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 Throat Exam
Patient Information: P.M. Age: 46 y.o. Sex: Female DOB: 8/5/1971

S.
Chief Complaint/Reason for Visit:
“Both of my ankles hurt, but more severe on the right”
History of Present Illness:
Ms. P.M is a 46-year-old Japanese female who works as a physical education teacher at a local school
district and presented with reports of bilateral ankle pain for the past 3 days. The patient reported that
she was playing soccer over the weekend when she heard a “pop” sound during the game. The pain
initially ranges from 6/10 on both ankles but after 5-10 minutes her right ankle pain started to increase.
According to her, she was able to bear weight on both ankles but felt more discomfort on the right side
when walking or standing. Although applying a cold compress on both areas provides relief, she noticed
that her right ankle has been swollen since yesterday.

The patient does not recall any recent accident and stated that she has been actively playing different
sports such as tennis, and volleyball all her life. The only difference that she noticed during the game
was that she did not have enough time to warm up since she was running late for the game. Upon
presentation, the patient reported 7/10 on her right ankle and 3/10 on her left side.
Current Medications:
1. One-A-Day Women’s Multivitamins one tablet daily
2. Ferrous Sulfate 325mg once daily

Allergies: NKDA, NKFA

Immunization History:
Flu Vaccine: October 2022
PMHx:
• Anemia (2020, managed by Ferrous Sulfate)
Fam Hx: Reported both parents are healthy and alive. The father has hypertension. Personal/Social
History: Patient is single. Works as a physical education teacher full- time. Does not smoke, drink or use
any illicit drugs. Physically active, exercises 5-6 time a week.
Review of Systems:
Constitutional: A&O x4, pleasant and cooperative. No acute distress. Denies weight loss, weakness, or
fatigue.
HEENT: Denies headache, sore throat or changes in vision and hearing.
SKIN: No rash or itching.
CARDIOVASCULAR: Denies chest pain or palpitations.
RESPIRATORY: Denies shortness of breath or cough.

Allergies: Nuts-hives Immunization History:

 Flu Vaccine: October 2017
PMHx:
• Anemia (2015, managed by Ferrous Sulfate)
Fam Hx: Reported both parents are healthy and alive. Father has hypertension. Personal/Social History:
Patient is single. Works as a physical education teacher full- time. Does not smoke, drink or use any illicit
drugs. Physically active, exercises 5-6 time a week.
Review of Systems:
Constitutional: A&O x4, pleasant and cooperative. No acute distress. Denies weight loss, weakness, or
fatigue.
HEENT: Denies headache, sore throat or changes in vision and hearing.
SKIN: No rash or itching.
CARDIOVASCULAR: Denies chest pain or palpitations.
RESPIRATORY: Denies shortness of breath or cough.

O. Physical exam: Vital signs: B/P 90/72, Pulse 88 (strong and regular); Temp 98.0F orally; RR 19; non-
labored; SpO2: 98% room air;
Height: 5' 6" Weight:135 lbs.
General: A&O x4, pleasant and cooperative. Not in any acute distress.
HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA. Oropharynx
red. No lesions. Moist mucous membranes.
Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules. Chest/Lungs: Clear to
auscultation bilaterally. No accessory muscle use.
Heart/Peripheral Vascular: Right ankle swelling. Regular rate and rhythm noted. No murmurs. No
palpitation. No clubbing or cyanosis; Normal capillary refill. Bilateral equal pedal pulses.
ABD: Soft, nontender, nondistended. No rigidity, rebound, or guarding. No palpable
hepatosplenomegaly.

Genital/Rectal: continent of bladder and bowel.

Musculoskeletal: Lower extremities with reports of pain. Right ankle swelling and 2x1.5cm ecchymosis
on mid-lateral malleolus area with tenderness 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 discomforts on the right ankle. No
bony tenderness, deformity, or crepitus is present.
Neuro: Alert and oriented x4. Strength and sensation intact.
Skin/Lymph Nodes: 2x1.5cm ecchymosis on the mid-lateral malleolus area of the right ankle. Intact skin.
No cervical lymphadenopathy. No rashes, or erythema. No lesions. Diagnostic studies:
Anterior Drawer Test: Positive
An Anterior Drawer Test is considered a screening test in the assessment of lateral ankle sprain and
suspected ATFL injury (Croy, Hertel, Koppenhaver, & Saliba, 2013). Inversion test: pain noted in the area
of the anterior talofibular ligament.
Imaging Studies:
Right ankle X-ray

 According to the rule, an ankle X-ray series is only required if there is any pain in the malleolar
zone plus 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 running, cutting, landing from a jump,
or from direct contact which can produce an audible tear or pop causing pain and swelling that
are immediate, but ecchymosis may lag a day or two behind (American Orthopaedic Foot &
Ankle Society, 2015).
- An ankle sprain is an injury to one or more ligaments in the ankle with symptoms such as pain,
swelling, soreness, bruising, difficulty walking, and joint stiffness
(American College of Foot and Ankle Surgeons, 2018).
- Based on the reported symptoms and physical assessment findings, ankle sprain is the
primary diagnosis for the patient. Anteroposterior lateral views x-ray preferably with weight
bearing or during inversion will reveal extent of ligament injury.
• Achilles tendinitis inflammation of the Achilles tendon producing symptoms of pain and
swelling where the tendon inserts into the calcaneus, and patient reports of feeling of tightness
that makes walking and running difficult (Baumann, Dains, & Scheibel, 2016, p. 269).
- The area of pain and tenderness noted with G.M. involves the mid-lateral area of the ankle.
Swelling of the Achilles tendon can be assessed in the posterior part of the ankle.
• Ankle fracture: may involve one or more of the ankle bones such as the tibia, fibula, and talus
with symptoms such as severe immediate pain, swelling, bruising, tenderness, deformity, and
inability to bear weight (American Academy of Orthopaedic Surgeons, 2013).

 • Anterior impingement: which is also known as footballer’s ankle with presenting symptoms
such as pain and inflammation including a decrease in overall ankle range of motion, mostly
affecting dorsiflexion (Stanford Health Care, 2017).
• Plantar fasciitis: affect women twice as often as men, is caused by chronic weight-bearing
stress when laxity of foot structures allows the talus to slide forward and medially, calcaneus to
drop, and plantar ligaments and fascia to stretch (Baumann, Dains, & Scheibel, 2016, p. 269).
Pain is worse on awakening and is relieved with non-weight-bearing activity often involving the
heel (Baumann, Dains, & Scheibel, 2016, p. 269).

Reference
American Academy of Orthopaedic Surgeons. (2013). Ankle Fractures. Retrieved
from [Link] to an
external site.
American College of Foot and Ankle Surgeons. (2018). Ankle Sprain. Retrieved
from [Link] to an external site.

American Orthopaedic Foot & Ankle Society. (2015, June). Ankle Sprain. Retrieved
from [Link] to an external
site.

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
[Link] anterior-
[Link]