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Had tendinitis and ankle sprain. X-ray showed large fracture fragment of the fibula. MRI showed severe right peroneus brevis. Treatment?

May 2014
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Practicing since : 2002
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I rollied my ankle in late May, and I thought it was just sprained. I went to the doctor in early July because it wasn't healing, and the doctor said I had tendinitis, an ankle sprain, and recommended x-rays which showed a large fracture fragment of the fibula. She referred me to a podiatrist, but the first appt was 6 weeks out in September. I asked what could be done to be treated sooner, and was referred to a PA who saw me a few days later, and she told me I was "all healed up" , even though I saw her within a week of the x-ray. I told her my ankle felt weak and hurt a lot, and she said I just needed to strengthen it, and gave me 5 pages of exercises to do. I saw the Podiatrist 5 weeks later, he saw the x-ray and said it needed a screw placed, and referred me to Otho along with ordering an ultrasound. That showed tendinosis of the peroneal tendons, a torn ligament, the fracture fragment, and a micro tear in the peroneal brevis tendon. I saw Ortho 3 weeks later, and he wrote an Rx for a fracture boot along with an MRI which was done about 10 days later. The MRI showed

1. Severe right peroneus brevis and moderate right peroneus longus
Superimposed longitudinal split tear of most distal supramalleolar and
entire inframalleolar peroneus brevis tendon.
Small, partial thickness intrasubstance tears of supra-,
inframalleolar and plantar right peroneus longus tendon.
Moderate supramalleolar and inframalleolar peroneal tenosynovitis.
Hypertrophic peroneal tubercle.

2. Very small partial thickness intrasubstance tears of right Achilles

3. Mild right anterior and posterior tibial, flexor digitorum longus
and flexor hallucis longus tenosynovitis.

4. Remote, nonunited avulsion fracture of right lateral malleolus,
with 6 x 6 x 8 mm ossicle.
Remote, moderate sprain of right anterior fibulotalar and
fibulocalcaneal ligaments

Now I'm scheduled November 6th for surgery to repair the fracture fragment and torn tendon. I'm also concerned that there has been more tendon damage because I keep getting sharp burning pains up the side of my calf and in my ankle.
Is what I've experienced the normal course of treatment?? Did the tendinosis and tendon ruptures most likely develop because of the stress on the joint from not being stabilized? It has gone from a simple fracture to my tendons failing, and I am very frustrated and painful.
Posted Sun, 3 Nov 2013 in Bones, Muscles and Joints
Answered by Dr. Vivek Chail 1 hour later
Brief Answer:
I guess you are getting the right treatment.

Detailed Answer:
Thanks for writing in to us.

Sorry to hear about your ankle injury. I have read through your query in detail and have done literature review on the problems highlighted by you.

I would like to share some information concerning tendiopathies and their treatment below.

Lower-limb tendinopathies are common. More and more athletes are spending an increasing amount of time training. This accounts for the large number of overuse injuries. The first line of management should be conservative, with physiotherapy playing an important role. If these measures fail, then consideration should be given to steroid injections, making sure that the injections is administered around, not in the tendon.

It should, however, be kept in mind that even such measures may fail. In these patients, it is probably worthwhile considering imaging. Surgery for the management of lower limb tendinopathies is technically demanding, and should be the last resort. Patients should be advised that even with surgery they may have to decrease their level of physical activity.

Treatment of tendon disorders has made great advances in the past few years. More aggressive postoperative rehabilitation has become a mainstay of treatment in an attempt to more quickly return patients to a high level of sports activities. Other important issues being examined are understanding the healing process, and the role of immobilization and early weight bearing in recovery. Minimally invasive surgery is now advocated and the use of pre-operative imaging makes surgical intervention more effective.

I think the approach taken by your doctors is the right methodology.

Hope your query is answered.
Wishing you a speedy recovery.

Above answer was peer-reviewed by
Follow-up: Had tendinitis and ankle sprain. X-ray showed large fracture fragment of the fibula. MRI showed severe right peroneus brevis. Treatment? 59 minutes later
So you're saying when the PA told me I was fine and should strengthen my ankle just a few days after an x-ray showed a fracture, that was acceptable and normal treatment???? Now my tendons are torn and the ankle is still fractured, so is that normal 5 months later?
Answered by Dr. Vivek Chail 1 hour later
Brief Answer:
Clarification to earlier reply.

Detailed Answer:
Thanks for writing in to us with an update.

I would like to make certain clarifications to my earlier reply.

The approach to treating a traumatic ankle injury is first physiotherapy, secondly the local pain and inflammation management is by administering steroid injections. If these fail in treating the pain, imaging is then recommended and followed by surgery if necessary.

As you must have noted, the above holds good in the event of a soft tissue injury with NO FRACTURE of bones. Once fracture occurs or is suspected, the entire management changes and it revolves on stabilizing the fracture with immobilization and allowing it to heal. Healing is monitored by regular imaging investigations. Fracture confirmation can only be done by imaging investigations like X XXXXXXX

Having said that, it is unfortunate that you consulted your doctor only in July and the healing process was delayed. As I am unable to see the X XXXXXXX showing fracture, it is difficult for me comprehend why the PA said, that “You were fine and should strengthen your ankle just a few days after an x-ray showed a fracture”. I have some disagreement on that point as you have rightly said.

However, the fracture and tendon tears occurred on the day of the ankle injury and the situation aggravated due to delay in approaching your doctor.

The MRI report clearly mentions “Remote, nonunited avulsion fracture of right lateral malleolus.“ As the damage is already done, screw fixation of the fracture fragment is the correct methodology in treating your condition, along with tendon repair. This is what I meant in stating that you are getting the right treatment at present. Though I agree that there was some delay in guiding you in the right direction after having detected a fracture on X XXXXXXX I am hoping that your surgery goes on well and the injury heals completely.

Best wishes.

Above answer was peer-reviewed by
Follow-up: Had tendinitis and ankle sprain. X-ray showed large fracture fragment of the fibula. MRI showed severe right peroneus brevis. Treatment? 13 hours later
Thank you.
Answered by Dr. Vivek Chail 7 hours later
Brief Answer:

Detailed Answer:
You are welcome and wishing you a speedy recovery.

Above answer was peer-reviewed by
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