Not Your Ordinary Ankle Sprain

Abstract

HISTORY: This is a case of an otherwise healthy 19-year-old running back who sustained a left ankle eversion type injury during a football game when an opponent landed on his lower leg forcing it into external rotation. He did not finish playing due to the inability to bear weight. PHYSICAL EXAMINATION: During initial evaluation, limited due to a significant amount of pain, he had tenderness over the deltoid, anterior talofibular, and calcaneofibular ligaments. During reevaluation two days later he was also complaining of some tenderness around the lateral aspect of his left knee. His exam showed mild edema at the level of his ankle, tenderness over ligaments as noted before, along with pain on external rotation of his foot, compression along his syndesmosis, and palpation over his tibiofibular joint with increased posterior translation of his proximal fibula compared to the contralateral side. His left knee exam revealed pain in the area of his fibular head with varus stress, but was otherwise unremarkable. DIFFERENTIAL DIAGNOSIS: Ankle fracture Syndesmosis injury Proximal tibiofibular joint injury TEST AND RESULTS: Stress radiographs of left ankle at the stadium: - no acute fracture and no obvious opening of his syndesmosis or medial joint space Repeat weight bearing radiographs of left ankle: - ossification of his syndesmosis likely indicative of previous injury, as well as decreased overlap between distal tibia and fibula - no clear evidence of medial ankle joint space widening MRI of left calf and ankle: - no ligamentous tear of the proximal tibiofibular joint, but changes consistent with chronic avulsion injury of the syndesmotic membrane from the distal portion of the tibia and probable injuries to his anterior inferior tibiofibular ligament and anterior talofibular ligaments FINAL WORKING DIAGNOSIS: Syndesmosis injury with proximal tibiofibular joint instability TREATMENT AND OUTCOMES: 1. Non-weightbearing for the initial 10 days post injury. 2. Open reduction and internal fixation of distal syndesmosis using a single tightrope fixation, along with stabilization of the proximal tibiofibular joint using the same technique. 3. Non-weightbearing for the following 6 weeks. 4. Gradual return to physical activity.