Description of patient (type of occupation, indication of age, intensity of sport):
A 17 year old patient fell down a few steps. There was an inversion injury. Unable to weight bear. Significant lateral bruising and swelling. Needed crutches for 2 weeks. Seen 4 months later ongoing anterior ankle pain and swelling. There is a feeling of slight instability.
History and previous treatment:
Intra-articular injection with steroid/Marcaine, the pain was gone for few days. Ankle arthroscopy on 10/09/2015. Bassets ligament debrided, mild laxity syndesmosis-debrided. Could just accommodate 3mm shaver. Six weeks postoperative the pain was gone. Running started 10 weeks after arthroscopy.
Seen 10 month later. He developed increasing anterior ankle pain after walking 45-60 minutes on cobbles and after skiing. Symptoms are the same intensity as before surgery. Feels unstable walking on cobble roads.
Tenderness anterior syndesmosis. Full range of motion with no pain. No effusion. Slight pain with standing single limb and external rotation stress of syndesmosis. No pain with valgus stress, Minimal pain with external rotation stress supine or standing. Drawer test negative.
[Picture 1 + 2]
X-ray ankle normal.
Additional investigation (CT/MRI):
MRI: Partial thickness tear anterior syndesmosis ligament. Mild bone contusion centerolateral talus. Lateral ligaments are normal.
[Picture 3 + 4] Remarks:
Laxity of syndesmosis appeared within the normal limits during ankle arthroscopy when ankle stressed into external rotation and valgus stress.
15 year old with significant ankle symptoms after ant syndesmosis injury after already having had an arthroscopic debridement with minimal changes on MRI
Question(s) to this case:
Can a mild instability of syndesmosis be a cause of symptoms? What next? Repeat arthroscopy? Debride tight-rope?
Yes, it looks like the slight instability of the syndesmosis is the cause of the pain. What you can do is tighten the anterior syndesmotic ligament, debride the internal syndesmotic area (aim to provide fibrotic/scar tissue in this area) and place a tightrope.