Medial Ankle Mass in a Division-I Volleyball Player

Abstract

HISTORY: 19 year old NCAA Division-I Men’s Volleyball player with PMH of multiple left ankle sprains presented with 5 days of left medial ankle pain with swelling. He developed mild pain without audible pop or snap while doing leg presses but was able to finish. He then gradually developed numbness in the plantar left 2nd, 3rd, and 4th toes spreading into the metatarsals. The ankle pain improved spontaneously over 2 days but numbness persisted. Ice, NSAIDs, and mobilization exercises provided little relief. PHYSICAL EXAMINATION: He was afebrile with stable vital signs. His gait was normal. There was a 15x5mm fluctuant mass without cyanosis or bruising in the left tarsal tunnel that was tender to palpation. Ankle and toes exhibited full range of motion, but there was mild weakness on plantarflexion of the left 2nd, 3rd, and 4th toes. Posterior tibialis and flexor hallucis longus strength were normal. Plantar left 2nd, 3rd, and 4th toe sensation to light touch were decreased. Dorsalis pedis pulse was full and intact but the posterior tibial pulse was difficult to palpate. Capillary refill of the toes was normal. Tinel’s test over the tarsal tunnel reproduced pain and exacerbated the numbness and tingling in the toes. DIFFERENTIAL DIAGNOSIS: 1. Aneurysm/Hematoma 2. Malignancy/Neoplasm 3. Accessory Soleus Strain 4. Tarsal Tunnel Syndrome 5. Posterior Tibialis Tear 6. Flexor Digitorum Longus Tear 7. Flexor Hallucis Longus Tear 8. Osteochondral Defect of the Ankle TEST AND RESULTS: MSK US: 19x6mm complex clotted hematoma in the tarsal tunnel with compression of the tibial nerve. Posterior tibialis, flexor digitorum longus, and flexor hallucis longus tendons were normal FINAL WORKING DIAGNOSIS: 1. Tarsal Tunnel Hematoma 2. Tarsal Tunnel Syndrome TREATMENT AND OUTCOMES: 1. He was treated with gentle range of motion exercises and warm compresses. 2. The hematoma and symptoms slowly resolved over 3 weeks. 3. He returned to volleyball 1 week after hematoma resolution without any issues.