Reasons vs. Results

I was immediately impressed by Mr. F.’s warmth and calm presence as we sat down to discuss what brought him to seek my help.

“It’s my ankle,” Mr. F. told me. “Well, sort of my ankle.” “Explain ‘sort of,’” I replied curiously.

“This isn’t a typical ankle sprain. The pain isn’t constant, but intermittent, and it’s a burning sensation, rather than an ache. It has been bothering me for several weeks at this point, so much so that I asked my wife about it.” He saw the quizzical look I gave him and went on to explain further.

“My wife is a physician, and I asked her to consider my problem as if I were one of her patients. Her reply was that she would send me to see you, so here I am!”

“Show me where you feel the discomfort and, if possible, describe the quality of the pain,” I said. Mr. F. pointed just below his medial malleolus.

“This is where it hurts. Again, it isn’t all the time, but happens frequently and randomly. That makes it frustrating to establish what I might be doing to irritate it.”

“How did this start?” I asked. “Was there a specific injury?”

“I was carrying some boxes into the house, cutting through the yard. I stepped on a board that wasn’t stable and my ankle collapsed to the inside just for a second. I remember feeling the pain and hoping that I hadn’t done something serious to my ankle. It seemed fine afterward, but the pain began about two or three days later.”

I began to run through a checklist of possible reasons (hypotheses) that would explain his presenting symptoms. For Mr. F., I could think of three possibilities:

• First, the deltoid ligament was a possible source, but not likely. The location and mechanism fit, but severe eversion of the ankle often results in a fracture, not a ligament strain. (The opposite is true with an inversion movement—the classic ankle sprain.) I decided to move the deltoid ligament to third place in the hierarchy, saving it to come back to if the other two strategies were incorrect.
• The second possibility involved the tibialis posterior muscle, as the tendon passes right where Mr. F. pointed, and would be overstretched during sudden ankle eversion.
• The third possibility involved overstretching of the posterior tibial nerve near the malleolus. The action of his misstep and the quality and frequency of his symptoms seemed a good match. It was time to test the theory.

Asking Mr. F. to lie supine with no bolster under his knee, I grasped his ankle and gently took it into eversion. He had hardly any discomfort with this motion, but I also noticed something far more interesting. I was surprised at the level of initial tightness in the range, which implicated muscular holding. Moreover, the response was immediate and seemed to let go as I deliberately held eversion. This caused me to wonder whether this was true muscular tightness or perhaps a protective measure by the muscle. If it was protective, was it protecting itself or was it protecting the nerve?

“Was it the muscle or the nerve that created your symptoms?” I wondered out loud. 

I raised Mr. F.’s straight leg until he felt tightness in his hamstring and behind his knee (about 65 degrees). I then repeated the same action, but this time everted his ankle to put the posterior tibial nerve on a stretch. Doing the straight leg raise with the ankle everted and dorsiflexed resulted in a loss of about 30 degrees of range. The moment I released ankle eversion, his hamstring range improved. At this point, the nerve seemed the most likely problem.

Asking Mr. F. to lie on his side with his knee bent (to slacken the nerve), I began to slowly examine his soleus muscle with deep slow friction movements in the direction of the muscle fibers. The posterior tibial nerve passes through the soleus canal and can be entrapped at that location. Mr. F. was surprised at the level of tenderness involved. This side-lying position is also ideal to examine the tibialis posterior, which was also very tender.

To avoid stretching the nerve, I kept his knee bent and his ankle in a slightly inverted position. In this way, I could treat the muscles with deep friction and also positively affect the nerve at the same time.

At his second appointment, Mr. F. relayed that he had substantial improvement. To best help the next person I see with similar symptoms, clarifying which strategy works is essential. While this clarification helps my knowledge base, it has relatively little importance for Mr. F.

“Was it the muscle or the nerve that created your symptoms?” I wondered out loud. Looking up at Mr. F., I saw a mischievous smile appear.

“You don’t really care, do you?” I teased.

“Nope,” Mr. F. confessed. “What is important for you are the reasons; what is important for me are the results!”