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. 

Marathon Blister. Should I pop it?

Question:
Hi MyRunningDoc!


I have been reading your site. This blister formed on my heel yesterday. It is huge and painful. I am running in the Avenue of the Giants Marathon on May 5, 2013 and really can't take a break from marathon training. Should I pop it?

Thanks!
W.H., San Francisco CA

Answer:
Thank you for your inquiry! That is certainly a Giant of a marathon blister. I can see how that would hurt and put a damper on your final marathon training.

There is always an advantage and a disadvantage to draining in any blister on the foot that pops up during training.

With a blister that large and a marathon that close, it is unlikely that you would be able to run the marathon without significant pain. In fact the blister is so big it would probably pop during the marathon anyway.

With most small blisters, it is typically better to let them go away on their own. If you do not drain a small blister and can keep it from getting rubbed when you are running, the fluid will gradually recede and the blister will re-adhere. It will eventually peel away revealing healthy skin underneath. It is also the least likely to get infected because you don't open the blister allowing bacteria to get inside the skin.  This actually will heal the fastest and is the safest approach.

Things get tricky when a running blister on the foot gets big.

When you have a big running blister that causes a great deal of discomfort when you run, it actually hurts because the fluid is getting pushed and compressed.  If you step on a water balloon, the balloon will squish outward under your foot. The balloon will push out and stretch as far as it can unless it pops.

So when you run on a blister like this one pictured here, the blister fluid actually pushes and continues to separate the layers of skin at the edge of the blister. This of course causes more irritation and more fluid accumulation, making the blister even bigger as you continue to run.  The only way to stop this process is to stop irritating the blister on the foot. One way to do this of course is to stop running.

If you can pad the blister and keep the pressure off of it you might be able to continue training without the blister getting any bigger.  That would be hard to do given the location of this blister on the inside of the foot and heel. It will be almost impossible to remove all the pressure from the heel inside the running shoe.

If you pop the blister, it will hurt more for the first day or two.  You can decrease the amount of discomfort by using moleskin or another type of blister cover that will stop the friction from rubbing the overlying skin. It may also be helpful to put some padding around the blister in order to decrease irritation.

If you decide to pop your blister, it is always best to drain the blister by making a small hole at the bottom edge of the blister down toward the bottom of the foot so that the fluid will continue to drain downward and out of the blister as it re-accumulates. Typically some more blister fluid will accumulate inside the blister for several days after you pop it.

The skin on the top of the blister is not what is painful. It is the skin underneath. Some people start to drain the blister and realize this and then trim off the entire top of the blister. If you are to do that in this case, it would leave an open sore about the size of a half dollar. This would of course leave an enormous raw spot that would be very painful whenever you run during training. You foot would be killing you during the marathon.

In these types of cases it is often better to simply drain the blister and leave the top of the blister intact to function as a biologic dressing. This will take slightly longer to heal than if you don't drain the blister.  However this assumes that you are of course going to continue to run, train and complete the marathon that you have planned.

It would be best to be evaluated in person or by a podiatrist or arrange a remote consultation with a running injury expert in order to get more detail, before making your final decision.  You can also learn more about blisters from running by clicking here.

Dr. Christopher Segler, DPM a marathon runner, podiatrist and 10-time Ironman Triathlon finisher who is is Board Certified, American Board of Podiatric Medicine.  He believes the best podiatry practice combines cutting edge technology with the old-school convenience of house calls. He makes podiatry house calls for runners in San Francisco, CA and Houston ,TX. He also does remote consults for runners who live outside of the United States. If you have a question, you can reach him directly at 415-308-0833. You can learn more about running injuries at www.DocOnTheRun.com 

I have Achilles Tendinitis and it hurts when I run. Can I do Yoga?

Hi Running Doc!

Question:  I have Achilles Tendinitis and it hurts when I run. I stopped running and have been trying to get the Achilles to heal. But I still want to exercise to stay fit and sane. I like Bikram Yoga. So my question is: can I do yoga without risking further injury to my Achilles tendon?
                        Thanks!
                        Aching Achilles in Berkeley.

Answer:  As a runner and sports medicine podiatrist, I firmly believe that injured runners heal fastest when they remain as active as possible.  This true for Achilles injuries as well.


The key with the Achilles tendon is making sure that the tendon is healing and that no further damage is taking place. Continued damage to the Achilles (such as repeated micro-tears) is what leads to tendinosis. Achilles tendinosis always precedes an Achilles tendon rupture.

In most cases of Achilles injury in a runner, there is a period of severely reduced activity. Sometimes a Platelet Rich Plasma (PRP) injection may even be necessary to stimulate healing. In the very worst cases, Achilles tendon surgery may even become necessary.

But once the injury is reversed and healing begins, it is important to get back to activity. If you are at the point where your doctor thinks the tendon is on the mend, it may be OK to add some Yoga to your routine.

With a healing Achilles tendon Yoga is mostly OK. However, there are a few Bikram yoga poses that are concerning, and should be avoided such as:
Garudasana (Eagle Pose)
Dandayamana - JanuShirasana (Standing Head To Knee Pose)
Dandayamana - Dhanurasana (Standing Bow Pulling Pose)
Tuladandasana (Balancing Stick Pose)
Tadasana (Tree Pose)
Padangustasana (Toe Stand Pose)

None of these poses are really likely to rupture the Achilles if done flawlessy. The problem is that if you have your Achilles completely taught (while attempting these poses) and then begin to lose your balance, it may be more than the tendon could take.

If you are doing Hatha Yoga, you should simply keep the risky poses mentioned above in mind and then sit out or modify any Hatha poses that your feel would put your Achilles in a precarious situation.

It is a great question! With any running injury the big trick is not just stopping activity, but being creative in identifying the activities you continue to keep the blood flowing, the mind calm and the healing in progress.

Dr. Christopher Segler, DPM is a sports medicine podiatrist and 10-time Ironman triathlon finisher. He is Board Certified, American Board of Podiatrc Medicine. His sports podiatry practice is limited to runners, triathletes and endurance athletes with complex injuries. He specializes in running injuries that don't heal with the conventional "just stop running" approach. His practice is unique in that he offers remote consultations all over the world via Skype. He travels constantly and is available to treat frustrated injured runners in person in both San Francisco, CA and Houston, TX. If you have an injury that isn't getting better, you can call him directly at 415-308-0833 or 713-489-7674.