Chronic Ankle Pain: A Journey Through Misdiagnosis and Treatment

Ankle pain lasting over a year, with each episode of pain not exceeding one minute?

The initial foot pain began over a year ago when I accidentally twisted my ankle after not noticing a pothole.
Since I had a habit of treating ankle sprains with traditional Chinese medicine, I applied a medicated plaster as usual.
However, after about a week with no improvement, I went to a large hospital's rehabilitation department, where the doctor referred me to the rheumatology and immunology department, suggesting my symptoms were more aligned with immune issues.
I underwent an ultrasound and blood tests, both of which returned normal results, but I continued to experience foot pain.
Later, I visited a local clinic for rehabilitation, where the doctor administered a corticosteroid injection at the site of the ankle pain, but there was no improvement.
After resting for a few days, my foot suddenly stopped hurting, and I did not continue seeing a doctor.
This period, from the onset of pain to its resolution, lasted about a month, with the pain starting in October and disappearing by November.
However, in January of this year, I noticed something unusual with my ankle; the area where I received the corticosteroid injection developed white patches.
I consulted a dermatologist, who diagnosed it as vitiligo.
By February, I began experiencing sudden sharp pains in my ankle, in the same location as before.
Each episode would leave me unable to move for about a minute, occurring infrequently—about once a week or sometimes every two weeks.
By April, the pain became more frequent, sometimes occurring 2-3 times a day, and I noticed indentations forming in my ankle.
Concerned, I visited a nearby clinic, and the doctor referred me to the neurology department, suspecting a nerve issue.
I underwent nerve tests, including electromyography and nerve conduction studies, all of which were normal.
The neurologist concluded that the ankle indentations were not due to nerve problems.
Subsequently, I was referred back to rheumatology and immunology, where the doctor suspected an immune-related issue.
I had more blood tests, with over ten vials drawn, but the results remained normal, and no cause was identified.
The doctor prescribed oral corticosteroids, but after a few days, I noticed the indentations in my ankle worsening, almost reaching my knee.
When I returned to the doctor, he assured me that corticosteroids would not cause ankle indentations and advised me to continue taking them.
However, I was hesitant to continue, especially since they did not alleviate my pain, and I stopped returning for follow-ups in May.
In August, I returned to a large hospital in my original county and consulted an orthopedic surgeon.
After listening to my lengthy history, the doctor indicated that I was experiencing side effects from corticosteroids, specifically fat atrophy, and referred me to plastic surgery for a fat grafting procedure.
About a week after the surgery, I still experienced the same pre-surgery ankle pain, with sudden sharp pains lasting less than a minute.
The surgery did fill in many of the indentations, but the pre-existing pain persisted.
When I reported this to the plastic surgeon, he stated that he could only assist with reconstructing the appearance, and I needed to consult another doctor for the pain issue.
I was then referred back to the same rheumatology and immunology doctor I had seen last year.
This time, the doctor reviewed my medical history from last year to this year and arranged for additional tests, including blood work, MRI, and repeat ultrasounds, but all results remained normal.
Given my current condition, what specialty should I consult? Recently, I have been experiencing a sensation of stiffness in my ankle after walking just a few steps, and I am unable to run; if I attempt to run, I end up limping.

I'm sorry, 20~29 year old female. Ask Date: 2023/11/07

Dr. Chen Yongxue reply Orthopedics

Hello, based on your letter, it does not seem to be an issue related to autoimmune rheumatism.
You should visit an orthopedic clinic for further examination.
If the orthopedic evaluation shows no issues, it is recommended to see a rehabilitation specialist for further rehabilitation treatment focused on the ligaments of the ankle joint.
Thank you.

Reply Date: 2023/11/07

More Info

Chronic ankle pain can be a complex and frustrating condition, especially when it involves a journey through multiple misdiagnoses and treatments. Your experience highlights several important aspects of chronic pain management and the challenges that can arise when seeking effective treatment.

From your description, it seems that your ankle pain began after an acute injury, which is a common starting point for many cases of chronic pain. Initially, you sought traditional remedies, such as topical treatments, which did not provide relief. This led to a series of referrals to various specialists, including rheumatologists and orthopedic doctors, who conducted numerous tests, including ultrasounds and blood tests, all of which returned normal results. This is not uncommon in cases of chronic pain, where objective findings may not correlate with the severity of symptoms.

The use of corticosteroid injections is a common approach to managing inflammation and pain in joints, but as you experienced, it does not always lead to improvement. In fact, the development of white patches on your skin following the injection raises concerns about potential side effects, such as fat atrophy, which can occur with repeated corticosteroid use. This side effect may explain the appearance of the indentation in your ankle, as the fat layer beneath the skin diminishes.

Your subsequent symptoms, including sudden sharp pains and the feeling of instability in your ankle, suggest that there may be underlying issues that have not yet been identified. The fact that your pain episodes are infrequent but increasing in frequency could indicate a chronic pain syndrome, where the nervous system becomes sensitized to pain signals, leading to heightened sensitivity and abnormal pain responses.

Given your extensive history and the lack of definitive findings from various specialists, it may be beneficial to consider a multidisciplinary approach to your treatment. Here are some recommendations:
1. Pain Management Specialist: A physician specializing in pain management can provide a comprehensive evaluation of your pain. They may offer treatments such as nerve blocks, physical therapy, or alternative therapies like acupuncture, which can help manage chronic pain.

2. Physical Therapy: Engaging in a structured physical therapy program can help strengthen the muscles around your ankle, improve stability, and reduce pain. A physical therapist can also teach you exercises to improve your range of motion and function.

3. Neurologist: Since you mentioned that nerve conduction studies were normal, it may still be worth consulting a neurologist who specializes in chronic pain or neuropathic pain. They can explore the possibility of complex regional pain syndrome (CRPS) or other neuropathic pain conditions.

4. Psychological Support: Chronic pain can take a toll on mental health. Cognitive-behavioral therapy (CBT) or other forms of psychological support can help you cope with the emotional aspects of living with chronic pain.

5. Alternative Therapies: Consider exploring alternative therapies such as acupuncture, chiropractic care, or massage therapy. Some patients find relief through these modalities, especially when traditional treatments have failed.

6. Re-evaluation of Medications: If you are currently taking medications for pain management, it may be worth discussing with your healthcare provider whether adjustments or alternative medications could be beneficial.

7. Second Opinion: If you feel that your concerns are not being adequately addressed, seeking a second opinion from another orthopedic or rheumatology specialist may provide new insights or treatment options.

In summary, chronic ankle pain can be multifactorial, and it often requires a comprehensive and multidisciplinary approach to management. It is essential to continue advocating for your health and exploring various avenues for treatment until you find a strategy that effectively addresses your symptoms. Remember, chronic pain is a complex condition, and finding the right combination of therapies may take time and persistence.

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