Persistent deep pain on dorsal side of foot

by Steven
(Hong Kong)

My left foot has been hit by fallen piece of steel rod. I felt severe pain and sought medical treatment. X-ray was taken but no fracture was found. I have received no treatment on the foot except analgesics. It is now just over 1 year from the date of the injury but there is no improvement. MRI showed "mild strain of the anterior talofibular ligament". No full-thickness ligament tear. There is no evidence of dislocations or subluxations of joints of the ankle and foot.

Please advise whether my condition can be improved.

RESPONSE

Hi Steven,

The earlier an injury is treated, the better the projected outcome. You have suffered from this problem for one year and that works against you.

The first thing we need to decide is whether or not the anterior talofibular ligament is even the issue. I have enclosed a diagram which shows where that ligament is located. It is essentially just below the lateral malleolus which is the outside portion of the ankle joint. The lateral malleolus is also the end of the fibula bone.

If your pain is occurring in that area then we can look at the ligament as the source of your pain.

The reason I want you to make sure that the ligament is the culprit here is because many times in an MRI, the radiologist will note any abnormality that he or she sees without that abnormality actually being the source of pain.

The second problem I have is that if it turns out that the anterior talofibular ligament is the offending structure, the MRI describes it as a mild strain which in most cases might cause a little discomfort but hardly enough that would cause no improvement over the course of one year.

I do not have the luxury of actually examining you, but I suspect there may be something else going on for you to be having no improvement in a twelve month period.

It is fairly simple for a doctor who is familiar with the foot, to palpate the anterior talofibular ligament in order to see if it is painful. If it is painful and that is the pain you experience when you walk, then you have your diagnosis.

So, since I have nothing else to go by at this juncture other than the MRI, and it does not mention anything about a fracture, we can assume you have some sort of soft tissue injury. If you had torn a ligament or tendon, that too would have shown up on the MRI.

The first thing I would recommend of course, is to have your foot examined by a doctor who specializes in the foot. If nothing more serious is found then that leaves you with the following.

I would recommend a combination of immobilization and physical therapy. By wearing a walking boot, and immobilizing the foot and ankle, when walking, you give whatever structure is damaged, a chance to heal. As I have stated numerous times on this site, when it comes to foot and ankle injuries, the simple act of walking can delay any injury to that area, although one year is pushing the issue.

Secondly, physical therapy will help rehabilitate whatever structure is damaged. As I said earlier, had you done this within a month of your original injury, it would have been far more effective. The problem with chronic inflammation of ligaments or tendons, is that is causes scarring over time (one year) and makes it more difficult to remedy.

The takeaway point here is that you have to become more aggressive in your treatment of this injury, otherwise it will continue to linger. In general, musculo-skeletal pain of a years duration will not go away on its own.

Marc Mitnick DPM
DISCLAIMER