Paul Reckinger: A 32-Year-Old Real Estate Agent With Severe Right Ankle Pain With an Associated Catching Sensation

Learning Objectives

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Learn the common causes of ankle pain.
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Develop an understanding of the unique anatomy of the ankle joint.
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Develop an understanding of the musculotendinous units that surround the ankle joint.
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Develop an understanding of the anatomy of the Achilles tendon.
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Develop an understanding of the causes of Achilles tendinitis.
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Develop an understanding of the differential diagnosis of Achilles tendinitis.
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Learn the clinical presentation of Achilles tendinitis.
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Learn how to examine the ankle and Achilles tendon.
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Learn how to use physical examination to identify Achilles tendinitis.
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Develop an understanding of the treatment options for Achilles tendinitis.

Paul Reckinger

Paul Reckinger is a 32-year-old commercial real estate agent with the chief complaint of, “I have a catch in the back of my right ankle that hurts like hell.” Paul stated that he recently competed in a tennis tournament at his country club and thought that was the reason for his ankle problem. “Doc, the competition was really brutal, but I gave it my all. I was up against this guy in the semifinals, and we were very evenly matched. The game went on for what seemed like hours, and neither of us could bring the game home. It was match point, and when I lunged for the ball I felt something in the back of my right ankle tear as I hit the ball. There was no way that guy was going to get to that ball the way I returned it, but from then on the back of my ankle has been hurting, especially in the mornings, when I first get up to go to the bathroom. Then I feel a catch and a sharp pain, and I have to hobble into the bathroom. It gets a little better after I’m up and on it for a while.”

I asked Paul about any antecedent ankle trauma, and he said no. I asked what made the pain better, and he said a couple of Aleves washed down with a couple of single-malt whiskeys seemed to help. I asked Paul what made it worse, and he said the heating pad and walking up and down stairs. I asked how he was sleeping, and he said, “Not worth a crap. Every time I roll over, if I move my ankle, the pain wakes me up. I can’t lie on my right side, and that’s the side I like to sleep on.” He denied fever and chills. I asked Paul to point with one finger to show me where it hurt the most. He pointed to the area above the posterior aspect of the right calcaneus.

On physical examination, Paul was afebrile. His respirations were 16, and his pulse was 72 and regular. He was normotensive with a blood pressure of 120/70. Paul’s head, eyes, ears, nose, throat (HEENT) exam was normal. His cardiopulmonary examination was completely normal. His thyroid was normal, as was his abdominal examination, which revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness, nor was there any peripheral edema. Paul’s low back examination was unremarkable. Visual inspection of the right ankle was normal. I asked Paul to get up and walk, and he walked with a flat-footed gait to avoid plantarflexing his foot. The area over the distal Achilles tendon was a little warm, but it did not appear to be infected. There was marked tenderness to palpation of the distal Achilles tendon, and I perceived a creaking sensation when I asked Paul to plantarflex his foot ( Fig. 6.1 ). Paul’s pain was reproduced with resisted plantarflexion of the foot. There was pain to externally rotate his ankle. The left ankle examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

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

The History

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History of acute trauma to the posterior ankle following lunging for a ball while playing tennis
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No history of previous significant ankle pain
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No fever or chills
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Acute onset of ankle pain following a traumatic event with exacerbation of pain with ankle use
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Pain in the right ankle
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A catching sensation when walking
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Sleep disturbance

The Physical Examination

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Patient is afebrile
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Tenderness to palpation of the distal Achilles tendon
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Palpation of the right Achilles tendon reveals warmth to touch
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Creaking sensation when palpating the right Achilles tendon during passive plantarflexion of the foot
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Increased pain with resisted plantarflexion of the right foot and ankle
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No evidence of infection
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Flat-footed gait in an effort to splint the inflamed Achilles tendon