Author: Michael DaRosa, DO
Co Author #1: Michael DaRosa, DO Deb Jacobson, MD

Patient Presentation:
38 year old male presents with a 3 month history of progressive pain, stiffness, and swelling of left ankle and foot.

History:
The pain was described as constant, sharp, throbbing, and burning. The pain was reported as six out of ten and was present with light touch. The patient reports decreased range of motion of ankle. His ankle is persistently hot and swollen and intermittently "blows up".� He reports pain wakes him up at night, and he has been off work (housekeeping) as he cannot ambulate without crutches. He has taken Advil 600 mg three times per day with minimal relief. He denies weakness, numbness, fever, or chills. Pain started three months ago when his ankle turned in while walking on uneven surface. He was evaluated at an outside hospital and told he had fractured his distal fibula. He was put in a short leg splint with instructions to follow up with orthopedics which he was unable to do as he was uninsured. He followed up seven weeks post-injury at an outside free clinic and placed in a walking boot and again was denied referral to orthopedics. He wore the boot for another 4 weeks and has been using crutches since. Last week he presented to the emergency room and had repeat x-ray of foot an ankle that were negative except for osteopenia thought to be secondary to underuse, and a healing distal fibular fracture. He was discharged home and instructed to follow up with our clinic to get set up with physical therapy.

Physical Exam:
Vitals: Temp 98.8, Heart Rate 85, Respiratory Rate 16, Blood Pressure 130/85, Height 5 feet 6 inches, Weight 200 pounds.
General: Alert, well appearing obese male,
Gait: Patient limping with crutches. Unable to bear weight on left ankle.
Cardiovascular: regular rate and rhythm, no murmur, +2 pulses bilaterally distal upper and lower extremity.
Left Ankle: Mild pes planus. Lateral/anterior/medial ankle to midfoot erythematous and edematous. Palpation of ankle reveals calor, thickened skin, and non pitting edema. Significant allodynia and diffuse tenderness to palpation anteriorly and laterally from ankle to forefoot. No specific point tenderness over bony prominences including bilateral malleoli. Range of motion when compared to right ankle had equal plantar flexion and lacked 20 degrees of dorsiflexion, 10 degrees of pronation, 20 degrees of supination. The following tests were negative: Fibular drawer, Homan's, squeeze test, anterior drawer, and talar tilt. Muscle strength 5/5, sensation intact. Case Photo #1 , Case Photo #2 , Case Photo #3
Right Ankle: normal

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