Answer Discussion2

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Case 2: Ankle Pain

Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?

 

 

 

answer based on this:

Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

 

 

Patient Information:

MJ, 46, Female, Caucasian

S.

CC: “I rolled my right ankle yesterday, and felt a pop.”

HPI:

MJ is a 46-year-old Caucasian female who rolled her right ankle while playing soccer yesterday. The patient states that “she felt a pop” and rates her pain as 6 out of 10. The patient says her pain does not radiate; however, her foot and right ankle are swollen. MJ admits to minimal joint pain in her left ankle. The patient describes her pain as sharp. The patient can bear weight, but it is uncomfortable. The patient has tried Ibuprofen, but it came with minimal relief. The patient said her pain improves when she rests, elevates, and ices her ankle. The patient says she is in too much pain when attempting to walk.

Current Medications:

  • Multivitamin, one tablet daily for nutrition supplementation. Taken daily for five years.
  • Ibuprofen 400mg, PRN for pain.
  • Loratidine, 1 10mg tablet prn. For allergy relief.

Allergies:

  • Penicillin- Hives
  • Peanuts- anaphylactic
  • Seasonal allergies

PMHx:

  • Up to date on all immunizations
  • Flu shot 10/1/2022
  • Tetanus immunization 8/22/2018
  • Appendectomy 7/23/2001

Soc Hx:

  • MJ is an accountant and enjoys playing soccer and tennis with her friends. She has been married for 23 years and has one son. MJ does not smoke or use any other form of tobacco. MJ drinks wine on Saturday nights with her husband but only has “one or two glasses.” MJ denies any use of recreational drugs. MJ does not text while driving and constantly monitors the smoke detectors in her home. MJ is part of the neighborhood watch.

Fam Hx:

  • Paternal Grandmother- died at the age of 90 from pneumonia
  • Paternal Grandfather- died at the age of 91 from natural causes
  • Maternal Grandmother- is 90 and has HTN
  • Maternal Grandfather- died at age 82 from a heart attack
  • Mother- is 68 and has hyperlipidemia and obesity
  • Father- is 69 and has HTN and type 2 diabetes
  • Son- is 21 and is healthy

 

ROS:

  • GENERAL:  No weight loss, fever, chills, fatigue, or insomnia
  • HEENT:  Eyes:  No blindness, diplopia, ocular pain, or need to wear glasses.
  • SKIN:  No pruritus, lesions, or masses present
  • CARDIOVASCULAR:  No angina, palpitations, or other cardiac issues.
  • RESPIRATORY:  Denies shortness of breath, asthma, apnea, wheezing, or stridor. Admits to an anaphylactic episode from accidentally eating peanuts in August of 2008.
  • GASTROINTESTINAL:  Denies nausea, vomiting, constipation, or any bowel irregularities.
  • GENITOURINARY:  Last menstrual period was last week. Denies any history of sexually transmitted infections. Monogamous with her husband.
  • NEUROLOGICAL:  Denies headaches, syncope, or history of head trauma
  • MUSCULOSKELETAL: Admits pain in her left ankle at 2/10. Admits to pain at 6/10 in her right ankle. The patient states that she cannot walk on her left ankle and can barely put any weight on it.
  • PSYCHIATRIC:  No history of depression or anxiety. No suicidal or homicidal ideation.

 

O.

Physical exam:

  • General- Well-nourished female with appropriate clothing and speech. The patient does not appear stressed; however, she has moderate pain in her right ankle.
  • Head- Normocephalic. No lesions, lumps, or abrasions were noticed upon inspection.
  • HEENT- PERRLA, no tracheal deviation, Tympanic membranes pearly gray bilaterally with no effusion present. No nasal discharge. Nasal turbinates are smooth and pink.
  • Cardiac- No murmurs, rubs, or gallops. S1/S2.
  • Respiratory- RRR. Lungs clear to auscultation in all lobes.
  • No bruits. Normoactive bowel sounds in all four quadrants. Liver palpable. Spleen not palpable.
  • Neuro- Cranial Nerves 1-12 intact.
  • Musculoskeletal: Diffuse edema and bruising on the lateral side of the right ankle. Tender to palpation on the dorsolateral part of the right foot. The patient can slightly dorsiflex their foot. Positive inversion stress test.

 

Diagnostic results:

  • Diagnostic X-ray- AP and Lateral films were taken. Negative for fracture.

A.

Differential Diagnoses:

  1. Anterior Talo-Fibular Ligament (ATFL) sprain
  2. Jones Fracture
  3. Distal Fibular Fracture
  4. Talus Fracture
  5. Achilles Tendon Rupture

There is a vast differential regarding injuries to the foot and ankle. As a provider, numerous tests and exams can help achieve a diagnosis. For this patient, MJ inverted her right ankle while playing soccer. Many anatomical structures are located on the right ankle’s lateral side. First, the ankle contains several ligaments that help conjoin the bones of the foot together. Other ligaments connect the bones of the lower leg to the foot. The lateral malleolus of the fibula is a bone that is frequently fractured in patients who suffer an inverted ankle injury. Other bones commonly fractured are the tibia, talus, calcaneus, navicular, and all of the metatarsals. Ankle sprains often take longer to heal than some fractures; however, an x-ray is not always necessary to diagnose an ankle sprain. Yavas et al. (2021) state that “the Ottawa ankle rules have been developed to predict the necessity of radiographs in acute ankle injuries” (Yavas et al. 2021, p. 92). I feel that implementing the Ottawa ankle rules is necessary for this patient. Patients should not be exposed to unnecessary radiation; therefore, thorough patient history and physical exam can dictate proper treatment plans for each patient.

I believe this patient suffered an injury to the anterior talofibular ligament. Inversion of the foot often results in “injury to the anterior talofibular ligament alone or in conjunction with the calcaneofibular ligament and posterior talofibular ligament” (Hopper et al. 2020, p. 1893). The instability of this ligament leads to chronic ankle sprains and injury recurrence. ATFL injuries are prevalent in athletes with an increased risk of rolling an ankle. Casado-Hernandez et al. (2021) state that the “anterior talofibular ligament is considered the ligament structure that is most frequently injured during sudden inversion movements of the ankle” (Casado-Hernandez et al. 2021, p. 94). This description matches the mechanism of injury this patient experienced while playing soccer.  There are several physical exam tests used to diagnose an ATFL injury. Li et al. (2019) state that the “anterior drawer test and the anterior lateral drawer test are valuable physical tests to assess ATFL injuries” (Li et al. 2019, p. 62). I will use these physical exams to help confirm this diagnosis.

Another possible diagnosis on the differential for this patient is a Jones fracture. A Jones fracture occurs when a break occurs at the most distal portion of the foot’s fifth metatarsal. Smidt and Massey (2022) state that “fractures of the fifth metatarsal are common injuries that must be recognized and treated appropriately to avoid poor clinical outcomes for the patient” (Smidt & Massey, 2022, p. 1). Jones fractures primarily occur in athletes who invert their ankles while running or jogging. Clinically, the bone is subclassified into three main zones. The most distal zone usually requires surgical intervention. Many patients who roll their ankles are unsure if they broke a bone or sprained a ligament. They know that they felt a pop and now have difficulty ambulating. It is common that when ankles are inverted, the ligaments can break off a piece of bone in the foot. That is why a Jones fracture is part of MJ’s differential.

Another possible diagnosis for this patient is a distal fibular fracture. Canton et al. (2021) state that “isolated distal fibula fractures represent the majority of ankle fractures” (Canton et al. 2021, p. 254). The distal fibula extends further than any part of the lower leg making it susceptible to fracture. When an ankle is inverted, many times, an avulsion fracture can happen. An avulsion fracture occurs when a ligament is stretched and pulls off a piece of bone. The distal fibula is one of the most common places in the body to have an avulsion fracture. Due to the mechanism of MJ’s injury, a distal fibular fracture is appropriate for her differential diagnosis.

Another condition on MJ’s differential is a talus fracture. The talus is the second largest bone in the foot and has various functions. Any trauma to the ankle can lead to a talus fracture. Russell and Byerly (2022) state that blood supply to the talus is “predominately extraosseous because of the extensive articular cartilage coverage and is therefore easily disrupted in the setting of displaced fractures” (Russell & Byerly, 2022, p. 1). For this reason, it is paramount to have an x-ray taken to confirm a talus fracture. If the fracture is displaced, swift surgical intervention is required to prevent osteonecrosis or non-union of the bone.

Another diagnosis for MJ’s differential is an Achilles tendon rupture. An Achilles tendon rupture typically occurs in athletes and is characterized by the patient feeling a large pop. Since MJ felt a pop after her soccer injury, it is appropriate for this condition to be a part of her differential diagnosis. Thermann (2019) states that “benchmarking for a definitive rupture is the inability to perform a one-leg heel raise” (Thermann, 2019, p. 863). Therefore, a one-leg heel raise is one of the best physical exam tests to determine an Achilles tendon tear. This test is needed to rule out this injury and to help diagnose MJ’s current condition.


References

Canton, G., Sborgia, A., Maritan, G., Fattori, R., Roman, F., Tomic, M., Morandi, M. M., &Murena, L. (2021). Fibula fractures management. World journal of orthopedics, 12(5), 254–269. https://doi.org/10.5312/wjo.v12.i5.254

Casado-Hernández, I., Becerro-de-Bengoa-Vallejo, R., Losa-Iglesias, M. E., Santiago-Nuño, F., Mazoteras-Pardo, V., López-López, D., Rodríguez-Sanz, D., & Calvo-Lobo, C. (2021). Association between anterior talofibular ligament injury and ankle tendon, ligament, and joint conditions revealed by magnetic resonance imaging. Quantitative imaging in medicine and surgery, 11(1), 84–94. https://doi.org/10.21037/qims-20-5

Hopper, G. P., Benson, D. M., Wilson, W. T., Rigby, R. B., & Mackay, G. M. (2020). Anterior Talofibular Ligament Repair With Suture Tape Augmentation. Arthroscopy techniques, 9(12), e1893–e1897. https://doi.org/10.1016/j.eats.2020.08.016

Li, Q., Tu, Y., Chen, J., Shan, J., Yung, P. S., Ling, S. K., & Hua, Y. (2020). Reverse anterolateral drawer test is more sensitive and accurate for diagnosing chronic anterior talofibular ligament injury. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 28(1), 55–62. https://doi.org/10.1007/s00167-019-05705-x

Russell, T. G., & Byerly, D. W. (2022). Talus Fracture. In StatPearls. StatPearls Publishing.

Smidt, K. P., & Massey, P. (2022). 5th Metatarsal Fracture. In StatPearls. StatPearls Publishing.

Thermann H. (2019). Achillessehnenruptur – Teil 1: Ätiologie und Diagnostik [Achilles tendon rupture-Part 1: etiology and diagnostics]. Der Chirurg; Zeitschrift fur alle Gebiete der operativenMedizen, 90(10), 863–872. https://doi.org/10.1007/s00104-019-01024-6

Yavas, S., Arslan, E. D., Ozkan, S., Yilmaz Aydin, Y., & Aydin, M. (2021). Accuracy of Ottawa ankle rules for midfoot and ankle injuries. Acta bio-medica :AteneiParmensis, 92(4), e2021241. https://doi.org/10.23750/abm.v92i4.9962