Friday, 23 May 2014

MRI Scan | Results | Next Steps

Courtesy of Circle Reading Facebook Page
MRI Scan
After not being too impressed with my physio; having an argument with her; and then convincing the doctor I needed an MRI; I eventually saw an Orthopaedic Consultant (and lead Trauma surgeon) at the Circle Reading. The hospital is private but I managed to see him on the NHS (very lucky!).

From the outset I was highly impressed. The building looks like a modern office block and the decor and service inside wouldn't look amiss in a 5 star hotel!

After registering and taking my complimentary coffee, the Orthopaedic Consultant came out to greet me in person. I'd only been waiting 5 minutes. Very impressive. I explained the history of the injury and almost immediately he told me he was going to scan it! Yeah! Those were the words I'd wanted to hear ever since I gone the bloody injury months' ago! I asked what it could be and he suggested a bruised bone or any one of several tendons in my foot. I immediately felt comfortable with this guy. 

Circle Reading
He led me down to Radiology and an appointment was made for an MRI scan for the next working day! It was Thursday evening and the scan was booked for 7:15pm on the Tuesday. Given the two Public Holidays, I was highly impressed. I would not have got that service had I gone to Royal Berkshire Hospital in Reading or any other NHS hospital; and yet here I was in a private hospital receiving private care on the NHS. A friend of mine who works at Royal Berks (you know who you are Fran!) say this is not unusual, but I think for most people is this unusual (or at least, generally unknown about). Anyway my MRI scan was now booked! One happy Mike!

I arrived on the Tuesday evening at 7:10pm and was immediately greeted by a very friendly Radiologist who said they were ready for me. After removing all metal items from my being, she led me into the MRI room; and there it was, a huge MRI machine. 

Circle Reading
I laid down on the couch top outside the scanner and she made me feel comfortable whilst adjusting the braces around my feet. I was told the scanner will make a loud buzzing/tapping sound so was offered really comfortable ear defenders. I also had the choice of music to listen to. I chose The Killers - I definitely needed something to make me feel alive prior to entering the plastic coffin that was the MRI machine. She also gave me a buzzer that I could press at any time which would alert the radiographers should I feel uncomfortable.

I was told procedure would take around 30 minutes and before I knew it she had left the room and the bed started to be pulled into the machine. It eventually stopped at my waist. I had to lie as still as possible so the best quality images could be obtained. It was quite relaxing: I was on a comfy bed; head on a comfy pillow; listening to good music and, after a long day at work, I was almost falling asleep! Before I knew it the scan was over. I was told I'd be contacted by the consultant the following week (week commencing 28 April) for the results.

So there we have it - I eventually got the MRI scan I was after. Now it was time to wait for the results - something I am more nervous about because I suspect, irrespective of what the condition it is I have, I'll be told to stop running for a period of time...and that period, irrespective of how long, will knock-out all my long-distance running challenges this year. Let's see what happens....fingers crossed!
Courtesy of Circle Reading Facebook Page

So  3 weeks and a failed marathon and successful ultramarathon later it was time to pick up my results. To be honest I was very nervous about the outcome and really wasn't looking forward to the visit.

I arrived at the Circle early (3:45pm) for my 4:30pm appointment. At 4pm the consultant came out and ushered me into his office. My heart was beating fast and before he could start I told him about my last 2 races and the pain in my foot. He remained calm and then quietly explained what the MRI showed as he read off the Radiologist's report. The full report is below in all it's medical-speak. In essence what what we thought was a damaged tendon is in actual face tibialis posterior tenosynovitis (an inflammation of the tendon sheath and not the actual tendon); whilst the MRI also picked up a number of other injuries to the foot and ankle as a whole:

MRI Right Ankle:
  • The tibiotalar joint and talar dome are normal.
  • A small tibiotalar joint effusion is present.
  • A large os trigonum is noted with a synchondrosis posteriorly.
  • Subtle oedema is present with some subchondral cystic change.
  • The subtalar joints and sinus tarsi are unremarkable.

  • Soft tissue oedema overlies the medial malleolus.
  • There is a moderate amount of fluid surrounding the tibialis posterior tendon without intra tendinous high signal, consistent with a tenosynovitis.
  • The flexor digitorum longus and flexor hallucis longus tendons are normal.
  • The flexor retinaculum is intact.
  • The neurovascular bundle is unremarkable.
  • The deltoid ligament complex appears intact.

  • There is soft tissue oedema overlying the lateral malleolus.
  • The personeal tendons and peroneal retinaculum are intact.
  • The lateral ankle ligaments are intact.
  • The Achilles tendon is normal in signal, but there is a slight loss of normal convexity of the anterior margin.
  • The Achilles tendon measures 13 x 6.5 mm, 4.5 cm above the Achilles insertion. 
  • The plantar fascia and mid foot are unremarkable.


Tibialis posterior tenosynovitis. No tendinopathy detected.

Os trigonum with subtle oedema and subchronic changes of the synchonrosis suggest a degree of posterior impingement, but clinical correlation is recommended to determine the clinical significance thereof.

Mild chronic Achilles tendinopathy.

In plain English what this means is the following:
  • I have a buildup of fluid in the ankle joint - this is what is causing the swelling in my ankle.
  • My right foot also has 'Os trigonum syndrome'. The os trigonum is an extra bone that sometimes develops behind the ankle bone. I've probably had this from birth. Only a small number of people have this extra bone. Thankfully this isn't causing me a problem at the moment...but it's amazing what they can find in your foot!
  • I have a subchondral cyst (fluid-filled sac) that is extruding from my ankle joint. Medical advice is to leave it alone. However it is indicative of early phase of osteoarthritis (breakdown of cartridge on the joint), and although the subchondral cyst improves without medical attention, the disease itself does not go away
  • I have an abnormal accumulation of fluid around the medial and lateral malleolus (the knobbly bone on the outside your ankle - mine is quite large!). Over time this will die down
  • What we thought was pain with the tibialis posterior tendon was in actual fact a damaged and inflamed sheath around the tendon, with yet more fluid
  • The Achilles tendon has been permanently damanged but this was done overtime. There is a slight loss of normal forward movement. The Achilles has also increased in size (stretched) to a point that it cannot repair itself. Again, this was done overtime. Achilles exercises from the physio should held retain movement. Need to be careful with sprint training and hills (both ascending and descending)

This means:
  • I have Tibialis posterior tenosynovitis
  • I have an additional bone, a cyst and quite a bit of fluid in the foot. This information needs to be passed back to my GP for a clinical correlation (i.e., he takes that information and compares to my entire medical history and what he knows about me to determine how significant this is and what the next steps may be if he does deem it significant)
  • I have mild chronic Achilles tendinopathy

The next steps are:
  • To let the pain and swelling disappear and then I can continue to run
  • Will be referred to see another Orthopedic consultant at Royal Berks who will look at the foot in more depth and see what can be done to mitigate further problems, given the collapsed arch I have. He will also look at the Achilles tendon. Will also likey result in new inserts to support the collapsed arch (gotta a horrible feeling I will need to pay for them!)
  • Speak to the doctor to determine whether the additional bone, the cyst and the fluid need to be a cause of concern given my wider medical history and what he knows about me
  • Continue to see a physio about strength exercises to support the collapsed arch (tibialis posterior tendon) and also the damaged Achilles.

What does this mean for my running?
I need to this about this a little more but my initial thoughts are:
  • This is a good outcome from what could have been a nightmare injury!
  • Once the pain and swelling goes down I will start back running (but gently to start with)
  • Will avoid off-road running (or running over tough terrain) for a good couple of months in order to allow the foot to settle down. This also means I will avoid wearing my off-road trainers where possible (as they are deliberately tight fitting)
  • Need to be careful with hill training/running and speed work - e.g., intervals. Just got to be careful with that Achilles, which is now actually damaged
  • Unlikely I will run the Trail Marathon Wales (due to the terrain) but 90% certain I will run Endure24 given the slower paced run and the gentle terrain
  • Will start to return to parkrun
  • Will probably take the next 5 days off from running and then start back.

Final Thoughts

I'm very lucky to get away with no damage to the tendon and that in theory I can continue to run, all be it I have to manage my runs to ensure no further injury. It's been a long and worrying time, but at least I now know what is wrong and can manage that going forward. I feel very lucky....

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