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Clinical Quiz Question

Persistent Ankle Pain After a 'Simple Sprain'

Wayne Stokes, MD; G. Brett Western, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 4 - APRIL 2001


A 19-year-old female college equestrian team member had a 6-month history of right lateral ankle pain with weight bearing and swelling. The symptoms interfered with her desired activity level and horseback riding. She reported that she had originally fallen from her horse but was uncertain of the mechanism of her ankle injury. She noted immediate lateral ankle pain and swelling. Findings on initial evaluation in her hometown (including ankle x-rays) were believed to be consistent with a right lateral ankle sprain. With protective taping, she returned to competitive riding within 5 days of the injury. She saw an ankle and foot specialist 1 month later. X-rays were not obtained at that visit.

The patient presented to our sports medicine clinic after returning to college 6 months after the initial injury. She reported ongoing right lateral ankle pain with walking and swelling with extended weight bearing and horseback riding. In addition, she reported intermittent popping without locking. She reported no giving way, numbness, weakness, or previous ankle injury.

Examination revealed right anterolateral ankle swelling. The patient had moderate pain with palpation over the lateral malleolus, anterior talofibular ligament, and anterolateral joint line, but no medial or posterior joint-line pain. Full range of motion was noted bilaterally, and active motion against resistance was nontender. Right ankle tibiotalar compression with rotation was associated with intermittent clicking. Examination of the ligaments revealed no laxity and was pain-free; her right ankle was symmetric to the left. There were solid endpoints with anterior drawer and talar tilt tests. The peroneal tendon was nontender and stable. Distal neurovascular exam was normal. A radiograph (figure 1) was obtained.

[Figure 1]

What is your diagnosis? What treatment would you recommend?

Dr Stokes is assistant professor of orthopedics at Albert Einstein College of Medicine in New York City. Dr Western is a third-year family practice resident at Altoona Hospital in Altoona, Pennsylvania. Address correspondence to Wayne Stokes, MD, Beth Israel Medical Center, Singer Division, Orthopedic Rehabilitation, 13th floor, 170 E End Ave, New York, NY 10128.


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