Imaging of Ankle Impingement Syndromes Essay

Patient Information: N.D. 46 y/o African American female S. Chief Complaint: Pain in both ankles. HPI: The patient is a 46-year-old African American female, whose chief she heard a “pop” while playing soccer on Saturday afternoon and has been experiencing mild pain in both of her ankles since then. Both ankles are still weight bearing, but she rates her pain a 4/10, and has been taking over the counter Ibuprofen, which has provided some relief. Current Medications: Methotrexate 10 mg, PO once per week – SLE Ibuprofen 200 mg, PO q 4 to 6 hours – ankle pain Multivitamin (One a Day), PO 1 tablet qam Allergies: Sulfonamides – rash, hives Dairy products – gastric distress PMH: When the patient was 28 years old, she was diagnosed with systemic lupus erythematosus (SLE), which is stable with medication. Imaging of Ankle Impingement Syndromes Essay Patient denies any history of fractures (that she is aware of), major childhood illnesses, or hospitalizations, but due to playing organized sports for most of her teen and young adult years, reports various muscle and tendon strains and ligament sprains throughout the years. Immunizations: Covid Vaccination: Shot #1 – 2/16/21, shot #2 – 3/07/21, booster – 4/12/22: all Pfizer. Influenza shot – 3/17/22. Last tetanus shot: 2017. Social History: Patient is a Clinical Director and licensed therapist at a drug and alcohol rehabilitation facility, and lives with her husband and two children (daughter, 10 and son, 8). She denies any use of tobacco products or alcohol and has never used either. Patient is an avid hiker and enjoys doing so with her family. As patient has been progressing in her career, she admits that her stress has been increasing, but she is careful to “stay grounded and mindful,” as stress is trigger for an SLE flare-up. Family History: patient’s mother, age 76, has rheumatoid arthritis and osteoporosis, but is generally healthy. Her father, age 80, suffers from hypertension, which is controlled with medication. Patient’s brother, 50, has type I diabetes, which is controlled with insulin, and her younger sister, 41, “seems to be pretty healthy.” Patient’s maternal grandmother died from heart disease and her maternal grandfather died from atherosclerosis. Her paternal grandfather died from complications from a cholecystectomy and her paternal grandmother died from obesity and type II diabetes. Review of Systems: GENERAL: Patient denies fatigue, any recent changes in weight, and any fever or chills. MUSKULOSKELETAL: Patient’s chief complaint of increasing pain in ankles, bilaterally. SKIN: Patient denies any current rashes, itching, or other skin issues. CARDIOVASCULAR: Patient denies palpitations, discomfort, pressure, or pain in the chest. No edema noted. RESPIRATORY: Patient denies shortness of breath, cough, or the production of phlegm.  Imaging of Ankle Impingement Syndromes Essay PSYCHIATRIC: Patient denies any history, or current episodes of depression or anxiety. O. Vital signs: BP: 110/68, HR: 80, RR: 16, SpO2: 96, T: 36.7 C (98 F). Physical exam: MUSKULOSKELETAL: Inspected and evaluated strength of dorsiflexion and plantar flexion of patient’s ankles, bilaterally. Inspected and evaluated range of motion of patient’s ankles, bilaterally. Tested strength of inversion of ankles and eversion of ankles, bilaterally. Palpated patient’s Achilles tendons and metatarsal joints. SKIN: No areas of skin breakage noted. No abnormalities on or around the affected areas of the ankles, and feet. CARDIOVASCULAR: Auscultated heart sounds: S1, S2, and S3 audible and no abnormal sounds detected. RESPIRATORY: Patient’s breathing is unencumbered and unlabored, with a regular rise and fall of the chest. Auscultation reveals clear breath sounds in all areas and no adventitious lung sounds noted. Percussion of chest wall finds all resonance in all areas and no areas of dullness. The Ottawa Ankle Rules The Ottawa Ankle Rules are applicable to this patient’s situation, as her injury was acute and she has been consistently participating in organized sports for years, so there is a definite need to rule out a bone fracture (Herman, 2021). A patient with traumatic ankle pain qualifies for ankle radiographs if they have any of the following: point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus; point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus; or the inability to weight bear (just four steps) immediately after the injury and in emergency department (Yavas et al., 2021). As the patient does have point tenderness, radiologic modalities of the ankle are ordered. Diagnostic Tests: Radiograph Ultrasound MRI X-ray CT Scan A. Differential Diagnoses Presumptive diagnosis: Osteochondritis Dissecans (OCD): OCD is defined as “a focal idiopathic alteration of subchondral bone with risk of instability and disruption of adjacent articular cartilage” (Chau et al., 2021).

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In other words, the separation of subchondral bone from its surrounding area causes the bone and the cartilage covering it to crack and loosen, and this chip fracture leads to a disturbance of the local blood supply, resulting in necrosis and pain to the affected area (Brun et al., 2018). This type of microfracture may be associated with a single traumatic event or repetitive microtrauma, such as the damage that the patient has done from playing sports throughout her life (Pallamar et al., 2022). Diagnosis #2: Acute Lateral Ankle Sprain (ALAS): Although Thompson et al. (2017) cite that a third of people who sustain an ALAS “suffer significant disability due to pain, functional instability, mechanical instability or recurrent sprain after recovery,” many others do not experience such severe complications, as was the case with the patient, whose chief complaint was simply bilateral ankle pain. Imaging of Ankle Impingement Syndromes Essay It is not surprising that the physically active patient would sustain an ALAS, as Smith et al. (2021) cite this as “the most commonly incurred sports injury with a high recurrence rate.” Post physical examination of the ankle, diagnosis of an ALAS is through the familiar use of modalities ranging from an X-ray (to rule out bone fractures), an MRI (for detailed images of the ankle’s soft internal structures), to CT scans (for detailed examinations of the bones) and ultrasounds (for real-time images to assess the ligament when the foot is in different positions) (Vuurberg et al., 2018). Diagnosis #3: Anterolateral Impingement of the Ankle: This injury occurs when osteophytes (or “bone spurs”), develop on the anterior aspect of the bones of the ankle, causing pain and range of motion limitations from the osteophytes impinging on each other or by pinching soft tissues between them (Zbojniewicz, 2019). Imaging techniques, such as radiographs and magnetic resonance imaging (MRI), are critical for diagnosing osseous and soft tissue abnormalities seen in ankle impingement injuries (Al-Riyami et al, 2017). Talbot et al. (2018) add that joint impingements of this sort may lead to not only osteophyte formation, but also synovial hypertrophy. Diagnosis #4: Tibialis Anterior Tendon Rupture (TATR): While a TATR can be either acute or chronic, both are due to a “sharp cutting trauma or blunt or hyperplantarflexion trauma,” and spontaneous ruptures are rare (Johansen et al., 2021). Clinical presentation of TATR again differs with frequency, as chronic ruptures can present without pain and result in an impaired gait, but acute insults are accompanied by the pain and popping sound that the patient described (Waizy et al., 2017). The diagnostic methodologies that are most helpful for are radiographs (because the three views of foot and ankle that this technique provides are helpful to exclude any associated osseous injury) and MRIs (effective in determining the severity of the rupture) (Chen et al., 2021). Diagnosis #5: Peroneal Tendon Subluxation (PTS): A PTS is a dislocation (or subluxation) of the peroneal tendons (which connect the outer muscles of the calf to the foot), involving an elongation, a tear or an avulsion (separation) of the superior peroneal retinaculum (the peroneal tendons’ fibrous stabilizing band) (Willegger et al., 2021). Often misdiagnosed as an ALAS, this is another sports injury which typically occurs due to a sudden forceful upward flexing or outward turning of the ankle (Oesman et al., 2019). As with most other major ankle injuries, an MRI is critical for an accurate diagnosis of a PTS (Fram et al., 2019), and its clinical presentation of pain matches the case study patient’s reports (Stenquist et al., 2018). Imaging of Ankle Impingement Syndromes Essay

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