Left Ankle Pain

Chief Complaint: A 16 year-old female presents with 2 weeks of left ankle pain.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination, and why?

Relevant History:

  • How did this begin?
  • Was there injury/trauma?
  • Where exactly is the pain? Quality, duration, aggravating/alleviating factors, radiation?
  • Unilateral or bilateral?
  • Has this ever happened before?
  • Is there weakness, numbness, or tingling?
  • What has she tried so far to alleviate the problem? Medications, therapy, bracing, injections, surgery?
  • Has she had any workup already for this problem?
  • Is she active? Does she play sports?
  • Family history?
  • Past Medical and Surgical History?
  • Medications?

Relevant Physical Examination:

  • Vital signs
  • Inspection
  • Palpation of bilateral ankles
  • Manual muscle testing of bilateral lower extremities
  • Sensory examination of bilateral lower extremities
  • Reflex testing
  • Special testing: Thompson test, Tinel at fibular head and medial malleolus, Anterior drawer of ankle, Talar Tilt, Straight leg raise, plantar fascia stretching with direct palpation

+ Challenge Question

  • Describe how to perform the Thompson test, and what you are looking for with it.

+ Challenge Answer

  • The Thompson test is performed to check for achilles tendon tears. It is performed by having the patient lie prone with their feet dangling over the edge of the exam table. The examiner then squeezes the patient’s calf muscle (gastrocnemius/soleus complex). In a normal patient, squeezing the calf in this way will elicit passive plantarflexion of the ankle, indicating an intact achilles tendon. In a patient with an achilles tendon tear, squeezing the calf will not cause plantarflexion (there is no achilles tendon fiber continuity onto the calcaneus, so plantarflexion cannot occur), indicating a positive Thompson test.
 

DOMAIN B: PROBLEM SOLVING

This patient is a 16 year-old female who has felt gradual onset posterior left ankle pain for the past 2 weeks. She plays on a competitive traveling soccer team and notices the pain while playing. She feels like she can barely play soccer due to the pain. She has no pain at rest. She denies weakness, numbness, or tingling. On exam, strength, sensation, and reflex testing are normal; however, there is significant pain with left-sided heel raises. There is visible grimacing with palpation of the posterior ankle and with passive dorsiflexion. Anterior drawer of the ankle and Thompson test are negative

+ What is your differential diagnosis for this patient's ankle pain?

  • Achilles tendonitis/tendinosis, achilles tendon tear, plantar fasciitis, lateral ankle sprain, medial ankle sprain, retrocalcaneal bursitis, retroachilles bursitis, calf strain, shin splints (medial tibial stress syndrome), calcaneal stress fracture, CRPS (complex regional pain syndrome), midfoot ligament sprain, midfoot fracture, talar fracture.
 

DOMAIN C: PATIENT MANAGEMENT

The patient is diagnosed with left achilles tendonitis.

+ What workup and treatment plan would you prescribe?

  • Initial rest followed by physical therapy focused on eccentric strengthening or heavy slow resistance training of the achilles tendons. Acetaminophen and/or NSAIDs (including topical diclofenac), heat, ice, TENS for symptomatic pain relief. No further workup is required at this point for achilles tendonitis.
 
 

DOMAIN D: SYSTEMS-BASED PRACTICE

She states that her soccer coach is wondering if she will be able to continue playing. Her team is in the playoffs right now and she is their leading scorer.

+ What would your next steps be?

  • It is not advised that she continue playing right now, given the extent of her pain during activity and with mechanical loading of the tendon (heel raises). Continued playing at her current level of pain may worsen her condition or even lead to achilles tendinosis or tearing. At the permission of the patient and her parent, offer to speak directly with her coach to relay your recommendations and rationale, as well as conditions for returning to play.
 

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

The patient undergoes a course of physical therapy for the achilles tendon. Her pain resolves. At a follow-up visit, while her mother is answering a phone call out of the room, she reveals to you that she exaggerated her level of pain, and she really just didn’t want to play soccer anymore. She has softball coming up and she is not interested in playing that, either.

+ How do you respond? This is our role-playing segment of the examination, so pretend I am the patient.

  • Thank you so much for keeping me informed. I am sorry that it sounds like you were playing soccer without having much enjoyment. I am glad your pain is better now, even if it wasn’t as bad as I originally thought. Are you planning to continue playing sports in any capacity, including softball coming up?

+ The patient responds:

  • I just don’t want to play any sports anymore. I don’t have fun. My parents have made me play a million different sports since I was 6, and I hate it.

+ Your response:

  • I’m so sorry to hear that. Have you tried talking to your parents about what you want and what your goals are?

+ Examiner:

  • Thank you. That concludes this case.
  • Note: The key here is to promote healthy communication between this patient and her parents. Whether she has informed them she doesn’t want to play sports or not, points would be earned in this Domain for promoting dialogue and open communication between the patient and her parents. It is important that she communicate her own individual desires and goals, as it is not clear if her parents are pushing her excessively to play sports, or if they believe she enjoys it as much as they do. The first, most appropriate steps, are to find out what both parties know and where they are coming from, and then promoting proper dialogue and understanding.*