General Medicine - Weightlifting

Abstract

HISTORY: A 49yo M, h/o prediabetes and hyperlipidemia, presented with R medial ankle pain and unilateral RLE swelling x5 days. Had acute onset of R medial ankle pain without a specific injury following a leg workout. Seen in urgent care and diagnosed with a deltoid ligament sprain; prescribed RICE, NSAIDs, crutches, and a CAM boot. The pain did not abate and the swelling progressed from the R ankle to the entire lower leg distal to the knee. Denied chest pain, dyspnea, history of malignancy, recent travel, and history of crystalline disease. Meds: None. Allergies: None. SH: Desk job, nonsmoker. PHYSICAL EXAMINATION: Obese male with normal vital signs. Normal cardiovascular, pulmonary, and neurologic exam. RLE notable for antalgic gait, 2+ pitting edema to the knee, no erythema, 2+ DP pulse, 2+ PT pulse. R ankle with full painless AROM; 5/5 strength in dorsiflexion, plantarflexion, inversion, eversion, toe flexion; intact distal sensation; non-focal tenderness to palpation over the posteromedial ankle; negative external rotation stress test, negative anterior drawer, negative talar tilt, and negative pronation talar tilt. DIFFERENTIAL DIAGNOSIS: 1. DVT 2. Gout 3. Deltoid Ligament Sprain 4. Osteoarthritis flare 5. Posterior tibialis tendinopathy TEST AND RESULTS: Imaging - Right ankle radiographs negative. BLE Venous Duplex Vascular Ultrasound negative. RLE MRI w/o Contrast showed diffuse circumferential subcutaneous edema about the lower leg, ankle, and foot with a small focus of bone marrow edema and periostitis at the posteromedial distal tibial cortex. Minimal posterior tibialis tendinopathy. No overlying ulceration or abscess. Labs - WBC 6.3 x 103 / uL. Creatinine 1.3 mg/dL. CRP 2.0 mg/L. ESR 6 mm/h. Uric Acid: 8.1 mg/dL FINAL WORKING DIAGNOSIS: Acute gout flare plus mild posterior tibialis tendinopathy TREATMENT AND OUTCOMES: 1. NSAIDs 2. Leg Elevation 3. Weight bearing as tolerated 4. Dietary modification 5. Pain free with markedly reduced RLE swelling at one-month follow-up. Returned to exercise. Did not start urate-lowering therapy.