medial malleolus pain

by Simone
(Australia)

Hi I fractured my ankle about 10 yrs ago the medial malleolus was screwed back into place with three screws I had them removed a year later but as long as I can remember I've always had pain since the accident I've had numerous X-rays bone scans and an ultrasound,which show up nothing ..... The pain is mainly located on the medial side of my foot it radiates from the medial malleolus down to the bottom arch of my foot the medial malleolus is also tender to touch at the top of the bone which is where the the fracture had occurred sometimes the pain goes up the inside of my leg to the knee but not very often, sometimes there is slight swelling around the medial malleolus usually at the end of the day, I find it very hard to sleep at night without strong pain killers and using pain relief creams, it seems to hurt more with rest and during humidity I also know when it will rain as the pain increases even more .... I'm having a MRI done tomorrow to see if they can find something that is causing the pain, thanks in advance your opinion and or guidance would be much appreciated.

RESPONSE

Hi Simone,

In general terms, many people who have had fractures that required surgical fixation end up with some degree of discomfort going forward. In our best efforts, surgeons cannot replicate the great job mother nature did when we were first created.
All musculo-skeletal surgery, actually all types of surgery results in some degree of scar formation. Scar tissue plain and simple, is not as healthy as original tissue.
That is one part of the problem. Additionally, there can be other issues as well. When you originally fractured your ankle, your doctor(s) immediately noticed the fracture and their goal was to go in and re-set the fracture. Apparently they did a fine job as the follow-up x-rays do not reveal any serious problems. But it goes beyond that.
Even with a great surgical result, the original fracture line may have some scar tissue in it which means although it looks pretty good on x-ray there may actually be parts of the fracture line that are not completely healed with new bone. The term in known as pseudo-arthrosis or false joint. In other words, if there are micro sized areas of fibrotic tissue (scar tissue) instead of real bone along the fracture line then the healed fracture is not as strong as it should be.
This "false joint" is one of the reasons why you have pain when it is going to rain. The increase in barometic pressure creates the same kind of swelling (and Pain) in this false joint as it does in normal arthritic joints in people who suffer from arthritis.
It is not surprising that nothing has shown up on x-ray or even a bone scan. The MRI might show something but there is a possibility the pathology will be so miniscule that the radiologist may not even consider worthy of mention.
The second problem to address is the soft tissue injury that occurred when you fractured your ankle. If the trauma was severe enough to break your bone, than one can assume there was damage to the medial ankle ligament, perhaps one of the tendons that passes below the medial malleolus or even some damage to one of the nerves which passes through that area.
As I said earlier, most of the soft tissue structures that may have been damaged possibly were just ignored while your surgeon fixated the broken bone.
So, what are your options?
Hopefully, the MRI will reveal something that will explain you ongoing pain such as a pseudoarthrosis or perhaps damage to a tendon or ligament and your doctor will be able to address that.
From a simple conservative standpoint (and I am making this suggestion without the luxury of examining you), a well constructed orthotic may help alleviate the stress on the inside of your foot and make your day (and night) more tolerable.
People who tend to be flat footed (pronated) will strain the structures on the inside of the ankle, so by wearing an orthotic, the structures will be relaxed and in theory should diminish pain.
If your pain is severe enough and the MRI reveals significant damage either to bone or soft tissue, you might have to consider an additional surgical procedure to remedy the problem.

Marc Mitnick DPM
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