Ryan Rostov: A 52-Year-Old Male With Right 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 causes of ankle joint arthritis.



  • Learn the clinical presentation of osteoarthritis of the ankle joint.



  • Learn how to use physical examination to identify pathology of the ankle joint.



  • Develop an understanding of the treatment options for osteoarthritis of the ankle joint.



  • Learn the appropriate testing options to help diagnose osteoarthritis of the ankle joint.



  • Learn to identify red flags in patients who present with ankle pain.



  • Develop an understanding of the role in interventional pain management in the treatment of ankle pain.



Ryan Rostov







Ryan Rostov is a 52-year-old roofer with the chief complaint of, “My right ankle is killing me.” Ryan went on to say that he wouldn’t have bothered coming in, but he was getting to where he was having a harder and harder time walking on roofs with a steep pitch. “Doctor, it’s getting to where I am afraid to work on some of these steep roofs. It’s not a height sort of thing, nothing like that. It’s just when I flex my right ankle to walk down the roof, I get a sharp pain. I am afraid it will hit when I am not expecting it, and I will lose my footing. I am not interested in falling off the roofs of some of the McMansions, if you know what I mean.” I asked Ryan if he had anything like this happen before. He shook his head and responded, “Just the usual aches that a guy my age comes to expect. You can’t work all day as a roofer and not have some pain. On some days I go up and down a ladder 100 times. Usually, I just take a couple of Motrin and use a heating pad. That will usually set me right after a day or so. What worries me this time is that this damn right ankle is hurting all the time. Especially, like I said, when I’m coming down a roof. I can live with the aching, but it’s that sharp pain that scares me. I’m pretty tough and I really like what I do. There’s a start and a finish to it. The roof leaks, I put on a roof, no more leaks. Kind of like being a doctor! But this ankle pain has me worried because if I don’t work, I don’t eat. In my younger days, when I should have been saving, I was playing. I really need to work if I ever want to retire, which I don’t yet! So help me get this ankle tuned up.”


I asked Ryan about any antecedent trauma, and he shook his head no. “Doc, this kind of snuck up on me. At first, my ankle had this deep ache that would get better with some Motrin and rest. Over time, the Motrin has just about quit working. But, like I said, I gotta work.” I asked Ryan what made his pain worse, and he replied, “The steeper the pitch, the worse the ankle.”


I asked Ryan to point with one finger to show me where it hurt the most. He grabbed his right ankle and said, “Doc, I can’t really point to one place because it kind of hurts all over. Although, by the end of the day, the front of the ankle is the worst. And you know, Doc, the crazy thing is, sometimes I feel like the ankle is popping.” I asked if he had any fever or chills, and he shook his head no. I continued, “What about steroids? Did you ever take any cortisone or drugs like that?” Ryan again shook his head no, then said, “You know me, I’m not one for taking pills. Pills and roofing really don’t mix.”


On physical examination, Ryan was afebrile. His respirations were 16, and his pulse was 74 and regular. His blood pressure was slightly elevated at 122/74. His head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. I did a rectal exam, which revealed no mass and a normal prostate. Visual inspection of the right ankle revealed no cutaneous lesions or obvious tumor. The ankle was cool to touch. Palpation of the right ankle revealed mild diffuse tenderness, with a mild effusion ( Fig. 1.1 ). There was tenderness at the anterior aspect of the ankle joint. There was mild crepitus, but I did not appreciate any popping or joint instability. Range of motion of the ankle joint was decreased, with pain exacerbated with flexion, extension, eversion, and inversion of the ankle. The anterior drawer test for anterior talofibular ligament instability was negative ( Fig. 1.2 ). The left ankle examination was normal, as was examination of his other major joints, other than some mild osteoarthritis in the right hand. 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.




Fig. 1.1


Palpation of the ankle joint.

From Waldman S. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . ed. 4. Philadelphia: Elsevier; 2021 [Fig. 262-1].



Fig. 1.2


The anterior drawer test for anterior talofibular ligament insufficiency.

From Waldman S. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . ed. 4. Philadelphia: Elsevier; 2021 [Fig. 264-1].


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


The History





  • No history of acute trauma



  • No history of previous significant ankle pain



  • No fever or chills



  • Gradual onset of ankle pain with exacerbation of pain with ankle use



  • Popping sensation in the right ankle



  • Sleep disturbance



  • Intermittent sharp pain in the anterior ankle with flexion of the joint



The Physical Examination





  • Patient is afebrile



  • Normal visual inspection of ankle other than mild effusion



  • Palpation of right ankle reveals diffuse tenderness



  • Decreased range of motion of the ankle joint; pain exacerbated with ankle flexion, extension, eversion, and inversion



  • No increased temperature of right ankle



  • Crepitus to palpation (see Fig. 1.1 )



  • Negative anterior drawer test (see Fig. 1.2 )



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



  • Examination of other joints was normal



What Tests Would You Like to Order?


The following tests were ordered:




  • Plain radiographs of the right ankle



Test Results


The anterior to posterior (AP) and lateral radiographs of the ankle joint indicate severe ankle arthritis with reduced joint space, anterior osteophytes, and sclerosis of the articular surfaces consistent with osteoarthritis ( Fig. 1.3 ).




Fig. 1.3


Anteroposterior and lateral radiographs of an ankle joint indicating severe ankle arthritis with a large anterior osteophyte (white arrow) .

From Adukia V, Mangwani J, Issac R, et al. Current concepts in the management of ankle arthritis. J Clin Orthop Trauma . 2020;11(3):388–398 [Fig. 1].


Clinical Correlation—Putting It All Together


What is the diagnosis?




  • Osteoarthritis of the right ankle joint



The Science Behind the Diagnosis


Anatomy of The Joints of The Ankle


The ankle is a hinge-type articulation among the distal tibia, the two malleoli, and the talus ( Fig. 1.4 ). The articular surface is covered with hyaline cartilage, which is susceptible to arthritis. The joint is surrounded by a dense capsule, which helps strengthen the ankle. The joint capsule is lined with a synovial membrane that attaches to the articular cartilage. The ankle joint is innervated by the deep peroneal and tibial nerves. The major ligaments of the ankle joint include the deltoid, anterior talofibular, calcaneofibular, and posterior talofibular ligaments, which provide the majority of strength to the ankle joint. The muscles of the ankle and their attaching tendons are susceptible to trauma and to wear and tear from overuse and misuse. There are a number of arteries that traverse the joint that can provide sources of bleeding when performing intraarticular injection of the ankle ( Fig. 1.5 ).


Nov 19, 2022 | Posted by in PAIN MEDICINE | Comments Off on Ryan Rostov: A 52-Year-Old Male With Right Ankle Pain
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