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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.

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acute posterior ankle pain in a high school football player

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
Personal Data/History
  • A 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.
physical signs and symptoms
Physical Signs and Symptoms
  • The athlete presented with exquisite tenderness on palpation of postero- medial 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
past history
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 symptoms5
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
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
Diagnostic Imaging/ Laboratory Tests
  • X-rays revealed a complete fracture of the os trigonum of the talus.
clinical course
Clinical Course
  • A 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.
clinical course9
Clinical Course
  • Athlete 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
discussion
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
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.