So let's look at a patient
with acute ankle pain.
A 22-year-old college basketball player presents
after injuring his ankle during practice.
After going up for a rebound,
he landed on a teammate's shoe,
causing him to roll his ankle.
And now he's been unable to bear
weight on the ankle since the injury.
So we have to come up with good
physical exam skills to help to tease apart
what could potentially be
going on with this patient.
It's important to remember some basic anatomy.
On the lateral side of the ankle,
we're thinking about the lateral malleolus.
And importantly, it's the certain ligaments,
particularly the interior talofibular ligament
indicated here that is the most
commonly sprained ligament in the ankle.
although there are a variety of other
ligaments and we'll work through them
when we move on with our physical exam content.
Looking at the medial side of the ankle, we
have a few more important structures there,
including the medial malleolus and
then several structures that are running just
posterior and inferior to it,
including your posterior tibial tendon,
your posterior tibial nerve, etcetera.
So we're going to have to look in that area in
particular and within the tarsal tunnel.
In terms of causes of ankle pain, we
have traumatic, we have overuse causes
and then inflammatory causes and we'll
go through a few examples of each.
Traumatic, just like in the patient we're talking
about now, perhaps he just sprained his ankle.
And when we're thinking about sprains,
the physical exam can help us to tease apart.
if this is just a grade I type of sprain,
which represents micro tears to the ligament,
something more like a moderate tear or grade II.
And then grade III is a
complete tear of that ligament.
And you can imagine that with a
complete tear, you'll have a lot of laxity
around the joint when you move it around.
In contrast, even potentially the
patient had more than just a sprain
and they may have, in fact, had a fracture
and we'll want to have some good exam skills
to help tease apart if a
fracture's occurred or not.
Also, remember, on the back of
the heel where the calcaneus is,
the Achilles tendon is going to insert
into that area, and we want to make sure
that we can also identify quickly at
the bedside an Achilles tendon rupture.
Thinking about overuse injuries, some of the
more common ones that can appear in the foot
are plantar fasciitis, classically characterized
by pain with the first step you take
when you get out of bed and stretch
that very inflamed plantar fascia
or tarsal tunnel syndrome, which I was alluding
to before with a burning paresthesia type pain
that's coming along the medial side of the
ankle and going towards the sole of the foot.
Thinking about inflammatory or degenerative
causes of pain, we, of course, can have gout
classically in the first
metatarsophalangeal joints known as podagra,
and this should be a very hot, swollen, painful
joint that should be not too difficult to identify.
And then just osteoarthritis, which can
manifest, particularly also in the first MTP,
as well as just around the ankle joint itself.
So it's going to be important that we keep
all of these different diagnoses in mind
as we move on to our physical exam to help
to characterize what exactly is going on
with our young 22-year-old
college basketball player.