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To enhance your diagnostic reasoning skills, follow these steps:
- Review the Information: Carefully read through the content in each section of the case scenario.
- Consider the Question: Reflect on the Diagnostic Reasoning Question presented. Take your time to think about your answer.
- Compare Your Answer: Attempt to answer the question before viewing our suggested answer. When ready, click “View Suggested Answer” to compare it with your own.
Repeat these steps for each section of the case scenario. Please note that the suggested answers are only indicative and not exhaustive. They serve as guidelines and should not be considered complete answers.
Patient’s History
In the sections below, you will find case history information designed to guide you through a systematic approach to performing a focused and relevant case history. This process will help you narrow down the potential causes of the patient’s complaint. As you go through the material, we encourage you to answer the questions provided to test and enhance your diagnostic reasoning skills.
Who is the patient and where is the pain?
When was the onset and what caused the onset?
Rosa, a 22-year-old steeplechaser, is experiencing pain in the anterolateral part of her right lower leg, just above the ankle (she points directly to the area over the talocrural joint). The pain began three days ago during a competition when she stumbled and landed awkwardly on her right foot, forcing her ankle to bend upward. The pain was immediate and severe.
Diagnostic Reasoning Question
What differential diagnoses would you consider for Rosa’s condition?
ViewHide Suggested Answer
- Ankle fracture or dislocation
- Syndesmotic ankle (high ankle) sprain
- Anterior ankle impingement
- Fibularis (peroneus) tertius myofascial pain syndrome
- Talar dome injury (osteochondral lesion of the talus)
What are the pain characteristics?
What are the aggravating and relieving factors?
What has been the course of the pain?
Rosa describes her pain as a deep ache with sharp exacerbations when bearing weight or walking, which she rates as an 8 out of 10. The pain is particularly intense with dorsiflexion of the right ankle. She notes a significant decrease in pain when not weight-bearing. Rosa also mentions that the pain was most severe during the first two days following the injury but has since started to ease. Despite this, she has been unable to resume training since the onset.
Diagnostic Reasoning Question
Distal anterolateral leg pain triggered by ankle dorsiflexion suggests potential damage to which structures?
ViewHide Suggested Answer
Distal anterolateral leg pain on ankle dorsiflexion can be caused by damage to various structures within and around the ankle, including:
- Anterior inferior tibiofibular ligament (ankle syndesmosis)
- Fibularis (peroneus) tertius muscle
- Talar dome
- Anterior ankle joint capsule and synovium
- Ankle extensor retinaculum
Are there any associated symptoms?
Upon further questioning, Rosa reports that her right ankle feels stable, and she has no additional concerns.
Diagnostic Reasoning Question
What does the absence of ankle instability indicate in the diagnostic process?
ViewHide Suggested Answer
The absence of ankle instability suggests that the ligaments are not severely damaged. However, partial tears may still be present, leading to significant pain and functional limitations without causing noticeable instability.
Is there any past history that may be relevant to the current complaint?
Rosa’s history includes two previous inversion sprains to her right ankle, both resolved quickly with conservative treatment and rest.
Diagnostic Reasoning Question
How does Rosa’s history of previous injuries impact the diagnostic process?
ViewHide Suggested Answer
Rosa’s history of previous ankle inversion sprains may have weakened the supporting structures, making her more susceptible to further injury. However, the current location of her pain is atypical for an inversion injury, suggesting that different structures may be involved this time.
Are there any red flags?
The following questions are asked to identify any “red flags” that could suggest serious pathology. Even if the patient has previously mentioned related information during the case history, it is recommended to revisit these questions to ensure a comprehensive evaluation.
- Does your pain disappear even for a short time? “The pain eases off substantially when I’m resting but does not go away altogether.”
- Does the pain wake you up at night? “The first night it did, but it hasn’t since.”
- Do you feel weak in your legs? “Well, I’m not really putting much weight on that leg, so I’m not sure.”
- Have you recently had any fever, chills, or night sweats? “No.”
Diagnostic Reasoning Question
Do any of Rosa’s answers raise a red flag?
ViewHide Suggested Answer
Although none of these responses raise a “red flag,” her description of the injury mechanism and sharp exacerbations of pain are concerning, suggesting the possibility of a fracture.
Differential Diagnosis
Diagnostic Reasoning Question
Based on the available history, how would you prioritize the list of differential diagnoses?
ViewHide Suggested Answer
- Syndesmotic ankle (high ankle) sprain
- Anterior ankle impingement
- Lateral malleolar, distal fibula, or distal tibia fracture
- Fibularis (peroneus) tertius myofascial pain syndrome
- Talar dome injury (osteochondral lesion of the talus)
Reflection Point
Pause and consider whether the key elements of a thorough and relevant patient history have been addressed. Are there any additional questions you would have asked? If so, what are they, and why would they be important?
Before reviewing the physical examination findings below, take a moment to reflect on which physical examination procedures you would perform to accurately assess this patient.
Physical Examination
In the sections below, you will find physical examination findings for this patient. The material outlines a systematic approach to conducting a focused and relevant physical examination aimed at narrowing down the potential causes of the patient’s complaint. As you review the material, we encourage you to answer the questions provided to test and enhance your clinical reasoning and diagnostic skills. Additionally, consider whether all essential elements of the physical examination have been thoroughly addressed.
Vital Signs
Rosa’s vital signs are within normal limits.
Diagnostic Reasoning Question
What is the significance of normal vital signs?
ViewHide Suggested Answer
Normal vital signs typically indicate that there are no immediate life-threatening conditions. Particularly, normal temperature indicates the absence of acute infection.
Inspection
Rosa appears to be in good overall health but has difficulty bearing weight on her right side. Inspection reveals mild, localized swelling over the anterior distal leg, just medial to the right fibula. There is no evidence of bony deformity or bruising.
Diagnostic Reasoning Question
How does the location of swelling and the absence of bony deformity contribute to the diagnostic process?
ViewHide Suggested Answer
- Localized Swelling – The localized swelling suggests an acute soft tissue injury, such as a muscle strain or ligament tear. Tendons of the muscles in the anterior aspect of the leg, including the extensor digitorum longus and fibularis tertius, could also be involved. In cases of anterior ankle impingement, swelling is typically found anterior to the talocrural joint rather than medial to the distal fibula. The specific location of the swelling in Rosa raises the possibility of a syndesmotic injury, such as a tear of the anterior tibiofibular ligament.
- Absence of Deformity – The absence of bony deformity reduces the likelihood of a dislocation or a displaced fracture.
Range of Motion
Assessment of the active and passive range of motion in the right foot and ankle exacerbates the patient’s pain in all directions, with the most pronounced discomfort occurring during passive dorsiflexion and eversion.
Diagnostic Reasoning Question
How do the range of motion findings contribute to the diagnostic process?
ViewHide Suggested Answer
Pain with movement in all directions suggests a joint injury. The pronounced pain during passive dorsiflexion and eversion specifically points to a potential injury of the syndesmotic ligaments, such as the anterior inferior tibiofibular ligament. Additionally, pain during passive movement could indicate inflammation or injury to the joint capsule or synovium, such as capsulitis or synovitis, possibly linked to anterior ankle impingement.
Palpation
Pronounced tenderness is noted on palpation over the distal aspect of the anterior leg, specifically in the region of the anterior tibiofibular ligament. There is no tenderness upon palpation of the anterior talocrural joint or the tendons of the fibularis (peroneus) tertius, and extensor digitorum longus muscles. The remainder of the distal lower extremity is normal on palpation, with no evidence of myofascial trigger points in the fibularis muscles, including the fibularis tertius.
Diagnostic Reasoning Question 1
How does the pronounced tenderness over the anterior tibiofibular ligament contribute to the diagnostic process?
ViewHide Suggested Answer
The pronounced tenderness over the anterior tibiofibular ligament strongly suggests involvement of the syndesmotic ligaments, indicating a potential high ankle sprain.
Diagnostic Reasoning Question 2
How does the absence of pain on palpation of the anterior talocrural joint and the tendons of the fibularis tertius and extensor digitorum longus muscles, contribute to the diagnostic process?
ViewHide Suggested Answer
The absence of tenderness on palpation over the anterior talocrural joint helps to rule out anterior ankle impingement. The absence of tenderness over the tendons of the fibularis tertius and extensor digitorum longus muscles helps exclude their involvement.
Diagnostic Reasoning Question 3
If myofascial trigger points were found in the fibularis tertius muscle, where is the pain likely to be referred?
ViewHide Suggested Answer
The pain from myofascial trigger points in the fibularis tertius muscle is likely to be referred to the lateral aspect of the ankle and foot. This referral pattern can cause discomfort and a sensation of tightness in these areas, often mimicking or contributing to lateral ankle pain.
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Reflection Point
Considering the patient’s history and examination findings thus far, take a moment to reflect on which special tests would be most appropriate to further evaluate this patient.
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Special Tests
The Crossed-Leg test reproduces Rosa’s anterolateral distal leg pain.
Diagnostic Reasoning Question
What is the purpose of the Crossed-Leg test?
ViewHide Suggested Answer
The Crossed-Leg test is designed to detect injuries to the ankle syndesmosis. The reproduction of pain in this patient suggests the presence of such an injury.
Please watch the video below to see how the Crossed-Leg test is performed.
The External Rotation Stress test reproduces the patient’s anterolateral distal leg pain.
Diagnostic Reasoning Question
What is the purpose of the External Rotation Stress test, and what do the results in this patient suggest for the diagnostic process?
ViewHide Suggested Answer
The External Rotation Stress test is designed to detect injuries to the ankle syndesmosis. A positive result in this test further reinforces the diagnosis of a syndesmotic ankle injury.
Please watch the video below if you wish to see how the External Rotation Stress test is performed.
The Squeeze test is performed, and it also reproduces the patient’s anterolateral distal leg pain.
Diagnostic Reasoning Question
What is the Squeeze designed to detect, and how does the result inform the diagnostic process?
ViewHide Suggested Answer
The Squeeze test is also designed to detect injuries to the ankle syndesmosis. The result of this test helps to confirm the diagnosis of a syndesmotic ankle injury in this patient.
Please watch the video below if you wish to see how the Squeeze test is performed.
The Talar Tilt test is performed, and is found to be negative.
Diagnostic Reasoning Question
What is the Talar Tilt test designed to detect?
ViewHide Suggested Answer
The Talar Tilt test is designed to detect lateral ankle instability, particularly injuries to the calcaneofibular ligament (CFL). Rosa’s negative result helps to rule out instability.
Please watch the video below if you wish to see how the Squeeze test is performed.
The Heel Tap test is performed, with Rosa reporting only mild aggravation of her anterolateral distal leg pain.
Diagnostic Reasoning Question
What does the finding from the Heel Tap test suggest?
ViewHide Suggested Answer
This test is designed to screen for fractures in the lower extremity. While the result in this patient does not indicate a fracture, the mild pain produced is most consistent with a distal tibiofibular joint injury.
Please watch the video below if you wish to see how the Heel Tap test is performed.
Reflection Point
Please pause and assess whether all the essential elements of a thorough and relevant physical examination have been completed for this patient. Are there any additional procedures you would have performed? If so, why?
Imaging
Plain radiographs show no evidence of fracture or widening of the distal tibiofibular joint. Diagnostic ultrasound reveals a partial tear in the anterior talofibular ligament.
Diagnosis
Diagnostic Reasoning Question
Based on the available information, what is the most likely diagnosis?
ViewHide Suggested Answer
Grade I syndesmotic ankle injury (high ankle sprain).
References and Suggested Further Readings
deWebber K. Syndesmotic ankle injury (high ankle sprain). www.uptodate.com
Morgan et al. Conservative management of syndesmosis injuries in elite football- an injury on the increase or an increase in recognition. Sports Med J 2014:602–13.
Lin CF, Gross ML, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther. 2006 Jun;36(6):372-84. Review.
Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: reliability and prediction of return to function. J Orthop Sports Phys Ther. 1998 Apr;27(4):276-84.
Aman AS, Hiller CE, Refshauge KM. Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med. 2013 Jul;47(10):620-8.
Porter A, Jaggers R, Barnes A, Rund A. Optimal management of ankle syndesmosis injuries. J Sports Med. 2014; 5: 173–182.
Srbely JZ, Dickey JP, Lowerison M, Edwards AM, Nolet PS, Wong LL. Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: A randomized controlled study. Pain. 2008 Oct 15;139(2):260–6.
Watson T. Ultrasound therapy. www.electrotherapy.org/modality/ultrasound-therapy.
Watson T. Laser Therapy. www.electrotherapy.org/modality/laser-therapy.
Baxter, D. (2008) Low Intensity Laser Therapy. Chapter 11 in : Electrotherapy : Evidence Based Practice.
Federative Committee on Anatomical Terminology. Terminologia Anatomica. Stuttgart, Germany: Georg Thieme Verlag; 1998.
Review Quiz
1. What is 2+2?
ViewHide Suggested Answer
The answer is????
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Copyright © Educom Pty Ltd: All content on the acemsk.com website, including text, graphics, videos, and downloadable files, is the property of Educom Continuing Education, a division of Educom Pty Ltd, and is protected by copyright and other intellectual property laws under international conventions. Unauthorized use or duplication of this material without express written permission from Educom Pty Ltd is strictly prohibited.
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