Not Your Ordinary Ankle Sprain - A Case Report - Page #1

Author: Amy McClintock, MD
Co Author #1: Nilesh Shah, MD
Editor: Rebecca Carl, MD, FAMSSM

Patient Presentation:
Eighteen-year-old female was referred to the sports medicine office for evaluation of right ankle pain for one month. Initial injury occurred one month prior when patient slipped while running around a car suffering an eversion type injury. She was evaluated in the emergency department on day of injury. Per ED report, radiographs were negative and she was diagnosed with an ankle sprain. She was given crutches and placed in an Aircast stirrup brace for comfort with instructions to follow up with her primary care physician (PCP). The patient limped into her PCP’s office 3 weeks later with slowly improving, but persistent right ankle pain. On review, her PCP noted official read of x-rays from ED showed an ankle fracture. She was instructed to be non-weight-bearing and referred to the sports medicine office for further evaluation.
The patient was seen one week later in the sports medicine office(4 weeks post-injury). She arrived walking on her right foot with slightly antalgic gait. She denied ankle pain at her visit. Her only complaint was mild ankle stiffness with plantarflexion and dorsiflexion. Review of systems was otherwise negative.

No significant past medical history. No history of prior injuries to right ankle.

Physical Exam:
Vital signs were normal. The patient is a healthy appearing female in no acute distress of normal body habitus. Right ankle inspection showed mild generalized ankle swelling, but no deformity. She had decreased active and passive range of motion in plantarflexion, dorsiflexion, inversion, and eversion. There was mild tenderness across talar neck area and anterior joint line
The remainder of her right ankle and foot was non-tender. Sensation was intact to light touch in all dermatomes of her right foot and ankle. She had 2+ dorsalis pedis and posterior tibialis pulses with good capillary refill.

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