Week 8 Case Study #2: Ankle Pain

Week 8 Case Study #2: Ankle Pain

Week 8 case study #2: Ankle Pain


Review of case study #2: Ankle Pain

Patient Information: Initials: F. F Age: 46 y.o. Sex: female Race: Caucasian

Week 8 Case Study #2: Ankle Pain


Chief complaint: Pain in both ankles, more severe on the right

HPI: Ms. F.F is a 46- years old Caucasian female who presented to the clinic with the chief complaint of bilateral ankle pain. She reported the ankle pain is more severe on the right than on the left ankle. She noted the onset of the Pain over the weekend when she played soccer with her children and heard the “pop” sound on the ankle. She described the Pain as uncomfortable around her ankles and rated pain 3/10 on the left and 6/10 on the right ankle. She can bear weight bilaterally but felt discomfort in her ankle while standing or walking. The patient report she has always been physically active, exercise 2-3 time a week, and did not have any recollection of an accident or incident that may have triggered this current Pain in her ankle. Week 8 Case Study #2: Ankle Pain

Current Medications: Methimazole 5 mg daily

Allergies: milk -wheezing Immunization

History: Flu Vaccine: November 2010 Last tetanus: unknown

PMH: hyperthyroidism (diagnosed 2017, managed with Methimazole)

Family History:

The patient report both parents are deceased; the father died of a heath attack at the age of 88, and the mother died of kidney failure at the age of 65. The patient unable to report grandparent\’s history, and she did not have any siblings

Social HX: The patient is a catholic and works in the church as an accountant. The patient is married, and she lives with her husband and three children. She enjoys outdoor activities with her family and works out in the gym two to three times a week. The patient denies the use of tobacco, alcohol, and prescribed OTC or illicit drugs. The patient report she drinks 3 cups of coffee daily and cooks dinner for her family most night. The patient reports she coped with stress by practicing yoga and meditation. She claims she takes all safety measures in the house and while driving. Week 8 Case Study #2: Ankle Pain

Review of the systems

GENERAL: The patient denies fever, chills, weakness, and fatigue. No report of unwanted weight loss.

HEENT: The patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No complaint of hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No report of skin discoloration, lesions, or rash.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No report of palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, denies nausea, vomiting, or diarrhea. No abdominal pain, no report of hematochezia or melena.

GENITOURINARY: Denies burning on urination, denies pregnancy. Last menstrual period, 04/01/2021.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Cranial nerves symmetric face with clear speech. Sensation to light touch is preserved.

MUSCULOSKELETAL: Bilateral ankle pain with weight-bearing that is uncomfortable. Swelling to both ankles. Week 8 Case Study #2: Ankle Pain

HEMATOLOGIC: Denies bleeding or easy bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No complaint of hopelessness, denies suicidal and homicidal ideation. ENDOCRINOLOGIC: Hyperthyroidism


Physical exam: Vital Signs: T: 36.5-degree C (Oral), HR: 98 (Peripheral), RR: 18, BP: 118/66 (Automated) SpO2: 99% Height: 5\’9 Weight 145 lbs.


The patient is alert and oriented times 4 with no acute distress noted. She is calm and cooperative, pleasant with assessment. Well-developed, well-nourished.


Head: Normocephalic, atraumatic.

Eye: Extra-ocular motions intact. Pupils are equal and round and reactive to light bilaterally. The sclera is non-icteric, and the conjunctiva is pink bilaterally. Week 8 Case Study #2: Ankle Pain

ENT: Oropharynx clear and without edema, injection, nor exudate. The uvula is midline. There is no appreciable cervical lymphadenopathy. The neck is supple with the full range of motion. No JVD. Trachea midline. No pain, swelling, or palpable nodules. Oropharynx red. No lesions. Moist mucous membranes. Mucous membranes moist no edema externally normal voice no stridor Lungs: sound clear on auscultation on all lobes with good air exchange No accessory muscle use. No respiratory distress. Heart : regular rate and rhythm no prominent murmurs. No gallop or rub. No edema is noted in either leg.

Abdomen: appears soft, non-tender, no distention no rigidity, rebound, or guarding on palpable.Skin: warm dry, no rashes or lesions, ecchymosis on the right ankle in mid-lateral malleolus area

Cranial nerves: strength appear intact with equal strength. Cranial nerves symmetric face with clear speech. Sensation to light touch is preserved.

Genital/Rectal: continent of bladder and bowel

Musculoskeletal: the patient able to ambulate without aids. Bilateral ankle swelling, more to the right side. Both ankles are warm to the touch. No pitting edema or deformity was noted. Ecchymosis to the right ankle. Pedal pulses palpable, tenderness on palpation. No active inflammation process note. The range of motion is limited to bilateral ankle. Pain and tenderness upon palpation to bilateral ankle.

Neuro: Cranial nerves symmetric face with clear speech. Sensation to light touch is preserved.

What foot structures are involved in ankle injury

Three separate articulations make up the ankle complex: the talocrural joint, the subtalar joint, and the distal tibiofibular syndesmotic joint. These joints, in conjunction with the soft-tissue anatomy, allow for mainly multiplanar motion during functional movement. However, excessive tension or strain during exercise may result in injury (Larkins et al., 2020). Week 8 Case Study #2: Ankle Pain

What other symptoms need to be explored

Instability of the ankle while standing or walking,Soreness, tenderness, achiness, numbness, tingling should be assessed. Ankle stiffness or Pain over the joint, monitor for swelling, warmth, or redness.

Diagnostic results:

X-RAY: rule out a fracture

Ankle soft tissue injuries are the most common, and most X-rays are not essential (Polzer et al., 2011). Plain X-rays of the ankle should be taken if there is pain in the malleolar zone or inability to bear weight. When radiographs are suggested to rule out ankle fractures in acute injury, the Ottawa ankle guidelines are used. Radiographs are recommended if there is discomfort around the distal aspect of the fibula or the proximal fifth metatarsal, if the patient is unable to bear weight for four steps after the fracture and during a clinical evaluation, and if pressure and swelling are evident across the ankle

Anterior drawer test:

The purpose of this test is to determine the mechanical instability or hypermobility of the ankle ligaments. The test is used to determine the anterior talofibular ligament\’s strength. Once fracture is ruled out, an anterior drawer test should be performed. An anterior drawer test assesses the integrity of the anterior talofibulare ligament (ATFL) is performed with the knee joint flexed. The ankle joint is held in 10–15° plantar flexion, and the clinician presses the heel forward while holding back the tibia (Larkins et al., 2020 Week 8 Case Study #2: Ankle Pain).

Fibula translation test:

The fibula translation test is performed by grasping the tibia and fibula directly and translating the fibula on the tibia in the anterior-posterior plane. The maneuver was deemed positive if it caused Pain by compressing the tibiofibular syndesmosis. Syndesmotic injury is one of the significant causes of ankle pain and arthritis in athletes (Larkins et al., 2020 Week 8 Case Study #2: Ankle Pain).

The squeeze test:

After excluding fractures, compartment syndrome of the leg, cellulitis, contusions, or abrasions, the squeeze test is used to diagnose syndesmotic sprains. Compression of the fibula to the tibia above the calf midpoint is used to perform the test. When proximal compression results in distal Pain in the area of the interosseous ligament or its supporting structures, the test is considered positive (Larkins et al., 2020).

Manual muscle testing (MMT)

MMT is used to determine the strength of the ankle joint. It includes heel raises, which require the individual with ankle pain to repeat as many times as possible to decide on plantar flexor strength (Rao et al., 2012 Week 8 Case Study #2: Ankle Pain)

Week 8 Case Study #2: Ankle Pain – Assessment Differential Diagnoses

Lateral ankle sprains (LASs) are a common occurrence in sports and during athletic participation (Medina McKeon & Hoch, 2019). LAS sometimes results in injury to the anterior talofibular ligament and the calcaneofibular ligament. LAS also causes injury to the anterior talofibular ligament and the calcaneofibular ligament. The anterior tibiofibular ligament and the posterior talofibular ligament should be tested as well. Multiple ligament involvement is linked to increased seriousness, while a syndesmosis fracture is connected to a “high ankle sprain.” (Newsham, 2019 Week 8 Case Study #2: Ankle Pain).

Ankle Impingement

Impingement of the ankle sometimes referred to as “athlete\’s ankle” or “footballer\’s ankle,” is characterized as pain in the ankle caused by impingement in one of two areas: the anterior (anterolateral and anteromedial) or the posterior (posteromedial). The tibiotalar (talocrural) joint is used to determine the location of Pain. In general, anterior ankle impingement relates to the entrapment of structures along the anterior edge of the tibiotalar joint during terminal dorsiflexion. Impingement of the posterior ankle occurs as structures posterior to the tibiotalar and talocalcaneal articulations are compressed during terminal plantar flexion. Pain is exacerbated by mechanical impediments caused by osteophytes and entrapment of different soft tissue structures resulting from infection, scarring, or hypermobility. Athletes, especially soccer players, distance runners, and ballet dancers, are prone to the disease.

Ankle Syndesmotic Injury

A syndesmotic injury may arise on its own or in conjunction with an ankle fracture. Ankle impacts can affect the distal tibiofibular syndesmosis, resulting in varying degrees of damage to the soft tissue or skeletal components that contribute significantly to ankle joint stabilization. A syndesmotic injury may occur alone or in conjunction with an ankle fracture (Zalavras & Thordarson, 2007).

Week 8 Case Study #2: Ankle Pain References

  • Larkins, L. W., Baker, R. T., & Baker, J. G. (2020). Physical examination of the ankle: A review of the original orthopedic special test description and scientific validity of common tests for ankle examination. Archives of Rehabilitation Research and Clinical Translation, 2(3), 100072. https://doi.org/10.1016/j.arrct.2020.100072
  • Medina McKeon, J. M., & Hoch, M. C. (2019). The ankle-joint complex: A kinesiologic approach to lateral ankle sprains. Journal of Athletic Training, 54(6), 589–602. https://doi.org/10.4085/1062-6050-472-17
  • Newsham, K. (2019). The ubiquitous lateral ankle sprain: Time to reconsider our management? The Journal for Nurse Practitioners, 15(5), 343–346.e3. https://doi.org/10.1016/j.nurpra.2019.01.019
  • Polzer, H., Kanz, K., Prall, W., Haasters, F., Ockert, B., Mutschler, W., & Grote, S. (2011). Diagnosis and treatment of acute ankle injuries: Development of an evidence-based algorithm. Orthopedic Reviews, 4(1), 5. https://doi.org/10.4081/or.2012.e5. Week 8 Case Study #2: Ankle Pain
  • Rao, S., Riskowski, J. L., & Hannan, M. T. (2012). Musculoskeletal conditions of the foot and ankle: Assessments and treatment options. Best Practice & Research Clinical Rheumatology, 26(3), 345–368. https://doi.org/10.1016/j.berh.2012.05.009. Week 8 Case Study #2: Ankle Pain
  • Zalavras, C., & Thordarson, D. (2007). Jaaos – journal of the american academy of orthopaedic surgeons. LWW. https://journals.lww.com/jaaos/Fulltext/2007/06000/Ankle_Syndesmotic_Injury.2.aspx