Author: Chad Nabors, DO
Co Author #1: Rachel Kee, DO
Co Author #2: Andrea Pitts, MD
Senior Editor: Emily Miller, MD
Editor: Christian Fulmer, DO

Patient Presentation:
A 22 year old female presented to Orthopedics for evaluation of left ankle pain. Her symptoms started approximately 7 months prior when she hit her ankle against a banister falling down the stairs. She denied any inversion, eversion, extreme plantarflexion or dorsiflexion type of mechanism with the fall. She was evaluated by her primary care doctor on two separate occasions, diagnosed with an ankle sprain and treated conservatively. Given persistent pain, she went to Urgent Care where an x-ray was obtained. This was read as an old fibular fracture with callus formation. Case Photo #1 She was subsequently placed in a walking boot and referred to Orthopedics. Upon initial exam in our clinic, her pain was located 3-5 cm proximal to her lateral malleolus and worsened with standing. She reported stiffness and sharp pain with prolonged walking. She reported that heat, ice, high-dose acetaminophen, and meloxicam provided minimal benefit.

History:
She reported a history of multiple osteochondromas with concern for hereditary multiple osteochondromas (HMO) that was diagnosed around age 3. She reported multiple sites of osteochondromas including bilateral knees, pelvis, right shoulder, and possibly ear canal. She was previously followed at Shriners Hospital but had not been seen in several years. She denied prior genetic work up or known family history of similar diagnoses.

Physical Exam:
Height: 167.6 cm (5'6")
Weight: 103 kg (227 lbs)
BMI: 36.64 kg/m2
General: Well developed, well-nourished, no acute distress
Left lower extremity: Pain with palpation 3 to 5 cm proximal to the left ankle joint without any palpable abnormality.
Ankle range of motion was full but she reported tightness with end range dorsiflexion.
Strength was 5/5 in plantarflexion, dorsiflexion, and inversion. Eversion strength was 4/5.
There was full sensation to the foot and ankle but she did report a band of numbness 3 to 5 cm proximal to the ankle joint.
There was a palpable firm, mildly tender mass on the medial aspect of the distal tibia..
Right lower extremity: Visible and palpable bony mass to the medial aspect of distal right tibia. Right ankle also demonstrated mild valgus deformity.
Back: A small palpable bony mass noted posterior to the medial border of the right scapula

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