Last year I was visited by a 38 year-old stay at home mom. She’d been pestered by walking pain in her left ankle for 16 months. Fifteen years earlier, she’d caught her heel in bike spokes and injured this site, but it had remained completely quiet within about three months after the bike incident. The current problem was not provoked by an accident, but began shortly after she’d initiated physical therapy for a pesky and still-persistent abdominal strain. She’d visited four orthopedists, an acupuncturist, three podiatrists, and two physical therapy groups. Among other things, her physical therapists had incorporated ankle strengthening exercises as part of her everyday program. Her diagnosis was “retrocalcaneal bursitis”, a very common issue at the outer corner of the heel bone where it touches the Achilles tendon, on the pinky-toe (or “lateral”) side of the Achilles. The diagnosis was arrived upon by the first doc, an orthopedist, and concurred upon by the subsequent string of docs she would see. She’d been prescribed orthotics, which instantly worsened her symptoms. She’d had a cortisone injection into the area where the bursa usually occurs. Acupuncture would ease her pain for inconsistent spates. Her abdominal physical therapists would pay attention to it occasionally. She’d thence discontinued all her recreational sports, including tennis, jogging, cycling and yoga.
Ultimately, and unfortunately, she’d experienced no relief, only transient activity-related pain, which was getting slowly worse. Pain did not last all day, sometimes it would not even appear for a few days. But she experienced it at least twice per week, for nearly a year and a half. On our visit day, upon my secretary’s request when she made her appointment, she brought a disc containing MRI images and the accompanying radiologist’s repost of the findings. As the MRI was taken after she’d had her cortisone shot, over 10 months and three more docs prior to her visiting me, I wasn’t surprised that no bursitis showed or was reported upon. The radiologist did report a small amount of scar tissue at the lateral corner of her Achilles, exactly where one would expect to find a bursa. She stated that this was where she’d had the cortisone shot. I poked the site…there was a little mass under the skin, but it was not tender. She quickly stated at that moment that her pain had never been exactly at this site, but slightly more forward on the heel bone, in the direction of the toes. When I palpated that spot she expelled, “that’s the spot!”
That was an unusual spot. I selected the appropriate view to check on the MRI disc. There was a 750 pound gorilla in her ankle. AKA, an accessory peroneal muscle. I’ve been inspecting MRI’s since 1992. I hadn’t seen very many of these accessory muscles, but I’ve seen many ankles not having this muscle. It was exactly at the site of her pain. As far as I could detect by radaring in on this little gremlin, there were no tears or injuries to its structure evident on the MRI.
That’s the problem with MRI. It shows abnormal and injured tissue quite often. But the technology has not yet evolved to creating a little neon sign pointing to an abnormal, yet healthy structure. For that, the physician has to know normal MRI anatomy for each area of his or her responsibility. Otherwise, one must trust the radiologist.
I went back to the radiologist’s report. In fairness, nestled in the middle of his brief paragraph describing the muscles and tendons, he did mention this muscle (called the peroneus quartus). As there was nothing wrong with the muscle, he unceremoniously moved on to describe the only pathology on the entire scan, the benign little bleb of scar tissue at the site of the bike injury. That’s what she’d been treated for, for 16 months.
That wasn’t her pain site. It is a good principle to realize that a physician must have at least twelve eyes, as I’ve been teaching my students at the podiatry school for decades. Two of these eyes are in one’s head. The other ten eyes must be the fingers. I always palpate to establish the exact site of the pain. Then I might look at an X-ray, MRI, ultrasound scan or whatever to correlate the site with pathology or deliberate if the pain is referred from an injured nerve, for example.
It is also a good principle to realize that human beings are made out of tissues, and usually they are normal tissues. Tissues which heal when treated appropriately, and don’t heal when they are not. So why was this otherwise-healthy young woman worsening? Two things were obvious. The diagnosis was incorrect, and some element in her habit/physique was perpetuating the problem.
I knew what the diagnosis was…something was overrecruiting the peroneus quartus. I then looked at her feet. Her forefoot-rearfoot relationship sabotaged her accessory muscle. Her forefoot was pitched in such a way as to cause a strain on her outer ankle (for you techies, she had a forefoot valgus). But I recalled she’d been doing her ankle strengthening exercises for so many months, twice per week, given to her by her physical therapists. I checked her ankle strength. It was super strong, and when I tested it, it replicated her pain.
The treatment plan became obvious. Simple. Stop the ankle strengthening. If that doesn’t work, I’ll make you some forefoot valgus-posted orthotics. And call me in one month. She did. Pain gone. If it ain’t broke, like her peroneus quartus, sometimes you just have to fix it.