Author: Sydney Karnovsky, MD
Co Author #1: Jenna Pellegrino, MD
Co Author #2: Nathan Cardoos, MD
Senior Editor: Heather Rainey, MD
Editor: Christian Fulmer, DO

Patient Presentation:
A 23 year old recreational runner and former collegiate golfer presented to clinic with left ankle pain from her left arch to medial malleolus. The pain had been intermittent for the past six years, with the current episode starting about six months prior to presentation.

History:
The pain was located between her left arch and medial malleolus. The pain had been episodic for many years prior to presentation, and she had previously seen orthopedics several years ago for similar pain and completed a course of physical therapy with temporary improvement in the pain. About 6 months prior to presentation to our clinic, she developed insidious onset of similar pain in the context of training for a half marathon. While training, her ankle became red and swollen and she presented to urgent care where she was treated with antibiotics for presumed infected insect bite. The pain improved slightly, and she ran the race several days later, ending in exquisite pain. She went to the emergency department and was told she had a "tendon issue" and saw orthopedics. Per her report, she had an X-Ray and ankle MRI that were normal aside from "mild tendonitis." She started PT as recommended by orthopedics. She saw some modest improvement with PT. She then moved to a different city and woke up one morning with severe swelling and shooting pain from her left arch to medial malleolus once again. This prompted her presentation to our clinic.

She had no significant past medical, surgical, family, or social history.

Physical Exam:
General: Well-appearing.

Skin: Left ankle without rash or signs of infection.

Left Ankle Exam: Mildly antalgic gait, favoring walking on the lateral portion of the foot. Pain with toe walking and hopping. Can heel walk without pain. Obvious edema over the medial malleolus. Tenderness along the area of swelling which follows the course of the posterior tibial tendon. No bony tenderness directly over the medial malleolus or lateral aspect of the ankle. Full range of motion in the ankle but mild discomfort with active dorsiflexion. Strength is 5/5 for eversion and plantarflexion and 4+/5 for inversion and dorsiflexion, limited by pain.

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