Chronic Ankle Instability and Progressing Pain - Wrestling

Abstract

HISTORY: 53 year old male active former D1 wrestler presented with right ankle pain located anteriorly and anterior lateral. He has an unstable right ankle with multiple episodes of giving away for the past 15 years. Patient had a previous right ankle surgery with bone fragment removed 15 years ago, but no ligament repairs. His activities are restricted, although his goal is to be able to snow board. PHYSICAL EXAMINATION: Examination revealed restricted ROM with PF to 25 deg and DF to 10 deg. Inversion and Eversion were found to be 15 and 10 degrees.He has more soft tissue thickening and swelling over the lateral gutter. No indication of infection. Patient was tender at the lateral gutter, the talofibular ligament, calcaneofibular and mild tenderness over the peroneal’s and sinus tarsi. Anterior drawer was positive. Patient had no pain on the Achilles, negative Thompson. No pain over anterior tib/posterior tib/flex hall longus tendons. Sensations were equal and intact with good pulses present DIFFERENTIAL DIAGNOSIS: 1. Tendonitis of multiple tendon 2. DJD of ankle 3. CPPD 4. Heterotrophic calcification 5. Synovial chondromatosis TEST AND RESULTS: Right ankle AP, oblique and lateral radiographs -DJD of ankle. Unstable with varus stress bilaterally. -Severe osteochondromatosis -Anterior bone spurs MRI of right ankle/hindfoot -Moderately severe to severe degenerative OA in the tibiotalar joint -Chronic instability from ATFL rupture and chronic sprain of deltoid ligament complex -Extensive osteochondromatosis present within the ankle joint, most concentrated in the dilation of the flexor halluces longus tendon sheath -Tenosynovitis of the PT, FD, PL and FHL tendon sheaths -Mild to moderate tendinitis of PL with minimal abnormal grade 2 signal centrally within the peroneus longus tendon -Full-thickness articular cartilage loss and subchondral reactive marrow changes in the tibial plafond and talar dome. FINAL WORKING DIAGNOSIS: Extensive osteochondramatosis within the flexor halluces tendon with tenosynovitis of multiple tendons secondary to chronic ankle instability and DJD TREATMENT AND OUTCOMES: 1. Stability shoe with inserts 2. Physical therapy 3. Ankle scope with bone marrow aspiration, LCL repair, varus hind foot osteotomy, removal of loose fragments and bone spurs schedule for Dec 2014