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.
          Why does that happen?
          How do we fix it?
          What's the surgery that she needs 
          to cure the snapping and pain?
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 fromdislocating 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 tosubluxing 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 causeperoneal 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  713-489-7674
Custom orthotics are simply the best way to correct subtle imbalances in the foot and ankle that can lead to running injuries. A custom orthotic is not just an arch support or a custom foot bed with extra cushioning.  A custom running orthotic is a completely custom made medical device designed to control abnormal motion, correct for alignment problems and correct faulty biomechanics that can lead to running-related injury. 

When a sports medicine specialist performs your biomechanical exam, the sports medicine doctor takes numerous measurements of of the positions and angles of the feet, ankle and legs. Based on all of this information, the podiatrist makes a plaster mold of the feet and writes a prescription for the orthotic fabrication. The orthotic lab uses all of this to create an exact replica of your feet and then custom forms the orthotics device that will correct any problems in alignment.  This can help to increase your running efficiency and decrease the risk of running injury.    

The biggest problem for many runners in Houston is that there isn't a lot of time to waste. Because our sports medicine podiatrist is an active 11 time Ironman triathlete, marathon runner, father and busy professional, he sympathizes with the common plight of the busy Houston Area athlete. For this reason his practice is dedicated exclusively to house calls for runners in the Houston Metro, Inner Loop, Montrose, Galleria, and Houston Heights.

If you need custom orthotics, he will come right to your home or office to perform your biomechanical exam and cast you for your custom running orthotics. He will even personally deliver the orthotics to you. That way you won't have to skip a business luncheon or afternoon run just to see an expert.  Let the expert come to you!

Dr. Christopher Segler, DPM is board certified, American Board of Podiatric Medicine.  He believes that the best medicine can be fast, convenient and low-cost treatment. His innovative housecall podiatry practice model helps to keep costs down for patient with making expert care more convenient than ever.  

If you have a tight work schedule we can even see you in your own office.  We often do house calls for executives so that they can be seen between meetings.  When there is no time to waste, a house call is definitely the best treatment and just what the doctor ordered!  

We offer house calls all over the Houston area, including the Galleria Area, West University, Bellaire, Southside Place, Downtown Houston, Midtown Houston, Uptown Houston, Memorial, Montrose, Houston Heights, and Washington Heights.

If you have a question about toenail fungus and wonder whether or not the laser fungus removal treatment might be right for you, you can call and speak directly with a toenail expert by calling  713-489-7674.  And yes, you will actually get to speak with the doctor.