feel from my own reading. if so this is apparently pretty rare in a child. i think it means that it cant be operated on immediately as you can with an adult and also that it is quite often recurrent with conservative physio. my daughter is desperate to continue with her dancing and performing. i did come across an idea for a fibreglass mould to allow her to continue performing which would still hold the tendons in place.

any further ideas, please?

[Canuck Physio]

Originally Posted by angeloftheuk

Like one of the other patients she is a dancer and a very serious one (has been offered a place at a vocational full time school). 3 years ago had a right lateral malleolus fracture and an MUA to correct it, in cast for 3 weeks then weeks of traditional physio - ankle turns, strengthening with thera bands, balancing exercises then gradually weight bearing. She seemed to recover fully then 6 months later appeared to have a bad sprain. Repeated all of recovery regime except for cast.
I think this is where traditional therapy appears to falter, often times the patient appears normal yet there is significany underlying weakness, imbalance, decreased joint proprioceptive feedback and balance control. I would hope that the rehab involved getting the ankle up to 110% and then testing it on day to day activities.

Nothing after that till January when had fall on mini-trampette (purchase of which advised by last physios!) She had been doing a lot of dancing prior to this, some on pointe. Was startled at hospital to hear she might have a non-union of distal fibula from original fracture. Was worried re this so got second opinion. The second consultant has a special interest in non-unions and is a paediatric orthopaedic surgeon. He was not sure if if was a non-union or a kind of malformation of fibula, malformation meaning that the distal part of the fibula had never united properly with the rest. Have only just got him the original xrays and have not had a definitive diagnosis out of him 3 weeks after my daughter has come out of her cast.
As the other post mentioned, this would be vitally important to understand through MRI, as this may indicate a significantly different course of treatment.

Have commenced physio - therabands again, balances etc but when she does double rises there is a clicking sound in her right ankle and a brief pain when she rises up. The pain she describes as a 1 on a 1-10 pain scale. Because of this it is difficult to strengthen the ankles more. She says she tends to rise quicker and not develop control because of trying to get past the pain. The pain has not got any worse and only occurs in rises. She does not experience pain in any other situation - she walks to school forty minutes a day and is very healthy in every other way. I am worried because I do not want to cause any more damage to her ankle. But as a dancer she certainly cannot progress without resolving this problem. she has just taken (for those ballet fans out there) her rad intermediate foundation with a distinction and had commenced her intermediate training.
There is no reason why she can not get to 110% and then have an ankle maintenance program thereafter. I would ask you to be adamant towards any practitioner to assess and re-assess the joint strength, mobillity, and stability to make sure that she is more than 100%, and able to do complex ballet movements. That should be your goal, and I believe intensive and progressive therapy is necessary. Additionally don't expect the therabands to work forever, the training adaptation response to those bands can occur after just a single workout, ask your physiotherapist how the exercises can be progressed and modified to optimize the strength of the ankle.

Even if she cannot do dance, athletics are her other great love and I am worried about her ankle in this respect also!
As suggested previously, the goal should be used to define the aims of physiotherapy treatment.

Any physio advice very greatly appreciated. sorry for long post.
am petrified of surgery she may have to undergo. she has already spent so much time in a cast!

As above, will wait for the results and further response/queries.

There is a lot of work that could be done to optimize the health of that ankle:
- Muscle balance work
- Massage
- Heat/cold therapy
- Myofascial release,
- Strength exercise
- Mobility exercise
- Joint mobilizations
- Proprioceptive work
- Plyometric work
- Stretch/Relax work
- Balance and stability work
- endurance work
- Facilitation of movement

To optimize the fitness/health of the ankle is important in maintaining physiological, and postural balance of other component parts of the body. Make sure you get a full and thorough assessment and a progressive treatment plan.

Regards,

[jesspt]

Maybe I've missed something in the previous posts, but it sounds like her pain levels are fairly minimal.
I've some quesitons:
1. Does the clicking sensation cause pain laterally, and does it occur 100% of the time when she does a heel raise?
2. Other than the clicking and the 1/10 pain, are there any other symptoms?

I would suppose that subluxing peroneal tendons are a possiblity.

From what I'm reading, her symptoms sound pretty mild. Does this seem to be due to the fact that she's dancing minimally, or have the symptoms been 1/10 for quite a while.

I suppopse her pain could be due to a non-union, but if that's the case, the clicking and the non-union may be totally unrelated.