Anna Coyle: A 24-Year-Old Dental Hygienist With Severe Medial Ankle Pain

Learning Objectives

  • Learn the common causes of ankle pain.

  • Develop an understanding of the unique anatomy of the ankle joint.

  • Develop an understanding of the ligaments of the ankle.

  • Develop an understanding of the causes of medial ankle pain.

  • Develop an understanding of the differential diagnosis of deltoid ligament strain.

  • Learn the clinical presentation of deltoid ligament strain.

  • Learn how to examine the ankle and associated ligaments.

  • Learn how to use physical examination to identify deltoid ligament strain.

  • Develop an understanding of the treatment options for deltoid ligament strain.

Anna Coyle

Anna Coyle is a 24-year-old dental hygienist with the chief complaint of, “I think I broke my ankle.” Anna stated that about 2 weeks ago, she was running a half marathon and stepped into a pothole and twisted her ankle. She tried to finish the marathon, but the pain was just too bad. By the time she limped back to her car, her ankle was swollen and black and blue. She made it home and immediately iced and elevated the ankle. Over the past 10 days, the bruising and swelling have improved, but Anna states that the inside of her right ankle continues to hurt. Running has been out of the question, and the ankle pain has really been “messing with my running.” I asked Anna if she ever had anything like this before, and she said, “I have had the usual aches and pains that you expect if you run marathons. Once I had what the shoe guy said was metatarsalgia when I didn’t replace my running shoes. I learned my lesson that time. It’s just hard to throw out expensive shoes! My ankle was fine until I stepped into that pothole. I twisted my ankle outward, and it felt like something on the inside of my ankle tore. It’s been bothering me ever since.”

I asked Anna what made the pain worse, and she said that any walking, weight bearing, walking on uneven surfaces, and putting on her jogging shoes all made the pain much worse. I asked her what made it better, and she said that she thought Advil helped, but it was upsetting her stomach. She noted that icing the ankle felt good, but the pain came back as soon as she took the ice off. I asked Anna about any other antecedent ankle trauma, and she said, “Not that I can recall.”

I asked Anna to use one finger to point at the spot where it hurt the most. She pointed to her right medial ankle just below the medial malleolus.

On physical examination, Anna was afebrile. Her respirations were 16, and her pulse was 64 and regular. Her blood pressure was 126/80. Anna’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination revealed some tenderness to deep palpation of the paraspinous musculature. Visual inspection of the right medial ankle revealed resolving ecchymosis, but the area appeared a little swollen. The area over the medial ankle felt a little warm but did not appear to be infected. The right medial ankle felt boggy on palpation. There was marked tenderness to palpation over the deltoid ligament, with the palpation of the area reproducing Anna’s pain. Range of motion of the ankle joint, especially active resisted eversion and plantar flexion of the ankle joint, caused Anna to wince in pain. The left ankle examination was normal, as was examination of her major joints. The eversion test for deltoid ligament injury was markedly positive on the right, as was the rotary drawer test ( Figs. 3.1 and 3.2 ). A careful neurologic examination of the upper and lower extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. I asked Anna to walk down the hall, where I noted an antalgic gait was present.

Fig. 3.1

Eversion test for deltoid ligament insufficiency.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . Philadelphia: Saunders; 2006:369.

Fig. 3.2

Clinical image of rotatory drawer testing for medial ankle instability.

From Beals TC, Crim J, Nickisch F. Deltoid ligament injuries in athletes: techniques of repair and reconstruction. Oper Techn Sport Med . 2010;18(1):11–17 [Fig. 4]. ISSN 1060–1872, , .

Key Clinical Points—What’s Important and What’s Not

The History

  • Onset of right ankle pain following a jogging injury to the right ankle

  • Pain localized to the area of the right deltoid ligament

  • Pain made worse by walking, going down stairs, and walking on uneven surfaces

  • No other specific traumatic events to the ankles

  • No fever or chills

  • Unable to jog due to persistent right ankle pain

The Physical Examination

  • Patient is afebrile

  • Point tenderness to palpation of the area over the deltoid ligament

  • Palpation of right ankle reveals warmth to touch

  • Right medial ankle is swollen, with bogginess over the deltoid ligament

  • No evidence of infection

  • Pain on range of motion, especially active resisted eversion and plantar flexion of the affected right ankle

  • Positive eversion test for deltoid ligament injury (see Fig. 3.1 )

  • Positive rotary drawer test for deltoid ligament injury (see Fig. 3.2 )

  • Antalgic gait is present

Other Findings of Note

  • Normal HEENT examination

  • Normal cardiovascular examination

  • Normal pulmonary examination

  • Normal abdominal examination

  • No peripheral edema

  • Normal upper and lower extremity neurologic examination, motor and sensory examination

  • Examinations of joints other than the right ankle were normal

What Tests Would You Like to Order?

The following tests were ordered:

  • Plain radiographs of the right ankle

  • Ultrasound of the right ankle

Test Results

The plain radiographs of the right ankle revealed mild soft tissue swelling over the medial ankle and a small medial malleolar avulsion fracture ( Fig. 3.3 ).

Nov 19, 2022 | Posted by in PAIN MEDICINE | Comments Off on Anna Coyle: A 24-Year-Old Dental Hygienist With Severe Medial Ankle Pain

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