ANKLE PAIN - SOCCER

Abstract

1771 HISTORY: A 6 1/2 year old male soccer player presented with a four month history of unilateral ankle pain after having his right foot stepped on. Podiatry prescribed an ankle brace for suspected ankle sprain. The patient subsequently complained of left ankle pain, presumed secondary to contralateral compensation. He was referred to a neurologist for suspected lower extremity weakness. His neurological evaluation was within normal limits. The patient received physical therapy for ankle rehabilitation. He presented several days later with enlarged cervical lymph nodes, lower extremity weakness, and pain significantly limiting his activities. He was unable to play soccer since the initial injury. He denied any other complaints. PHYSICAL EXAM: The patient was alert, and in no apparent distress. Vital signs were normal. Skin appeared pale without ecchymoses. HEENT exams were all within normal limits. Lymphadenopathy was noted at multiple sites. All lymph nodes were nontender, firm and mobile, the largest measuring 5cm × 4cm. Chest and cardiovascular exams were normal. Hepatomegaly and splenomegaly were present. Extremities were warm but pale. Capillary refill and pulses were normal. Deep tendon reflexes were normal and equal. Strength was slightly less on the right lower extremity as compared to the left. Moderate tenderness and pain were elicited with passive dorsiflexion of both ankles. No edema was noted. The patient had full active and passive range of motion, with pain. Sensation was intact. DIFFERENTIAL DIAGNOSIS Traumatic: Sprain/Strain/Fracture/Synovitis Nerve entrapment/Impingement/Tendonitis Vascular: DVT/phlebitis/popliteal artery entrapment Systemic: Neoplasm: Bone tumor/Leukemia/Lymphoma/JRA Infectious: Septic arthritis/Osteoarthritis TESTS AND RESULTS: Hgb=7.9 WBC=8.7 with 56% lymphoblasts. Absolute neutrophil count 348. Platelets 36,000. UA negative. Chemistries normal. LFT's normal. Monospot positive. EBV serologies consistent with past infection. Bone marrow aspiration and biopsy diagnostic for acute lymphoblastic leukemia. FINAL/WORKING DIAGNOSIS: Acute lymphoblastic leukemia (ALL) with bone and joint pain as the presenting complaint. TREATMENT: Within two days, this patient was registered on Children Cancer Group Protocol CCG-1952, and begun on induction chemotherapy including prednisone, vincristine, L-asparaginase and intrathecal ARA-C and methotrexate. His ankle pain slowly resolved with aggressive physical therapy.