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Os trigonum syndrome

Posted by Mary L. on 4/16/03 at 19:23 (116351)

After sustaining my thrid ankle sprain in 16 months (the same ankle), my doctor perscribed Physical therapy. However, I don't know if this is just a sprain. I have read up on os trigonum syndrome and my symptoms seem to match. When I point my foot or it is done by the physical therapist I feel pain on the outside of my ankle behins the joint, almost where the my heel meets the ankle. It's been 3 weeks and the noraml ankle sprain pain is gone like over the anterior talofibular ligament. Could this be os trigonum syndrom? My doctor did not take x- rays my ankle this time or the last, but did the time before and it was normal.

Re: Os trigonum syndrome

Dr. David S. Wander on 4/17/03 at 01:19 (116381)

Mary,

Any pain at the posterior aspect of the ankle (back of the ankle) can certainly be os trigonum syndrome, or a fracture of the posterior process of the talus. An os trigonum is an accessory bone at the posterior aspect of the talus, and has to be differentiated from a fracture of the posterior process of the talus. Often, the treatment for these conditions is the same, including physical therapy, casting/immobilization, cortisone injections or surgical removal of the fractured posterior process of the talus or removal of the symptomatic accessory bone. X-rays should certainly be taken and evaluated and compared to previous films, or compared to the opposite ankle. There are additional radiology tests such as CT scan or MRI that would also aid in the diagnosis. Discuss your concerns with your treating physician. A problem with a posterior talar process fracture or os trigonum is certainly a reasonable concern if there is pain in the area of the back of the ankle.

Re: Os trigonum syndrome

Mar on 4/17/03 at 07:39 (116393)

Dr W --

Above you wrote 'removal of the symptomatic accessory bone'. It made me think -- When my original pod (who did the bunion surgery)thought I had a fracture in the sesamoid, he said if it didn;t heal in 6 weeks, he would remove the sesamoid bone. I didn;t have a fracture; I have an inflamed bipartite sesamoid. No other pod has ever suggested removing it, but I wonder if that would solve that problem without creating other problems. Do you have any thoughts on this? Mar

Re: Os trigonum syndrome

Dr. David S. Wander on 4/17/03 at 15:51 (116436)

Mar,

Come on, you know I have thoughts on EVERYTHING! Removal of the sesamoid bone could certainly be an option if you've got an inflamed sesamoid that has been symptomatic. Removal of the sesamoid below the first metatarsal can cause some complications if not carefully performed. The flexor tendon of the large toe actually splits into two halves and uses the sesamoid bone as a fulcrum to increase the lever arm of the pull of the tendon (sounds complicated, but it's just a little physics). When one of the sesamoid bones below the first metatarsal is removed, that 1/2 of the tendon can loose some of it's strength and other soft tissue attachments can begin to pull the large toe in the opposite direction. This can be avoided if there is no damage to the flexor tendon during removal of the sesamoid bone, and if the proper surrounding tissue is 'tightened'. Discuss this option with your doctor, if you're sure the pain is coming from the sesamoid.

Re: Os trigonum syndrome

Mar on 4/17/03 at 17:39 (116440)

Dr W -

The inflamed bipartite sesmoid was diagnosed in November 2001. It has been painful, causes pain across the ball of the foot, and I cannot put full weight on the front of the foot since June 2001. It has not responded to any treatment, much like the heels. I remember when I went to my second pod (whom I now consider my family pod; in addition to you guys here, I kind of have 4 pods - well 3, the bunion guy is history) in Nov 2001 for a second opinion on what my surgeon pod diagnosed as a stress fracture, he said don;t let anyone ever remove the sesamoid bone. It can cause all kinds of other problems in your foot. Then I had the CT and discovered it was not a fracture but the inflamed bipartite. I never asked about surgery again because my bunion surgery was so unsuccessful. I do remember him saying again one time - don;t let anyone operate on your foot. Hmmm... I will take your info to him when i see him and see what he thinks now. Anyway - you may have thoughts on EVERYTHING, but I too always have a lot to say!! Enough said, except -- thanks! Mar

Re: Os trigonum syndrome

Dr. Z on 4/17/03 at 17:44 (116442)

Mar,

Removal of the sesamoid could be the answer.

Re: Os trigonum syndrome

Mar on 4/18/03 at 07:48 (116497)

Docs -

Now what do you suppose caused the chronic sesamoiditis? The way i walked after the bunion surgery? The way the foot was repositioned after the surgery? Something done wrong during the surgery? What starts something like this? What prevents it from healing even without walking on it much?Now if I have more surgery to remove it, is there the possibility of something else becoming chronically inflamed so that I still would not be able to put full weight on the foot or even be able to walk at all? The idea of getting rid of this diseased and painful bone is so appealing to me but the possibility of further complications makes it almost impossible. The whole irony of the suggestion to remove the bone is not lost on me! I left my surgeon because he was eager to do more surgery (said it was his favorite part of being a pod- with a glint in his eye!) and now i may wind up right back in surgery! Mar

Re: Os trigonum syndrome

Dr. Z on 4/18/03 at 10:10 (116519)

ITs time for a visit Mar. Would be able to really tell you what I think with your foot in my hands.

Re: Os trigonum syndrome

Dr. David S. Wander on 4/18/03 at 12:00 (116531)

Mar,

It's difficult to look back and determine the cause of the sesamoid pain. It could be from surgery, walking differently following surgery, etc., etc. Surgical removal may be an alternative to living in discomfort. As I outlined in a prior posting, there can be complications, but those complications can be minimized in the hands of the right surgeon. Let me know if I can help in any way.

Re: Os trigonum syndrome

Mar on 4/18/03 at 16:48 (116548)

Dr Z -

OK! As soon I can take a day off work comfortably, I will be there. I'm telling you right now, when you put my foot in your hands, it better be gentle. I;ve had more strong palpating than i can stand! ;-) Thank you for caring so much -- Mar

Re: Os trigonum syndrome

Mar on 4/18/03 at 16:49 (116549)

Dr W --

THANK YOU SO MUCH for your help and your concern -- Mar