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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)

His symptoms were constant in nature with no clear aggs/eases.

He reported no neurological symptoms.

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.

A protuberance was noted to the lateral ankle, and the patient reported he had noticed this growth over the last 3 months. 

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

  • Sural nerve entrapment / irritation 

  • Early onset osteoarthritis

  • 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.

The x-ray results were returned 2 weeks later reporting a loose screw and mild osteoarthritic changes. 

The results were discussed with the patient, and a referral to orthopaedics was agreed. 

Take home points?

  • As always consider asking about previous surgery or injury when asking PMH

  • Ensure to look, feel, and move the joints to help with your assessment and diagnosis

  • Can you refer directly for x-rays? 

  • Do you know your local criteria for referrals into orthopaedics?

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