by Steve Bender, Virginia Youth Soccer board member
Actually, the exact words I heard last August were "Dad, my ankle hurts!" It was at the end of our third practice of the season, and she hadn't done anything that day that might have injured it. I was surprised because she had never complained about pain. Whenever she was kicked or cleated, all she ever said was a quick "Ow!" and went on playing.
She took off her sock so that we could look at her ankle. There, on the inside of her right ankle just below and behind the ankle bone was what looked like a second ankle bone. We weren't sure what she had done, but we knew that it wasn't normal. It was the beginning of a long journey through the world of medicine - in fact, that we have not yet completed. I want to share it with you because what has surprised me most has been that many physicians have little or no knowledge of her problem.
My assistant and I questioned her for a minute about all the things she had done in practice that might have caused the lump to appear. No one had kicked her. No one had stepped on her. She hadn't twisted it while running. She hadn't done anything that would explain it. After all those questions she finally told us that it had been there a while, ever since I stepped on her ankle in practice the previous fall! She said "I kept forgetting to tell you before now."
The next day her pediatrician studied the x-rays of her ankle. She wasn't sure, but she thought she saw a possible fracture. She spoke with the radiologist, and he concurred that there might be a fragment broken off of the end of the ankle bone. We were sent upstairs to see an orthopedist. That doctor was not convinced that there was a break. She put my daughter in an ankle brace and sent her home to rest it for a few days before a follow-up appointment.
On the follow-up, we were able to see my own knee surgeon who is also a soccer player. He looked at the x-ray and told us there was good news and bad news. The good news was that there was no break. The bad news was there was no break. He explained that whatever the growth was, he couldn't identify it from an x-ray. The look of concern on his face was obvious. He ordered an MRI to get a better look at the mass and to try to rule out what he called "anything ominous."
He reassured me that the MRI would give a clearer picture than the X-ray. Like a stack of overhead transparencies, the x-ray shows a fuzzy image of a three dimensional bone compressed into a two dimensional image. The MRI takes a series of cross sections through the ankle, much like separating the transparencies and examining them one at a time. It was fascinating imagery of the human body but it still didn't show much. That was good because it meant there was no tumor growing in her ankle. It also gave him a fairly good idea of what was wrong, but needed yet another series of CAT scans to confirm it.
When those images came back, we finally had our answer. She has a congenital condition known as a subtalar carteligenaous coalition. The problem was virtually unknown before the advent of the CAT scan and MRI imaging systems. It is now diagnosed much more frequently by orthopedists, not because it is more prevalent, but because the MRI and CAT images make it more accurately identifiable.
It begins as a malformed growth plate on one of the foot bones. As the child grows, the bone grows farther than it is supposed to. Cartilage in the area becomes more and more fibrous to counteract the abnormal bone. At puberty, calcium begins to deposit in the fiber. That restricts motion in the ankle, producing more and more pain as it is flexed in directions where there isn't as much room to give.
By now, you are probably wondering why this matters to you as a soccer coach or soccer parent. The most surprising information from my orthopedist was the fact that very few general practitioners, pediatricians and internists diagnose this problem correctly. In our case, there was just enough on the x-ray to justify a referral to orthopedics. Otherwise, it would have been treated as a sprain, and we would have been sent home none the wiser. Most literature, including some published as recently as the mid- to late-1990s, treats this as a very rare occurrence, less than 1 percent of the population. But more recent studies are examining skeletal remains from the 1800s and records of recent coalition diagnoses. According to our doctor, preliminary results indicate this some degree of coalition may occur much more frequently - in perhaps as much as five to ten percent of the population. If that number holds up, that means that every coach has a good chance of having a player with a similar condition.
The next question was whether or not to treat it with surgery. The conservative approach involves limiting activity and using shoe inserts (orthotics) that better support the ankle and limit the range of motion so that the mass does not inflict as much pain. That solves the short term problem of pain, but doesn't make the cause go away. After seeing another pediatric orthopedist for a second opinion, we canceled surgery and tried the orthotics. As you will see if you link to the websites below, there is little evidence that they work, but from our perspective, $65 and a few months was a good tradeoff against the potential risks of surgery.
In our case, the orthotics don't seem to be working, but we know we tried it first. So we are now planning for surgery at the end of the summer. That involves going removing the malformed tissue and inserting body fat as a spacer. Then there's healing time - six weeks in a cast and six months of no soccer. But we seem to have caught it early enough. If the calcium buildup is too bad, the ankle and heel bones actually have to be fused together permanently.
There is a risk that my daughter won't be able to play pain free again. In fact, she may not be able to play again at all. But we are told the chance of that is very low. What is certain is that as she continues to grow older, the site will continue to calcify and become more and more brittle. As that happens, it becomes easier for her to fracture something, and a break then could be much worse than surgery now.
While I am not a doctor, and do not intend for this article to be a diagnosis of any player's foot problems, I do want to make coaches and parents aware of something that that was unknown to me and my pediatrician. Perhaps you have a child or player with similar complaints. If so, the website below will give you and your parents additional information to enable you to ask informed questions when talking with your doctor. I hope the information here is some you will never need, but if you do, perhaps it it will help make your journey considerably shorter than our two year expedition.
For additional reference: medmedia.com.