Our Patient
Our patient is a 44 year-old female complaining of ankle pain. She had sprained the ankle two years prior and had been successfully treated with physical therapy.
The Challenge
Eight months after her initial treatment, the patient’s ankle pain returned, somewhat distal to the original site of trauma. She reported worse pain and instability when wearing high heels vs sneakers. She returned to the same physical therapist, who then treated her with the same exercises, but the pain did not go away. She developed mild numbness and tingling in her 4th and 5th digits while performing ankle stabilization exercises.
Our Diagnostic Process
We performed a clinical examination followed by high-resolution diagnostic ultrasound imaging.
Clinical Exam Results
- There was tenderness upon palpation along the patient’s ankle, particularly at the anterior talofibular ligament (ATFL)t.
- The prone anterior drawers test was positive, but she was able to maintain good single leg balance, even with perturbation.
- She had normal talocrural joint range of motion.
- There was notable swelling slightly distal to the ATFL ligament, which was tender to the touch, and palpation reproduced tingling sensations in the 4th and 5th toes.
- Performance of the star excursion banner test was adequate for stability and control of the ankle joint.
Diagnostic Ultrasonography Results
- We did not detect fluid or impingement in the ankle joint.
- The ATFL ligament, while lax upon dynamic testing, was intact.
- We identified a large oval hyperechoic mass over the extensor digitorum brevis muscle, where sono compression reproduced a tingling sensation in the 5th digit.
- The large hyperechoic mass was sitting on top of the flat branch of the deep peroneal nerve, but the nerve appeared normal.
Our Diagnosis
Based on the results of our diagnostic ultrasound imaging, we hypothesized that the patient had a lipoma that was irritating the lateral branch of the deep peroneal nerve.
Our Treatment Plan
The patient was referred to a cosmetic surgeon for steroid injections, and if that did not work, liposuction of the lipoma, which was rather large. She had improved only about 50 percent at two weeks after the steroid injection, with no further improvement over time. She then underwent liposuction. Her pain completely disappeared, and she was able to wear high heels again without pain or instability.
Conclusion
Even mild ankle sprains can cause long-term pain and instability. Ultrasound imaging can reveal details of the injured region while ruling out other problems. When pain returns after an ankle sprain, imaging is recommended.
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