Patient Information: CC: 46-Year-Old Female Reports Pain

Patient Information: CC : A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle

The patient is a 46-year-old female presenting with bilateral ankle pain, more pronounced on the right, following playing soccer when she heard a "pop." She is able to bear weight but experiences discomfort, suggesting possible ligamentous injury or fracture. The anatomy of the ankle involves the distal tibia, distal fibula, talus, calcaneus, and associated ligamentous structures such as the anterior talofibular ligament, calcaneofibular ligament, and deltoid ligament. Structures likely involved include ligaments supporting the lateral and medial malleoli, which can be strained or torn with such trauma. Additionally, tendons such as the Achilles tendon, and bone structures can be involved in more severe injuries like fractures.

Key symptoms to explore further include the exact location of pain, presence of swelling, bruising, inability to move or bear weight, and any audible sounds like "pop" indicating ligament tear or fracture. Symptoms such as instability, severe swelling, or deformity may suggest ligament rupture or fracture. It is also critical to rule out associated injuries like Achilles tendon ruptures, ligament sprains, or fractures.

The differential diagnoses for ankle pain in this scenario comprise: (1) lateral ligament ankle sprain—common in sports injuries with inversion trauma, (2) Achilles tendon rupture or strain—especially with heard "pop" and inability to push off, (3) ankle fracture—particularly distal fibular or tibial fracture, (4) syndesmotic injury, and (5) less commonly, tendinitis or cartilage injury. These conditions vary based on the severity and specific injury mechanisms.

Physical Examination and Special Maneuvers

On physical examination, inspect for swelling, deformity, ecchymosis, and skin integrity. Palpate carefully over the medial and lateral malleoli, navicular, and Achilles tendon for tenderness. Perform neurovascular assessment to check distal pulses including dorsalis pedis and posterior tibial arteries, capillary refill, and sensation. The range of motion in dorsiflexion and plantarflexion should be assessed, with attention to pain response.

Special maneuvers include the anterior drawer test for ankle stability—positive indicating anterior talofibular ligament injury—and the talar tilt test to assess calcaneofibular ligament integrity. The Thompson test can be used to evaluate Achilles tendon rupture—absence of plantar flexion with calf squeeze suggests rupture. The Ottawa ankle rules should be applied to decide if radiographic imaging is necessary: tenderness over the malleoli, inability to bear weight for four steps, or bone tenderness directly over the posterior distal fibula or tibia indicate the need for X-ray imaging.

Application of Ottawa Ankle Rules

The Ottawa ankle rules are highly sensitive in detecting fractures and are recommended before ordering imaging. If the patient has pain near the malleoli and exhibits point tenderness or inability to bear weight, an X-ray is indicated. This reduces unnecessary imaging while ensuring fractures are not missed, which is especially vital in the setting of trauma with heard "pop."

Assessment and Differential Diagnoses

The primary assessment involves a combination of history, physical examination, and appropriate imaging. The history indicates a sports injury with "pop" sound, pointing towards ligament injury or fracture. The examination findings of edema, tenderness, erythema, and inability to bear weight lean toward ligament sprain or fracture. The absence of deformity and ability to bear weight suggests sprain over fracture but mandates imaging to confirm.

Differential diagnoses include:

1. Lateral ankle ligament sprain: The most common injury in inversion trauma, characterized by ligament tear, swelling, tenderness, and sometimes bruising. Usually stable with no fracture signs.
2. Achilles tendon rupture: Sudden "pop," inability to plantar flex, swelling, and palpable defect in the tendon noted in physical exam, especially with positive Thompson test.
3. Ankle fracture: Bone injury involving distal tibia or fibula; presents with swelling, deformity, ecchymosis, and inability to weight-bear; confirmed with imaging.
4. Syndesmotic injury: Disruption of the distal tibiofibular syndesmosis, often associated with rotations injuries with swelling and pain over the anterior ankle.
5. Tendinitis or cartilage injury: Less common acutely but may present with localized pain.

Imaging and Diagnostic Approach

Implementing the Ottawa ankle rules, radiographs should be ordered if there is point tenderness over the posterior edge or tip of the lateral malleolus or medial malleolus, or if the patient cannot bear weight for four steps. Radiography typically includes anterior-posterior, lateral, and mortise views, allowing assessment for fractures or dislocation. If initial X-rays are inconclusive and the suspicion persists, further imaging like MRI can be utilized for soft tissue assessment, especially to rule out ligament tears or tendinous injuries. CT scans may be reserved for complex fractures, providing detailed bony anatomy.

Management Considerations and Conclusion

Initial management begins with RICE (Rest, Ice, Compression, Elevation) to reduce swelling and pain. Analgesics can be administered for pain relief. The patient's ability to bear weight is encouraging for conservative management unless imaging confirms fracture or ruptures requiring surgical intervention. Follow-up includes physical therapy to restore strength and range of motion, as well as activity modification to prevent re-injury.

In summary, in a young athletic female with acute ankle "pop" and swelling, careful clinical evaluation guided by the Ottawa ankle rules is key to determining the need for imaging. Differential diagnoses span ligament sprains, fractures, and tendon injuries, with management tailored accordingly. Recognizing the anatomical structures involved and conducting appropriate physical tests are crucial steps in proper diagnosis and treatment.

References

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