Popping, Clicking Ankle Pain. What, Why and How!

Hi My Running Doc!

My daughter has sprained her ankles a number of times. She keeps turning her ankles and they swell up. She also seems to have this popping and clicking sound from the ankle when she walks and it's really bothering her.

     Questions:

          Why does that happen?

          How do we fix it?

          What's the surgery that she needs 
          to cure the snapping and pain?

Thanks!

S.B., Berkeley, CA

Answer: Ankle sprains are the most common musculoskeletal injury. In fact, there is no sports injury that shows up in the emergency department more often in a twisted ankle. Fortunately ankle sprains heal just fine most of the time. But in some cases there can be a significant injury to the ankle that prevents them from healing properly and causes problems down the road.

There are 3 primary potential causes of popping and clicking in the ankle that might be associated with persistent ankle sprains and chronic ankle instability.

1. Torn Peroneal Retinaculum

2. Lateral Process Fracture of the Talus Bone

3. Osteochondral Lesion of the Talar Dome

One common cause of popping and clicking in the ankle is from dislocating or subluxing peroneal tendons. The peroneal tendons run down the back to leg behind the fibula. They turn around the end of the fibula as they curve down toward the outside of the foot. 

There is a thin band of tissue called the peroneal retinaculum that holds the peroneal tendons in place behind the fibula. In some cases involving ankle sprains, the peroneal tendons actually fire so hard to try to keep the foot under the leg when you roll the ankle that the perineal retinaculum actually gets torn off of the fibula bone. Because it is torn, the peroneal tendons are not held firmly in place behind the fibula.

When this occurs, the peroneal tendons are free to slide forward over the leading edge of the fibula bone. As the tendons snap back and forth across the fibula, they cause a popping and clicking sound and/or sensation as you walk. When this occurs it is not always painful but it certainly can be painful. It is more worrisome if it is painful simply because this might signify a tear or a split in one of the peroneal tendons.

If one of the peroneal tendons is torn or split it might need a platelet rich plasma injection (also known as a PRP injection) to help stimulate healing. If the torn peroneal tendon cannot heal on its own, it might require surgery to sew it back together. In any event pain in this area should not be ignored.

Another cause of popping and clicking in the ankle can be a misdiagnosed or undiagnosed lateral process fracture of the talus bone. The talus bone is the bone that connects the top of the foot to the bottom of the ankle. Lateral process fractures are sometimes referred to as snowboarders fractures.

We used to think that lateral process fractures were a rare occurrence. However Dr. Segler led a team of investigators through the largest study ever completed on lateral process fractures of the talus. He and his team won an award from the American College of Foot and Ankle Surgeons for this research. What his team found was that these fractures are about 10 times more common than previously thought. They just get missed all the time.Is

Lateral process fractures are frequently misdiagnosed as ankle sprains. Yet a broken bone does not generally heal the same way as a torn ligament. If not treated correctly, the broken bone can develop into a nonunion where the bone actually never heals. When this occurs, there can be continued pain and swelling in the ankle. Sometimes there can be a popping and clicking sensation as well.

The third potential cause of popping and clicking in the ankle after an ankle sprain is an osteochondral lesion of the talus. An osteochondral fracture is a crack in the bone underneath the cartilage. Basically what happens is the ankle rolls and the talus bone can tilt so far that the corner of the talar dome smacks into the tibia bone or fibular bone. If the talus has a hard enough impact as it twists, it can crack the bone and damage the cartilage. 

Sometimes the cartilage and the fractured piece of bone (known as an osteochondral fragment) can become loose. If not treated correctly this may not heal. If the cartilage is loose and has a flap of tissue that flips back and forth it can cause a clicking or popping sensation. This is often associated with swelling and pain in the ankle.

If there is popping and clicking from the ankle, but no history of a serious ankle sprain, the shape of the fibula can potentially lead to subluxing peroneal tendons. The retinaculum might actually still be intact but because there is not a very deep groove in the back of the fibula the peroneal tendon still slide back and forth causing a popping and clicking sensation at the side of the ankle. This can cause peroneal tendinitis.

If this is the case, it is possible to perform surgery to deepen the groove at the back of the fibula in order to help the peroneal tendons stay in place. This will stop the popping and clicking and prevent chronic irritation of the tendon that can lead to tears in the peroneal tendons.

Another related issue with chronic ankle instability and persistently weak ankles is that the ankles can get sprained over and over. If you often find yourself rolling your ankles when walking on uneven surfaces or running on trails, the first step would be physical therapy or a home rehabilitation self-treatment program to try to strengthen the ankles and restore stability.

In some cases of chronic ankle instability the ankles are so weak that the ligaments on the outside of the ankle need to be surgically repaired or rebuilt. 

In any case, if you have popping and clicking, especially associated with pain and swelling of the ankle, it shouldn't be ignored. Get it checked out right away.

Dr. Christopher Segler, D.P.M. is board certified, American Board of Podiatric Medicine. His practice is limited to  runners, triathletes and active young adults who want to stay active. He travels often to accommodate patients with complicated injuries in San Francisco, Houston, and Hawaii. He also provides remote consultations via Skype for injured expat patients living abroad who need expert advice, but cannot readily access a true foot and ankle expert while overseas. If you have a question about a complicated foot or ankle injury that just isn't getting better, you can reach him directly at 415-308-0833. 

Do I Have Gout in the Big Toe Joint

Gout is one of the most painful conditions I see as a Podiatrist in San Francisco. Usually gout attacks the big toe joint. The question is, how do you tell if you are having an attack of gout in the foot?

When gout happens the first thing you will notice is pain, swelling and redness around the joint. In the foot this is most often the base of the big toe in the joint podiatrists call the "metatarsaophalangeal joint." Gout can happen in any of the joints in the foot, but usually it the big toe joint.

When gout develops, you get uric acid crystals forming and being deposited in the joint itself. If untreated, the crystals may continue to form and lead to the buildup of a chalky paste-like substance called tophi. You can see the huge lump on the bottom of the big toe joint in the picture above. All of that is uric acid crystals in the joint.

Because these sharp needle-shaped crystals end up in the joint, it can be incredibly painful to move the joint. Every time you move the big toe, it is like having a thousand little needles poking the inside of the joint. This of course hurts.

In response, your body reacts with inflammation. That is where the classic pain swelling and redness comes in. The foot will be warm to the touch, red and very painful. Many gout sufferers will say they can't even have a bed sheet touching the foot because it is so painful.

The biggest problem with trying to tell if you actually have gout is that gout mimics two other conditions: infectious arthritis and Charcot. Charcot arthropathy is an emergency that can look like gout, but is actually more serious. It is most common in people with diabetes. Infectious arthritis is where bacteria (instead of uric acid) is invading the joint. Both of these are emergencies. With either, it is important to start treatment right away to prevent further damage and the potential for losing the foot to an amputation.

Many people who have had multiple attacks of gout can seem to tell when it is coming on. However, if you have never been diagnosed with gout, it is important to see a foot specialists who can make sure you don't have a more serious condition.

The most accurate way for your podiatrist to diagnose gout is through a small procedure called joint aspiration. In this way, the uric acid crystals in the joint can easily be identified. More importantly, your foot doctor can rule out a bacterial infection. Blood tests and x-rays may give clues that you have had gout, but can be unreliable if used alone to diagnose gout.

Once you have been diagnosed with gout, your podiatrist will likely make recommendations on modifying your diet to prevent it from happening again. You can view our recommendations on a Gout Diet here. If you are given a prescription to treat the gout, you will be given written instructions that you should follow closely.

Dr. Christopher Segler was selected in 2010 as one of "America's Top Podiatrists." He has a podiatry house calls practice in the San Francisco Bay Area. To learn more about gout, visit the Gout page on our website. If you have gout and need pain relief right away, he makes podiatry emergency house calls 24/7. If you think you might have gout and would like to speak directly with him to ask a question, you can call him (415) 308 0833.