Assessing Musculoskeletal Pain

Patient Information: CC : A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She can bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?

Initials, N/A Age, 46 Sex, Female Race, not indicated

CC: Bilateral Ankle pain 

HPI: Pt c/o bilateral ankle pain, worse on R s/p hearing a “pop” while playing soccer this past weekend. Pt is able to bear weight, with some discomfort and was more concern about her R ankle.

Location: Bilateral ankle

Onset: Over the weekend

Character: Bilateral ankle pain, worse on the right. She was playing soccer over the weekend and heard a “pop.”

Associated signs and symptoms: She can bear weight, but it is uncomfortable

Timing: over the weekend and heard a “pop. “while playing soccer

Exacerbating/ relieving factors: She can bear weight, but it is uncomfortable

Severity: She can bear weight, but it is uncomfortable

Current Medications: Not indicated

Allergies: None indicated

PMHx: None indicated

Soc Hx: played Soccer over the weekend

Fam Hx: None Indicated.

GENERAL:  No weight loss, fever, chills, weakness or fatigue indicated 

HEENT:  Eyes: PERRLA, no visual impairment blurred vision, double vision or yellow sclerae indicated. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat indicated 

SKIN:  No rash or itching nor discoloration indicated

CARDIOVASCULAR:  No chest pain, chest pressure or SOB. No palpitations or edema indicated 

RESPIRATORY:  No shortness of breath, cough or difficulty breathing indicated

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood indicated 

GENITOURINARY:  No Burning on urination. No indication of Pregnancy. Last menstrual period not indicated.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control indicated 

MUSCULOSKELETAL:  bilateral ankle pain, worse on R. Positive pulses on both dorsalis and pedis bilaterally. Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the left ankle.

HEMATOLOGIC:  No anemia, bleeding or bruising indicated 

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  None indicated

ENDOCRINOLOGIC:  No reported 

ALLERGIES:  NkDA

Peripheral Vascular: Right ankle with 1+edema, erythema; and tenderness on palpation noted. No edema or erythema noted on the left ankle Positive pulses on both dorsalis and pedis bilaterally.

Assessment:

Additional questions

More needed questions may include

Point exactly where your pain is?

What’s your pain scale on 0-10, o no pain and 10 being the worst? 

Have you taken anything for the pain?

What makes it better or worse?

Diagnostic results: This will include X-Ray, Ct scan and MRI According to Ball, Dains, Flynn, Solomon, and Stewart (2015) an x-ray of the ankle should be done when pain is present in the malleolar area with one of the following locations: Bony tenderness to the distal 6cm of the posterior edge or tip of the lateral malleolus, bony tenderness on the distal 6cm of the posterior edge or tip of the medial malleolus, or the inability for the patient to be weight bearing.  According to Ball, Dains, Baumann, & Scheibel 2016, Ottawa Ankle Rules are used to identify the need for diagnostic testing in the patient with ankle pain.  This tool determines that if a patient has ankle pain the malleolar area of the ankle in addition to bone tenderness near the posterior fibula, bone tenderness near the posterior tibia, or the inability to bear weight for four steps, he or she should be sent for an ankle radiography series. Also, Ottawa have 98.5%sensitivity level in identifying fracture.

Differential Diagnoses

1.  Ankle Sprain is an injury that occurs to one or more of the ligaments in the ankle that produces symptoms like pain, swelling, bruising, soreness, joint stiffness, and difficulty walking Sports injuries are very common when running, landing a jump, or any direct contact that can create pain, swelling, and even an audible tearing or popping, yet ecchymosis can be delayed by a few days (American Orthopedic Foot & Ankle Society, 2015).

1. Achilles tendon injury: Occurs from a sudden snap in the lower calf with the inability to stand on the toes of the affected side (Saglimbeni, 2016). 
2. Post-exercise muscle soreness: Appears as a discomfort or pain to the distal portion of skeletal muscles after physical activity that one is not used to, as well as decreased strength and flexibility (Kedlaya, 2016).
3. Achilles tendon injury presents through a sudden snap in the lower calf with the inability to stand on the toes of the affected side (Saglimbeni, 2016). 

5.  Ankle Fracture: Stress fractures in the foot are most often seen in the calcaneus, navicular, and metatarsal bones, and less often in the cuboid bone.  An ankle fracture usually manifest with swelling, bruising, and an inability to bear weight (Unnithan & Thomas, 2018).

 References

American Orthopedic Foot & Ankle Society. (2015, June). Ankle Sprain. Retrieved from http://www.aofas.org/PRC/conditions/Pages/Conditions/Ankle-Sprain.aspx

American College of Foot and Ankle Surgeons. (2018). Ankle Sprain. Retrieved from https://www.foothealthfacts.org/conditions/ankle-sprain

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s 

guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Kedlaya, D. (2016). Post-Exercise Muscle Soreness. Retrieved from http://emedicine.medscape.com/article/313267-overview#a4

Kelly, J. (2015). Ankle Fracture in Sports Medicine. Retrieved from http://emedicine.medscape.com/article/85224-clinical#b4

Luke, A. (2011). Ankle Physical Examination. Orthopedic Trauma Institute. Retrieved from http://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-medicine/physical-examination-info/ankle-physical-examination/