Case Study: Demystifying Persistent Ankle Pain

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.


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.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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