Author: Gracia Pierre-Pierre, MD
Editor: Jason Mogonye, MD
Left lower extremity pain and weakness x 2 days
16-year-old male presented to clinic 2 days following a twisting injury to his R ankle that occurred while cutting during football. He reported immediate intense pain in his proximal left lower leg with difficulty walking and decreased sensation in the lateral left lower leg from proximal fibula down to his foot. Four hours later he went to the ER for evaluation; X-rays were obtained and were negative for fractures. The patient was provided crutches, prescribed naproxen and referred to orthopedics. He denies any previous issue with the leg.
Denies fever; weight loss; night sweats; night pain; back pain.
Reports normal bowel and bladder function.
Gen: Unable to fully bear weight on L leg
L knee: Decreased flexion due to pain at lateral proximal 1/3 of lower leg. Otherwise unremarkable.
Inspection: Localized mild swelling of the proximal 1/3 of lateral aspect of the lower leg.
Palpation: Pain on palpation of lateral proximal 1/3 of the fibula. Lateral aspect of ankle non tender. Compartments soft.
ROM: Active ankle dorsiflexion and great toe extension to 0 degrees. Inversion 5-10 degrees with pain. Pain free full plantar flexion. Active eversion to 5 degrees with pain. Full passive ROM except for limited passive inversion due to pain in fibular head area
Strength: Ankle dorsiflexion, great toe extension and eversion 2/5. Inversion and plantar flexion 5/5
Special test: Negative anterior drawer and talar tilt. Unable to assess fibular head stability due to pain
Neurovascular: Decrease sensation to light touch of the anterolateral aspect of lower leg, dorsal aspect of the foot, 1st web space. Normal patellar and Achilles tendons reflex. Intact vascular status. Positive Tinelís test at the fibular head.
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