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Solomon Sallfors

Ambulatory Morning Report: Ankle Pain

Chief Complaint: A 35 year old Caucasian woman without significant past medical history presents with right
ankle pain.
HPI: 3 days prior, patient was practicing organized softball and was hit on the anterior right ankle by a softball
thrown by the pitcher at high speed. No pop was heard at the time. Patient immediately felt pain, 7/10, but was
able to finish the practice with weight bearing intact. During the following two days, her ankle although painful
was weight bearing to mild activity. Pain during this time was milder than initially. Patient had some relief with
NSAIDs. When she returned to work earlier today, her pain increased til she could no longer tolerate weight
bearing. Patient is in obvious discomfort due to pain. Pain is aching and constant without radiation.
PMHx: None relevant. FMHx: None relevant. Surgeries: 2 ACL repairs on right. Allergies: Opioids
(hallucinations). MEDS: none. Social: Works in sales, physically active, no recreational drugs.
ROS: Neg. except as in HPI, including fever, rash, chest pain, shortness of breath, focal neurological
complaints, history of arthritis, connective tissue disease, diabetes, neuropathy, or prior trauma.
PE: Gen: Awake alert cooperative. Patient well kept and appropriately dressed. Insight and judgment intact.
Musculoskeletal: Pain and moderate swelling on right ankle in malleolar zone. Tender to passive and active
range of motion (resistive not attempted). ROM is decreased compared to left due to pain. Crossed leg test POS
(syndesmotic sprain). No warmth or erythema or ecchymosis. No bone pain on distal tibia or fibula (medial and
lateral malleoli) or fifth metatarsal or navicular bone.
TENDONS: 2 Intact muscle tendons posterior to the lateral malleolus (fibularis longus, post. at malleoli and
attaches at inf. first metatarsal, and brevis tendons, attaches base fifth metatarsal).
3 Intact tendons posterior to the medial malleolus (posterior tibialis, flexor digitorum longs, and flexor hallucis
longus). 3 Intact tendons of anterior ankle (tibialis anterior, extensor hallucis longus, and extensor digitorum
longus, med. to lat.; TA at hallux). Posterior ankle: Neg Thompson test (heel cord rupture), Achilles non-tender.
LIGAMENTS: no inc laxity on inversion in 3 planes (anterior talofibular ligament, posterior talofibular
ligament, calcaneofibular); no inc laxity on eversion (deltoid complex) (Normal dorsiflexion 10-15, plantar
flexion 50-70, inversion 40, eversion 10.). Anterior drawer neg (ATF). Talar tilt neg (CF). Talar external
rotation neg (syndesmotic sprain with joint widening; deltoid if med. malleolus moves/Kleiger test; sensitivity
20%, specificity 84.8%.). Distal tibiofibular joint/syndesmotic sprain (or fractures/Maissonneuve): Compression
test neg (sensitivity 30%, specificity 93.5% ).
Neuro: Proprioception intact. Crude sensation intact. Achilles reflex 2/4. Sural nerve (purely sensory): lat post
foot over 5th digit and metatarsal, sensation intact. Peroneal nerve intact (dorsal surface of the foot).
Extremeties: 2/4 pedal and post tibial pulses. Diffuse edema in right ankle/malleolar zone. Cap refill <2 secs.
Other systems: neg.
LABS: None.
DDx: Sprain vs Strain (less likely) vs Fracture (unlikely).
Dx: Secondary injury on acute ankle sprain, unspecified, possibly syndesmotic sprain.
Treatment: Patients ankle was wrapped in compression bandage, for cost conscious care, though a brace
maybe preferred. PRN Tylenol preferred over NSAIDs due to possible inhibition of healing cytokines and
macrophages. Patient instructed on rehab and educated on long-term significance of injuries.

Solomon Sallfors
Considering a fracture, guided by Ottawa rules for ankle X-Rays, both for single x-ray and x-ray series
(standard AP, mortise AP, and lateral).

Figure 1. Ottawa ankle rules. Adapted from Stiell IG, et al. Implementation of the Ottawa ankle rules. JAMA 1994; 271: 82732.

Treatment: Functional treatment preferred over immobilization and usually consists of three phases: (1) the
PRICE protocol is initiated within 24 hours of injury to minimize pain and swelling and limit the spread of
injury; (2) exercises to restore motion and strength usually begin within 48 to 72 hours of injury (see
accompanying patient handout for exercise descriptions); and (3) endurance training, sport-specific drills, and
training to improve balance begin when the second phase is well underway.1
Reexamination three to five days after injury
Lateral ligament sprains:
Grade I: Ligament integrity, minimal swelling, conservative care: brace, ice, avoid pain, weight-bearing allowed
Grade II: slight laxity, Goose egg swelling, protected weight-bearing w/ weight-bearing exercise in 2 wks
Grade III Complete rupture, Immediate diffuse swelling, heard pop, immobilized in removable walking cast
3-4wks; rehab, and surgery (esp. for elite athletes); reconstruct if fxnl ligament instability.


1 Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly KD, Struijs PA, van Dijk CN. Immobilisation for acute ankle sprain. A systematic review. Arch Orthop Trauma Surg. 2001;121:46271.