Author: LaRae Seemann, MD
Co Author #1: George G.A. Pujalte, MD, FACSM, FAMSSM
Co Author #2: Neil P. Shah, MD
Senior Editor: Natalie Stork, MD
Editor: Kevin Gray, MD

Patient Presentation:
16-year-old male football player presented with a right heel blister sustained 2 weeks prior while playing a football game in cleats several sizes too small.

History:
16-year-old male transferred from an outside emergency department where he initially presented for purulent drainage from a right heel blister sustained 2 weeks prior while playing a football game in cleats several sizes too small. He underwent incision and drainage and was discharged on oral clindamycin and trimethoprim/sulfamethoxazole for 2 weeks at the time of the initial Emergency Department Visit. He returned for worsening skin and soft tissue infection, which notably progressed to involve the medial ankle and Achilles paratenon. The patient was afebrile and reported sharp pain when practicing football, which he had continued to do after discharge from the Emergency Department. He reported circumferential wound enlargement, increasing redness, and copious purulent drainage despite incision and drainage and antibiotic therapy. He ambulated without difficulty until 3 days prior to presentation, when he started using crutches due to progressive difficulty with ambulation.

Physical Exam:
Integumentary: There was an open wound on the posterior aspect of the right ankle overlying the calcaneus and Achilles tendon measuring 7 cm x 6 cm with a central, deeper area of dark red tissue measuring 0.5 cm deep and 2 cm x 1 cm in surface area Case Photo #1 . The surrounding tissue was erythematous and warm to touch, extending towards the medial ankle. There was diffuse edema around the medial malleolus.
Musculoskeletal: Diffuse right ankle swelling. Pedal pulses intact bilaterally. Sensation intact. Range of motion fully intact. No pain on palpation, except for the soft tissue surrounding the wound. An antalgic gait was observed.

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