Acute Posterior Ankle Pain in a High School Football Player
Stuart Freed, MD Dale Blair, MS, CSCS, ATC Andrew Behler Adam Noble Allen Noble Wenatchee High School Wenatchee, Washington
Personal Data/History
16 y/o male varsity football player c/o acute postero-medial pain in the right ankle. The athlete was cutting on a plantar flexed foot, felt a pop, and then experienced immediate pain. The athlete continued to compete with discomfort.
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Physical Signs and Symptoms
athlete presented with exquisite tenderness on palpation of posteromedial aspect of the talus and medial malleolus No tenderness was present over the lateral aspect of the ankle Full ROM w/ pain in terminal plantar flexion
The
Past History
Athlete
had fractured his os trigonum on the contralateral ankle in a non-sports related injury approximately one month earlier.
Physical Signs and Symptoms
No
instability with ligament laxity tests
Manual
muscle tests (especially DF and PF) were limited by pain. A biomechanical evaluation revealed a forefoot varus.
Differential Diagnoses
Achilles tendon strain Flexor hallucis longus strain Tibialis posterior strain Deltoid ligament (post. tibio-talar) sprain Os trigonum fx Osteochondral lesion of talus Posterior tibio-talar impingement Posterior talo-calcaneal ligament avulsion
Diagnostic Imaging/ Laboratory Tests
X-rays
revealed a complete fracture of the os trigonum of the talus.
Clinical Course
course of conservative management including walking boot immobilization for the ankle (neutral position) for three weeks. Following the removal of the walking boot, he performed pool workouts progressing to running and cutting.
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Clinical Course
was fitted with orthotics to correct his forefoot varus. He was also given stretching and strengthening exercises with emphasis on his posterior ankle/calf musculature
Athlete
Discussion
Os trigonum =Accessory bone found just posterior to talus Present in 50% of normal feet It may fuse w/ lateral tubercule or remain as separate ossicle Os trigonum is round, oval, or triangular and of variable size It may be considered a non-united portion of the lateral tubercle.
Deviated From Expected
The os trigonum is a “normal variant” of bony ankle anatomy The os trigonum fracture can be easily confused with other posterior pathologies. Lateral x-rays to confirm diagnosis; Continuing pain w/ neg. x-ray, a bone scan may be a useful evaluative test.
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