Author: Rathna Nuti, MD
Co Author #1: Dr. Robert Dimeff, MD

Patient Presentation:
A 9 year-old female presents with a chief complaint of left ankle pain for 1-1.5 years.

History:
She described diffuse ankle pain which was worse after running, especially uphill, and improves with rest from activity. She denied any swelling, discoloration, locking, instability, weakness, or paresthesias. She participated regularly in tumbling, soccer, and dance. After skiing moguls and ice-skating, she developed severe left ankle pain and was evaluated at the ski resort urgent care center, had normal xrays, and was treated with RICE and analgesics. Upon returning home, a pediatric orthopedist diagnosed her with growth-related pain and muscle-tendon imbalance, prescribed a walking boot for 3 weeks, followed by a stretching program. Symptoms improved with rest, but recurred with stretching.
A few months later, she was evaluated by another pediatric orthopedist, repeat xrays were normal, and she was treated with formal PT and activity as tolerated without improvement. She was subsequently treated by a chiropractor without improvement who referred her to the sports medicine clinic. At the time of presentation, she was also complained of diffuse, mild, intermittent right ankle pain for the past 6 months that was also worse after activity.


Past medical, surgical, allergy, system review, family and social history were unremarkable.

Physical Exam:
General: Healthy, well developed, well nourished female, no distress
Lower extremities:
Normal gait.
Hips and knees normal with full pain free range of motion.
Left leg 1 cm shorter with ankle hyperpronation. Pes cavus bilaterally with left greater than right.
Right foot and ankle with full pain free range of motion, no pain with resisted motions. No foot tenderness.
Left foot and ankle had loss of 5 degrees of ankle dorsiflexion. Mild pain with forced ankle dorsiflexion.
Mild tenderness of the dorsal medial and posteriomedial ankle.
Weakness with single-leg squat on the left without pain.
Mild left ankle pain with single leg jump.
Pulses and sensation are intact.

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