Case Analysis: Ankle Sprain

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. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

 

Episodic/Focused Soap Note: Ankle Pain

Patient Information:

Initials: L.T.,      Age: 46 years old,     Sex: F,        Race: Caucasian

S.

CC: “Ankle pain.”

HPI: A 46-year-old L.T. female presents with bilateral ankle pain. It is worse on the right ankle. The patient reports having heard a “pop” sound when playing soccer last weekend. L.T. reports bearing weight, but it is uncomfortable. The initial pain was rated at 4/10, but with mobility, the patient rated right ankle pain as 6/10. L.T. denies pain radiation to any part of the body. She states that immobility, cold compression, and rest provide relief. Reports pain is aggravated by movement.

Location: ankle

Onset: a week ago

Character: uncomfortable

Associated signs and symptoms: discomfort when bearing weight on the affected ankle

Timing: after any form of movement.

Exacerbating/ relieving factors: Movement/ rest, cold compression., immobility

Severity: 6/10 pain scale

Current Medications:

  • Ibuprofen 600mg PRN
  • Albuterol inhaler 90cm PRN

Allergies: NKDA

PMHx: Asthma (diagnosed at two years old), all immunizations up to date, Flu shot given in October 2022.

Soc Hx: L.T. works as a librarian. She is a devoted Christian married with two children. She lives in a single-family home with her husband and children. The patient is physically active and jogs every morning for about 30 minutes. L.T. is also devoted to community service, especially within her church, where she is s treasurer. She also plays soccer every weekend and swims once a week at the game complex near her home. L.T. denies drinking alcohol, smoking tobacco, and using illegal drugs.

Fam Hx: Not provided as the patient was orphaned at a young age.

ROS:

GENERAL:  Alert x4, oriented, and cooperative during the examination. Denies unintentional weight loss, weight gain, nausea, fever, and chills.

HEENT:  Eyes:  No visual changes. Ears: No history of hearing loss. Nose: No running nose/sneezing. Throat: no sore throat.

SKIN:  No discoloration or rashes.

CARDIOVASCULAR:  No edema or palpation. LT denies CP.

RESPIRATORY:  History of asthma, denies SOB.

GASTROINTESTINAL:  Reports bowel movements and denies diarrhea and anorexia.

GENITOURINARY:  Denies frequency or burning with urination. Last menstrual period, 7/2/2023.

NEUROLOGICAL:  No numbness or tingling sensation on the nerves.

MUSCULOSKELETAL:  Reports bilateral ankle pain worse on the right side.

HEMATOLOGIC:  No bleeding.

LYMPHATICS:  No history of splenectomy or enlarged lymphatic nodes.

PSYCHIATRIC:  NO history of mental health illness.

ENDOCRINOLOGIC:  No history of polyuria/polydipsia.

ALLERGIES:  History of asthma. No history of hives/eczema.

O.

Physical exam:

Vitals: BP 119/88, T 97.3F, SpO2 99%, R.R. 19, P 75, Ht 5’7, Wt 159 lbs.

General: Patient is oriented x4, alert, and cooperative during the examination. Well-nourished and developed and does not appear in distress.

Respiratory: equal bilateral chest expansion

CV: S1, S2 normal, no S3 and S4, gallops or murmurs. Regular rhythm.

Neurological: L.T. is alert and oriented x4. Strength and sensation intact.

Musculoskeletal: Bilateral pain in ankles pos for limited ROM on inversion or plantar flexion. Bilateral weight bearing with severe pain on right ankle. No tenderness or deformities were noted. Ecchymosis on lateral malleolus area. Tenderness on palpation of the lateral ankle over the anterior talofibular ligament.

Skin: Warm, dry, no discoloration noted.

Diagnostic results:

  1. X-ray (right ankle) – Ball et al. (2019) posit that an X-ray can be performed on the ankle if the patient reports pain in the malleolar area. Using the Ottawa Ankle Rules, it is easy to recognize the significance of diagnostic tests on patients presenting with ankle pain. On the other hand, Dains et al. (2019) add that the Ottawa Ankle rule has approximately 98.5% sensitivity level in determining ankle fractures.
  2. Anterior drawer test: This screening tool assesses and identifies ankle sprains and suspected anterior talofibular ligament injury.

A.

Differential Diagnoses:

  1. Ankle Sprain: This is common in people who play sports, especially soccer. Clinical manifestation includes pain with the capacity to bear weight but with discomfort (Halabchi & Hassabi, 2020). Occurs mostly in the lateral ankle. The patient’s presenting symptoms align with the diagnosis of ankle sprain.
  2. Plantar Fasciitis: This is a condition involving chronic weight-bearing difficulties when the laxity of the structure of the human foot allows the talus to slide forward and medially. (Rhim et al., 2021) This is not the likely diagnosis because plantar fasciitis can be alleviated by stretching.
  3. Navicular Fracture. The fracture occurs in the middle of the foot, which manifests as moderate pain. It also develops to the dorsum of the foot (Marshall et al., 2020). This is not the likely diagnosis since the patient’s pain does not develop with time.
  4. Ankle Fracture. This condition often presents with the inability to ambulate or bear weight. Affects the tibia, fibula, and talus (Kyriacou et al., 2021). The pain is intense and involves swelling. However, the patient can bear weight making this diagnosis unlikely.
  5. Tendinitis in Achilles: This is the inflammation of the Achilles tendon, which causes pain, tenderness, and swelling in the area where the tendon connects to the calcaneus. It causes issues with mobility (Silbernagel et al., 2021). However, the pain complains of pain but is able to bear weight even though it is comfortable, thus making this an unlikely diagnosis.

 

 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal of Orthopedics, 11(12), 534–558. https://doi.org/10.5312/wjo.v11.i12.534

Kyriacou, H., Mostafa, A. M., Davies, B. M., & Khan, W. S. (2021). Principles and guidelines in the management of ankle fractures in adults. Journal of Perioperative Practice, 31(11), 427–434. https://doi.org/10.1177/1750458920969029

Marshall, D., MacFarlane, R. J., Molloy, A., & Mason, L. (2020). A review of the management and outcomes of tarsal navicular fracture. Foot and Ankle Surgery, 26(5), 480–486. https://doi.org/10.1016/j.fas.2019.05.020

Rhim, H. C., Kwon, J., Park, J., Borg-Stein, J., & Tenforde, A. S. (2021a). A systematic review of systematic reviews on the epidemiology, evaluation, and treatment of Plantar fasciitis. Life, 11(12), 1287. https://doi.org/10.3390/life11121287

Silbernagel, K. G., Hanlon, S., & Sprague, A. (2020). Current clinical concepts: Conservative management of Achilles tendinopathy. Journal of Athletic Training55(5), 438–447. https://doi.org/10.4085/1062-6050-356-19

Answer

Case Analysis: Ankle Sprain

According to the information presented, the patient is a 46-year-old female with bilateral ankle pain that is worse on the right side. She heard a “pop” sound while playing soccer last weekend, and the pain was first evaluated as 4/10, but it rose to 6/10 with mobility. The discomfort is unpleasant and made worse by movement, but rest and ice compression provide relief. The patient denies any pain radiation to any other region of his body. She has a history of asthma and uses ibuprofen and an albuterol inhaler as needed. The clinician performed a physical assessment and requested diagnostic testing, including an X-ray of the right ankle and an anterior drawer test, to rule out ankle sprains a

nd probable anterior talofibular ligament injury.

Differential Diagnoses

Ankle Sprain

Ankle sprains are common occurrences in sports medicine and the emergency department. These injuries can result in both short-term morbidity or recurrent injuries and, therefore, the need for an accurate diagnosis (Mugno & Constant, 2020). Conservative management in the absence of surgery has shown success at times, but the clinician needs to be careful by doing a careful evaluation and avoid long-term complications. 

The anterior talofibular ligament and the calcaneofibular ligament are the most commonly affected ligaments in these injuries. The tear of these ligaments produces a “pop” sound, as shown in the case of LT, depending on whether the injury was a low or high-energy mechanism. These injuries are common in people involved in high-intensity sports, as is the case of LT, and therefore, this is the most probable diagnosis. 

Diagnostic Tests

           In evaluating a patient with an ankle injury, history, and physical examinations are key. The history needs to elicit the mechanism of injury and possible day-to-day activities that might have exposed the patient. Any history of previous injuries is also important. The physical examination has to include inspection, palpation, and functional testing. In the case of LT, palpation of the medial ankle is also important. The entire fibula should also be palpated to rule out any radiating pain or crepitus. 

           The Ottawa ankle rules have shown precision in determining whether a patient presenting with ankle injuries should have x-rays done to rule out fractures. The rules state that an x-ray is done in a patient who has pain in the malleolar region and any tenderness over the distal 6 cm or tip of the lateral malleolus’s posterior edge, tenderness over the distal 6 cm or tip of the medial malleolus’s posterior edge and an inability to bear weight immediately following the accident and for four steps during the evaluation (Melanson & Shuman, 2023). LT had discomfort bearing weight and is a qualified candidate for the X-ray series. Ankle sprains are managed by protection, rest, cold compression, and elevation. In the case of LT, the pain is relieved by cold compression and immobility, making ankle sprain the more likely diagnosis. 

Possible Conditions

Syndemotic injury- damage to the syndesmotic ligaments produce pain and tenderness over the anterior talofibular ligament, though more severe. 

Subtalar dislocation– this injury also presents with severe pain and an inability to bear weight

Ankle fracture– this can be a possible condition since it occurs as a result of trauma and presents with an inability to bear weight. 

Lisfranc injuries– damage to the Lisfranc joint in the midfoot can also present with an inability to bear weight. 

Inversion ankle sprain- a type of ankle sprain occurring due to inversion of the foot and gives a similar presentation to the case of LT. 

Plantar Fasciitis

           Plantar fasciitis is caused by degenerative irritation of the plantar fascia, which originates in the heel’s medial calcaneal tuberosity and the adjacent perifascial tissues. The fascia itself is vital in providing arch support and shock absorption. The classical cause of plantar fasciitis is stress overuse rather than mechanical damage. The pain presents sharply and is localized on the heel. Plantar fasciitis is, therefore, an unlikely diagnosis considering the mild ankle pain LT presents with. 

           A clinical diagnosis rather than imaging is done in the case of plantar fasciitis. Imaging with x rays is only necessary when fractures are suspected (Buchanan & Kushner, 2020). Classical history is progressive pain in the inferior and medial calcaneus with proximal radiation in the most severe cases. 

Navicular Fractures

Navicular bone fractures are usually caused by severe injury or extreme stress, which is more common in younger people and sports. The pain typically presents in the midfoot. This is why it is an unlikely diagnosis in the case of LT, where pain presents on the ankle. The three-view radiograph of the foot, which includes a non-weight bearing anteroposterior, lateral, and oblique X-ray, is used as the initial radiographic examination. (Gheewala et al., 2022). 

Ankle Fracture

Ankle fractures are common injuries ranging from a little twisting injury in elderly individuals to high-energy trauma in children. The Ottawa ankle rule is applied in this case (Wire et al., 2023). If there is pain or tenderness in either malleolus and one of the following: tenderness of the bone at the lateral or medial malleolus’s posterior edge or tip (within 6 cm) or the patient was unable to bear weight at the time of the incident and when he arrived at the emergency department X-ray is required. The case of LT does not give a history suggestive of an ankle fracture. 

Tendinitis in Achilles 

           This condition is characterized by inflammation and pain in the Achilles tendon. Localized pain, focal or widespread sensitivity, edema, morning pain, rigidity in the Achilles tendon, and a positive arc sign are all clinical indications and symptoms of Achilles tendinitis. These presentations rule out this diagnosis in the case of LT. Imaging of the calcaneus is the most common diagnostic test (Medina Pabón & Naqvi, 2023). X-ray of the calcaneus shows calcification in the case of Achilles tendinitis. 

           

References

Buchanan, B. K., & Kushner, D. (2020). Plantar fasciitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431073/

Gheewala, R., Arain, A., & Rosenbaum, A. J. (2022). Tarsal navicular fractures. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542221/#:~:text=Fractures%20of%20the%20tarsal%20navicular

Medina Pabón, M. A., & Naqvi, U. (2023). Achilles tendonitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538149/#:~:text=Physiotherapy%20improves%20the%20pain%20and

Melanson, S. W., & Shuman, V. L. (2023). Acute ankle sprain. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459212/#:~:text=Mild%20to%20moderate%20ankle%20sprains

Mugno, A. T., & Constant, D. (2020). Recurrent ankle sprain. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560619/

Wire, J., Hermena, S., & Slane, V. H. (2023). Ankle fractures. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542324/#:~:text=Ankle%20fractures%20should%20be%20differentiated%20from%20other%20foot%20and%20ankle%20traumatic%20conditions.&text=Examination%20usually%20shows%20tenderness%20and

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