Should you apply the Ottowa ankle rules to determine if you need additional testing?
1 day ago
Lorna Isaac
Cast study #2 Ankle Pain
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Review of case study #2: Ankle Pain
Scenario: A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?
Episodic/Focused SOAP Note for Ankle Pain
Patient Information: L.M. Age: 46 year old Sex: Female Race: non-Hispanic
S.
CC:
“Both of my ankles hurt, but more severe on the right”
HPI:
Ms. L.M. is a 46-year-old non-Hispanic female reports bilateral ankle pain x2 days. Patient states she was playing soccer during the weekend when she heard a “pop” sound. The patient rated the initial pain as a 4 on a 0-10 pain scale but within 10 min the pain intensified. Pt states she is able to bear weight but feels more discomfort on the right side while standing or ambulating. Relieving factors are applying ice, rest, and elevation, patient has not tried compression and states her right ankle has been swollen since a few hours after the game. Patient is an avid sports fan plays many sports regularly. Patient does not recall any recent accidents or injuries besides the one the patient has already reported. Patient states the only variant in this game is that she did not take the time to complete her usual warm-up before starting the game At this time patient reports pain in Right foot 6 out of 10 and L foot 2 out of ten.
Current Medications:
Tylenol 500 mg q6 PRN
Lipitor 10 mg QD
Allergies: Bee stings- anaphylaxis. NKDA, No food or latex allergy.
Immunization Hx:
Flu Vaccine: November 2019
PMHx:
• Borderline hyperlipidemia
FHx: Patient reports adoption at age 4, does not know any biological family hx
SHx: Pt is married with 0 children. Works as a full-time Occupational Therapist. Pt reports she does not smoke, use ETOH or any illicit drugs. Pt reports being physically active with a 30-45 min walk 4-6 times per week.
ROS:
General: A&O x4, amiable and compliant, no acute distress, denies weight loss, weakness, or fatigue.
HEENT: Pt denies any auditory or visual changes.
SKIN: Skin is intact with no itching or redness.
CARDIOVASCULAR: Patient reports no chest pain or palpitations.
RESPIRATORY: Patient has no SOA or cough.
GASTROINTESTINAL: Pt reports regular bowel movements and denies any abdominal pain or tenderness. Pt denies any nausea or vomiting and reports a good appetite.
GENITOURINARY: LMP 03/27/2020. Denies any burning on urination or any changes in urinary patterns.
NEUROLOGICAL: Pt reports no headaches, dizziness, numbness or tingling.
MUSCULOSKELETAL: Pt states bilateral ankle pain x 2 days with pain worse on R side. Pt rated R ankle pain as 4-5 on a 0-10 pain scale. Edema began within the last 24 but weight-bearing is possible with some discomfort.
HEMATOLOGIC: No clotting or blood disorders noted with no bleeding present. Bruise located on right ankle injury site.
LYMPHATICS: No irregularly palpable nodes or organs.
O.
Physical exam: Vital signs: B/P 122/76, Pulse 74 regular rate and rhythm, Temp 98.4F, RR 16; non-labored; SpO2: 99% with no supplemental O2
Height: 5′ 6″ Weight:134 lbs.
General: A&O x4, amiable and compliant. No acute distress noted.
HEENT: Normocephalic with no trauma noted, PERRLA. Oropharynx pink without lesions.
Neck: Full ROM with no discomfort, swelling or palpable nodules.
Pulmonary: Clear to auscultation bilaterally. No accessory muscle use.
Cardio: RRR present with no irregularities noted. No murmurs. No palpitation. No clubbing or cyanosis; Normal capillary refill. Bilateral equal pedal pulses.
ABD: Soft, non-tender, non-distended. No rigidity, rebound, or guarding. No abnormally palpable organs.
Genital/Rectal: continent of bladder and bowel.
Musculoskeletal: Bilateral ankle pain. Edema without pitting to R ankle. swelling and 2×1.5cm bruise on mid-lateral malleolus area with sensitivity upon palpation on the lateral side of the ankle over the anterior talofibular ligament (ATFL). Range of motion with pain and limitation on dorsiflexion, plantar flexion, and inversion. Skin intact. Able to bear weight on BLE, with discomfort to the right ankle. No tenderness on bone, no deformity or crepitus present.
Neuro: Alert and oriented x4. Strength and sensation intact.
Skin/Lymph Nodes: 2×1.5cm bruise on R ankle, no skin breakdown. No rashes, or redness.
Diagnostic studies:
Anterior Drawer Test: positive
This test for assessment for lateral ankle sprain and possible ATFL injury (Croy, Hertel, Koppenhaver, & Saliba, 2013).
Inversion test: pain noted in the area of anterior talofibular ligament.
Imaging Studies:
Right ankle X-ray- An X-Ray series is not indicated at this time is only necessary if the pain is location in the malleolar zone, in addition to one of the following: bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus bone tenderness along the distal 6cm of the posterior edge or tip of the medial malleolus or an inability to bear weight both immediately and in the emergency department for four steps (Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 252).
A.
Differential Diagnoses (DD):
Grade 2 Lateral Ankle Sprain: Sports injuries occur when most often when kinetic energy is involved such as running, jumping, or from some type of direct connection, which will at times an generate a distinct tearing or popping sound-producing discomfort or edema immediately, but bruising may occur hours or days after injury (American Orthopedic Foot & Ankle Society, 2015). A sprain is damage occurring to one or more ligaments, in the ankle in this case, with indications such as pain, edema, tenderness, ecchymosis, trouble ambulating, and stiffening of the joint (American College of Foot and Ankle Surgeons, 2018). After reviewing the patient’s symptoms, assessment, and other findings, ankle sprain is the most probable explanation for the patient’s injury. The degree of injury could be better assessed with an anteroposterior lateral views x-ray, best seen while bearing weight if possible or with transposition.
Achilles tendonitis or inflammation of the Achilles tendon: This condition can produce many of the same signs such as edema around the area where the tendon inserts into the calcaneus. The pt typically reports feels of rigidity that makes mobility challenging (Baumann, Dains, & Scheibel, 2016, p. 269). The area of discomfort with this condition involves the mid-lateral area of the ankle. Inflammation of the Achilles tendon can be evaluated in the posterior part of the ankle.
Ankle fracture: This condition can involve one or more of the bones in the ankle with indicators of instant severe pain at the time of injury, inflammation, ecchymosis, discomfort, malformation and being unable to bear weight (American Academy of Orthopaedic Surgeons, 2013).
Anterior impingement AKA footballer’s ankle: This occurs with indicators of pain and swelling with reduced range of motion, especially affecting dorsiflexion (Stanford Health Care, 2017).
Plantar fasciitis: This condition is much more prevalent in women it is brought on by repeated chronic weight-bearing stress with negligence of foot structures allows the talus to slide forward, calcaneus to drop, and plantar ligaments and fascia to stretch (Baumann, Dains, & Scheibel, 2016, p. 269). Discomfort upon wakening that lessens throughout the day with non-weight bearing activity often involving the heel (Baumann, Dains, & Scheibel, 2016, p. 269).
Additional Testing
The Ottawa ankle rule should be applied in this case, this will help determine what additional testing needs to be done. If an X-ray is indicated an anteroposterior lateral views x-ray should be completed for further diagnosis and rule out a fracture. A Talar tilt test could be performed as well as an anterior drawer test, squeeze test and Thompson test could all be performed to help assess the extent of the damage.
References
American Academy of Orthopaedic Surgeons. (2013). Ankle Fractures. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-broken-ankle/
American College of Foot and Ankle Surgeons. (2018). Ankle Sprain. Retrieved from https://www.foothealthfacts.org/conditions/ankle-sprain
American Orthopaedic Foot & Ankle Society. (2015, June). Ankle Sprain. Retrieved from http://www.aofas.org/PRC/conditions/Pages/Conditions/Ankle-Sprain.aspx
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Croy, T., Hertel, J., Koppenhaver, S., & Saliba, S. (2013). Anterior Talocrural Joint Laxity: Diagnostic Accuracy of the Anterior Drawer Test of the Ankle. Journal of Orthopaedic & Sports Physical Therapy,43(12), 911-919. doi:10.2519/jospt.2013.4679
Stanford Health Care. (2017). Anterior Ankle Impingement (Footballer’s Ankle). Retrieved from https://stanfordhealthcare.org/medical-conditions/bones-joints-and-muscles/ankle-anterior-impingement.html
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