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Remote Fellowship – Foot & Ankle Fundamentals – 11/2/2020

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Patient History

47-year-old man with medial and lateral left ankle pain after stepping in a hole 1 week prior 

Findings

SKELETAL/BONES:

Osteoedema consistent with microtrabecular injury/contusion of the medial talus and anterolateral talar head and osteoedema of the lateral cuboid (consistent with nutcracker phenomenon related to previous inversion mechanism of injury).

Mild periostitis/stress related osteoedema adjacent to a small plantar calcaneal spur.

No further pattern of reactive marrow edema/contusion, micro- or macro-trabecular fracture.

Incidental prominent Stieda process without osteoedema.

Incidental bipartite type 1 os navicularis (os tibial externum) without osteoedema or inflammation.

No os trigonum.

No hindfoot valgus deformity or pes planus.

ARTICULATIONS:

Unremarkable. No osteochondral defect or erosion.

LIGAMENTS:

High ankle: Intact.

Low ankle: Complete full-thickness tear/rupture the distal ATFL, at the talar insertion, with approximately 6 mm proximal retraction of the torn ligament. Retracted ligament itself measures 12 mm in length. No osseous avulsion identified.

High-grade full-thickness tear of the proximal calcaneofibular ligament at the origin. The remainder of the calcaneofibular ligament is diffusely thickened/edematous.

Posterior talofibular ligament intact.

Deltoid ligament complex contused/swollen with intermediate signal intensity.

Subtalar/Chopart: Unremarkable.

TENDONS:

Intact. Mild stripping the anterior aspect of the peroneal retinaculum at the fibular attachment. No tearing of the peroneal retinaculum. Peroneal tendons unremarkable, without tearing, subluxation or dislocation.

GENERAL:

Sinus tarsi: Unremarkable.

Muscles: No traumatic muscle injury. No volumetric muscle atrophy.

Soft tissue:  Diffuse extensive subcutaneous soft tissue swelling/edema adjacent to the lateral malleolus, surrounding the peroneal retinaculum and posterior to the medial malleolus. Soft tissue swelling involving the dorsal lateral aspect of the midfoot.

Plantar fascia: Thickened central cord of the plantar fascia proximally and at the calcaneal origin and mild perifascial inflammation, consistent with chronic plantar fasciitis with a degree of active fasciitis. Thin undersurface partial-thickness micro-tear measuring 5 mm in length. Small plantar calcaneal spur with periostitis/stress-related osteoedema.

Neurovascular complex/tarsal tunnel: Unremarkable. No evidence of entrapment neuropathy.

Intra-articular/loose bodies: None.

Impressions

Evidence for a recent inversion mechanism injury with a 2-part low ankle sprain as follows:

  1. Ruptured anterior talofibular ligament distally at the talar insertion (approximately 6 mm retraction, with the retracted ligament measuring approximately 12 mm in length).
  2. High-grade full-thickness proximal calcaneofibular ligament tear. 
  3. Contused deltoid ligament complex. No meniscoid lesion.
  4. Mild osseous contusions involving the medial talus, anterolateral talar head (consistent with nutcracker phenomenon related to previous inversion mechanism injury), and lateral cuboid.
  5. Plantar fasciitis associated with 5 mm micro-tear.