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Acute Posterior Ankle Pain in a High School Football Player

Acute Posterior Ankle Pain in a High School Football Player. Stuart Freed, MD Dale Blair, MS, CSCS, ATC Andrew Behler Adam Noble Allen Noble Wenatchee High School Wenatchee, Washington. Personal Data/History.

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Acute Posterior Ankle Pain in a High School Football Player

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  1. Acute Posterior Ankle Pain in a High School Football Player Stuart Freed, MD Dale Blair, MS, CSCS, ATC Andrew Behler Adam Noble Allen Noble Wenatchee High School Wenatchee, Washington

  2. Personal Data/History • A 16 y/o male varsity football player c/o acute postero-medial pain in the right ankle. • The athlete was cutting on a plantar flexed foot, felt a pop, and then experienced immediate pain. • The athlete continued to compete with discomfort.

  3. Physical Signs and Symptoms • The athlete presented with exquisite tenderness on palpation of postero- medial aspect of the talus and medial malleolus • No tenderness was present over the lateral aspect of the ankle • Full ROM w/ pain in terminal plantar flexion

  4. Past History • Athlete had fractured his os trigonum on the contralateral ankle in a non-sports related injury approximately one month earlier.

  5. Physical Signs and Symptoms • No instability with ligament laxity tests • Manual muscle tests (especially DF and PF) were limited by pain. • A biomechanical evaluation revealed a forefoot varus.

  6. Differential Diagnoses • Achilles tendon strain • Flexor hallucis longus strain • Tibialis posterior strain • Deltoid ligament (post. tibio-talar) sprain • Os trigonum fx • Osteochondral lesion of talus • Posterior tibio-talar impingement • Posterior talo-calcaneal ligament avulsion

  7. Diagnostic Imaging/ Laboratory Tests • X-rays revealed a complete fracture of the os trigonum of the talus.

  8. Clinical Course • A course of conservative management including walking boot immobilization for the ankle (neutral position) for three weeks. • Following the removal of the walking boot, he performed pool workouts progressing to running and cutting.

  9. Clinical Course • Athlete was fitted with orthotics to correct his forefoot varus. • He was also given stretching and strengthening exercises with emphasis on his posterior ankle/calf musculature

  10. Discussion • Os trigonum =Accessory bone found just posterior to talus • Present in 50% of normal feet • It may fuse w/ lateral tubercule or remain as separate ossicle • Os trigonum is round, oval, or triangular and of variable size • It may be considered a non-united portion of the lateral tubercle.

  11. Deviated From Expected • The os trigonum is a “normal variant” of bony ankle anatomy • The os trigonum fracture can be easily confused with other posterior pathologies. • Lateral x-rays to confirm diagnosis; Continuing pain w/ neg. x-ray, a bone scan may be a useful evaluative test.

  12. Thank you

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