At 2 weeks after injury, his initial x-rays of his knee, foot and tibia/fibula were negative. A limited diagnostic ultrasound of the extensor hallucis longus tendon and lateral ankle were unremarkable.
Six weeks from injury, MRI of the left tibia was obtained after no improvement with therapy with his school’s athletic trainers and continued numbness. The MRI Case Photo #2 showed an oval structure along the medial peroneal tendon that originated near the fibular head. The structure measured 1.8x0.7x18.7cm along the peroneal tendon to the distal fibular shaft Case Photo #1. It was noted to be a chronic/subacute hematoma with some mild myositis of the peroneal longus muscle.
Eight weeks from injury, an EMG was ordered after increasing numbness and tingling in his great toe but now also into the sole of his foot. EMG showed injury to the deep peroneal nerve between the extensor digitorum longus and extensor hallucis longus. There was also peroneal motor conduction injury with some areas that remained intact. Also there was an injury to left superficial peroneal nerve
Patient was evaluated by foot and ankle surgeon, podiatrist and evaluated for possible compartment testing and an EMG
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