Author: John McNeil, MD
Co Author #1: Dr. Mark H. Mirabelli FAAFP, FAAMSM
Senior Editor: Yaowen Hu, MD, MBA
Editor: Naga Sai Venkata Madhavapeddi, MD

Patient Presentation:
Patient was a 26-year-old male recreational soccer player sent to the sports medicine clinic seven months after injuring his right ankle while playing soccer. He presented to the clinic after being evaluated by multiple specialists for weakness in his right ankle and foot.

History:
Patient initially presented to the Emergency Department (ED) a day after an atraumatic event. Examination in the ED demonstrated right ankle and foot swelling with tenderness up into the distal leg. He was diagnosed with a high ankle sprain and conservative treatment was recommended. Two months later, the patient went to the Foot and Ankle Surgery clinic with persistent right foot and ankle weakness. Physical exam at that time was concerning for tendon injury or neuropathy of the distal leg. An MRI of the right ankle did not show any tendon injury. He was referred to the Physical Medicine and Rehabilitation clinic and recommended to start physical therapy. Physical exam two months later at the physical medicine and rehabilitation clinic showed continued foot and ankle weakness. An MRI of the right lower leg and an Electromyogram and Nerve Conduction Study (EMG/NCS) were ordered. He was recommended to continue physical therapy and to start using an ankle foot orthosis (AFO) and was referred to the Sports Medicine Clinic for deep peroneal neuropathy.

Physical Exam:
Vital Signs were normal. A detailed right leg and foot exam was conducted and there were no superficial skin or vascular changes. There was no effusion or soft tissue swelling. There was steppage gait and weak heel walk along with right extensor digitorum brevis muscle atrophy. There was no tenderness to palpation over the foot or ankle but there was mild tenderness over the anterior compartment of the right leg. His plantar flexion was approximately 50 degrees while his inversion and eversion within normal limits. He had absent dorsiflexion. He had normal Dorsalis pedis and posterior tibialis pulses. There was decreased sensation to light touch within the first interdigital web space. Strength testing revealed 0 out of 5 great toe extension (extensor hallucis longus), 0 out of 5 second to fifth digit extension (extensor digitorum longus), 0 out of 5 dorsiflexion of the foot, and 5 out of 5 strength in plantarflexion of the foot, inversion, and eversion. He had normal patellar and Achilles reflexes.

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