Clinical Case Study
Ankle Pain
Background
A 28-year-old male presented to the clinic with a 3 week history of insidious lateral ankle pain.
He denied any injury or recent change in activity. He was normally fit and well. He recalled a fracture to his lateral ankle 6 years ago which was managed with ORIF (open reduction and internal fixation)
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His symptoms were constant in nature with no clear aggs/eases.
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He reported no neurological symptoms.
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He worked in a desk-based role. He was a Non-smoker, and drank alcohol socially. His hobbies involved playing casual 5-aside football.
Clinical presentation
The patient mobilised into the clinic with a normal gait. He had good ankle ROM however inversion was painful. He had 5/5 strength.
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A protuberance was noted to the lateral ankle, and the patient reported he had noticed this growth over the last 3 months.
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The patient was neuro-vascular intact but did have positive sural nerve tension testing in the Straight Leg Raise position.
Differential Diagnoses
Some possible differential diagnoses for this case include
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Sural nerve entrapment / irritation
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Early onset osteoarthritis
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pathology related to metalwork
Working diagnosis
The working diagnosis for this case was loosening of a screw from the ORIF due to the hard protuberance identified objectively with subsequent sural nerve irritation.
What next?
Following the assessment a shared decision was made to X-Ray the ankle. It was requested that we also have a comparison of images from 6 years ago to check for movement of metal work or screws.
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The x-ray results were returned 2 weeks later reporting a loose screw and mild osteoarthritic changes.
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The results were discussed with the patient, and a referral to orthopaedics was agreed.
Take home points?
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As always consider asking about previous surgery or injury when asking PMH
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Ensure to look, feel, and move the joints to help with your assessment and diagnosis
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Can you refer directly for x-rays?
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Do you know your local criteria for referrals into orthopaedics?