Sudden pop in the Lt ankle while playing soccer

15y/o healthy ♂; was playing soccer; while running backwards, felt a sudden pop a/w immediate onset of severe pain in the left ankle; fell on the ground; wasn’t able to mobilize initially; limping now; no prior similar episodes; no ankle pain prior to this incident; no previous injuries to the Lt ankle; ROS non-contributory; 

PMH: non-contributory; 

E/O: VSSA; 

Lt ankle: mild posterior swelling and ecchymosis; no erythema; no atrophy; tenderness over Achilles tendon with a palpable gap 4cm above its calcaneal insertion; Thompson’s test +ve; 

I/P: Achilles tendon rupture; NSAIDs; RICE; urgent ortho consult; 

Discussion^(1-2):

>75% occur in 30-40 yr olds; Male/Female=10/1; usually happens 30-40min after the start of the activity; Patients feel as if “I was kicked in the back of the leg” a/w a painful snap; 

Total rupture: Thompson’s/Simmonds’ calf squeeze test +ve; “Hatchet strike” defect (palpable, tender defect 3-6cm proximal to the calcaneal insertion) may be present in the immediate post rupture period; not palpable after a few days due to swelling; Only 25% of the tendon fibers are needed for normal Achilles tendon function, hence the difficulty in Dx of partial tears; Weak or absent active dorsiflexion; 

NSAIDs prn; RICE; ortho consult; surgical vs conservative management; needs careful patient selection; recent trend toward conservative Rx with early ROM (cast for 2wk then functional brace); conservative Rx earlier return to function; surgery less re-rupture at 1-4% (conservative at 10-30%), but ↑complications (infection, DVT & PE, adhesions); 

References: 

1. https://itunes.apple.com/ca/app/5-minute-sports-medicine-consult/id445352494?mt=8

2. Brukner, P., Brukner, P., D.R.C.O.G, & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill.

Ankle pain in a teenager

ID: 13 y/o healthy ♂ with gradual onset of Rt ankle pain 2/52 ago; now limping; not able to fully weight bear on the Rt foot; 

HPI: dull aching pain with activity; no pain at rest; no radiation; pain has gotten worse over the past 2 wk; no recent injury; Hx of mild remote injury 2mo ago while ice skating, did not seek medical advice at that time and the pain resolved completely after a few days, with no pain in the interim; no similar Sx in other joints; no previous similar episodes; involved in competitive ice skating; skipped a few ice skating practice sessions; ⊘fever/chills; ⊘B-Sx; ⊘blurred vision; ⊘GI Sx; ⊘am stiffness; 

PMH: non contributory

E/O: looks well, NAD, VSSA

Rt lower limb: 
Hip and knee joints unremarkable with full ROM.
Ankle: ⊘swelling, ⊘erythema, ⊘skin ▵s, ⊘atrophy, symmetrical compared to the Lt ankle; limited, painful dorsiflexion, ROM otherwise Ⓝ; post. heel area tender to touch; no plantar tenderness; unable to stand on tiptoe due to sever pain; pes planus; neuromuscular unremarkable;  

I/P: Rt heel pain due to Sever’s disease; RICE; reduction of athletic activities; NSAIDs prn; gradual increase of activity when pain better to a pain tolerance level; good quality shoes; vesicoelastic heel caps; f/u if pain refractory to conservative management; 

Discussion(1): 

Sever’s disease (calcaneal apophysitis) is the foot equivalent of Osgood-Schlatter disease; a traction over use syndrome; not an inflammatory condition (apophysitis is a misnomer); pain can be so sever that pt needs to use crutches; 

A cause of late childhood, early adolescent heel pain; most often between the ages of 8 and 13 yr; bilateral in ≈60%; 

Usually pt is involved in sports that need a lot of running (esp. on hard surfaces with low heeled shoes) & jumping; 

Dx is clinical; X-ray is not necessary; medial/lateral compression causes pain in the pos 3rd of the heel; sever pain with standing of tiptoe (Sever sign); Pain on foot dorsiflexion; X-ray if Dx is in question or refractory to conservative Rx (may indicate calcaneal stress # which needs immobilization 3-4wk); 

DDx may include: 

1. calcaneal bursitis
2. Achilles tendinitis
3. plantar fasciitis
4. calcaneal stress #

Rx is conservative if no response ➜ short leg cast or walker boot (duration? probably determined by the severity of the Sx); good quality shoes with adequate shock absorption and firm heel counter; ⊘ long-term sequelae; time to resolution variable, but complete resolution with skeletal maturity; 

Reference: 

1. https://itunes.apple.com/ca/app/5-minute-sports-medicine-consult/id445352494?mt=8

Wrist Pain in a Construction Worker

ID: 38 y/o ♂ otherwise healthy, came in with Rt wrist pain.

HPI: pain started gradually yesterday a few hr after moving heavy timber, no restricted ROM yesterday; woke up this am with significant Rt wrist pain; unable to move Rt wrist due to significant pain; no recent trauma; reports weak grip; no fever/chills; no previous Rt upper extremity injuries; mild swelling; no bruising or colour changes; no deformity; no numbness/tingling. 

PMH: ⊘

All: NKDA

E/O: A+O ✗ 3 - NAD - ⊘ ill/toxic

VSSA

Rt upper extremity: shoulder, elbow, MCP, and PIP joints are unremarkable. 

Wrist mildly edematous; ⊘ color/temp ▵s; significantly reduced active/passive ROM due to pain; no anatomical snuff box tenderness; severe tenderness on the ulnar aspect of the wrist; weak grip; neuro-vascular exam Ⓝ; 

X ray wrist ➜ ⊘ #

U/S wrist jont ➜ ⊘ effusion, possible TFCC tear.

I/P: 38 y/o ♂ with acute Rt wrist pain most likely caused by TFCC (Triangular Fibro-Cartilage Complex) tear.

RICE (Rest, Ice, Compression, Elevation), NSAIDs, protective bracing, physiotherapy; discharge home w F/U precautions; 

Discussion⁽¹⁾: 

TFCC consists of, triangular fibrocartilage, ulnar meniscus homolog, ulnar collateral ligament, carpal ligaments, extensor carpi ulnaris tendon sheath

Mechanism of injury: compressive loads to the wrist esp. if accompanied by ulnar deviation; can also be injured in distal radial/ulnar #s or disruption of the distal radio-ulnar joint; arthroscopy can be done for Dx or Rx purposes. 

Tenderness on the dorsal ulnar aspect of the wrist; pain on resisted dorsiflexion and ulnar deviation; Press test +ve;   

Reference: 

1. Brukner, P., Brukner, P., D.R.C.O.G, & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill. 

Jones fracture

ID: 43 y/o ♀ previously healthy came in due to Rt foot pain and swelling. 

HPI: Pain started suddenly 2wk ago in her dancing class. The pain came on suddenly with a direction change while practicing her steps. Thought it was a sprain, and did not seek medical attention. Pain and swelling did not resolve; pain is worse, does not radiate; constantly present but worse with weight bearing; interferes with walking, and work; causes limping; OTC NSAIDs help; ⊘ ankle pain; 

Very active lifestyle;    

PMH: Noncontrubutory

Meds: ⊘

All: NKDA

E/O: A + O ✗ 3; NAD; ⊘ ill/toxic

VSSA

Rt foot: Swollen compare to the Lt side; mild bruising mid foot region; 5th metatarsal (MT) base tender to touch; MTP and ankle joints Ⓝ painless ROM; 

Neurovascular Ⓝ; ⊘ deformity;  

Gait: antalgic; 

Foot XR: proximal 5th MT # (Jones #)

Fig1⁽¹⁾

I/P: A 43 y/o lady in good health, and active lifestyle with Jones#. 

Pain management; non-weight bearing cast for 6-8wk. Outpatient F/U Ortho, next week. 

Discussion: 

Jones # is the fracture of the proximal 5th MT at the metaphyseal-diaphyseal junction(1.5cm distal to the tuberosity). Involves the 4th-5th MT joint. 

Fig.2⁽²⁾

Should not be confused with the avulsion # of the 5th MT styloid which is more common (90% of the cases). Other DDx include, stress #, and os peroneum. If acute (≺3mo)+minimal displacement conservative Rx. 

Recently more tendency in favour of early surgical management (earlier return to full weight bearing(wb) in 2-4wk)⁽³⁾. Non union is potential concern in conservative Rx. 

Stress # usually caused by overuse; more gradual onset of pain; may have Sx before +ve XR; distal to 4th-5th MT joint; more prone to nonunion. 

References: 

1. http://radiopaedia.org/cases/jones-fracture

2. http://radiopaedia.org/images/141041

3. Brukner, P., Brukner, P., D.R.C.O.G, & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill.