Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in the Emergency Department. Your next patient is Edward Elric, a 26-year-old gentleman presenting with ankle pain. Please take a history and perform a relevant examination.
Patient History:
Your name is Edward Elric, a 26-year-old professional tennis player.
Over the past few weeks, you noticed that your left ankle pain has gradually worsened. It's getting more painful at the heel and worsens whenever you try to play more tennis. You tried to use some ibuprofen gel which only improved the pain slightly. You rate the pain as 5/10 on average, but when it is worse, it can go up to a 7/10. The pain doesn't radiate anywhere. Your left ankle is also becoming gradually more swollen than usual. Because of this, you have been having trouble walking and running especially during tennis practices.
The movement of your left ankle is limited due to pain in all directions. You feel your left foot has gotten weaker, especially while pushing off the ground. You are not sure if you have ruptured any tendons - you hope not, as your profession is being a sportsman. No injuries you can recall, but you play tennis a lot.
No fever, but recently, you were diagnosed with prostatitis and were given antibiotics.
Ideas, Concerns, Expectations:
You don't know, but you think you might have accidentally injured your left ankle without yourself noticing. You are concerned that it is becoming more difficult to continue playing tennis because of the pain and swelling in your left ankle. You want to know what is causing the problem and have a scan or some sort.
Past Medical History:
Ankylosing spondylitis, type 1 diabetes
Drug History:
Ciprofloxacin (for recent prostatitis five days ago).
Allergic to penicillin (Rash)
Family History:
Rheumatoid Arthritis
Social History:
You live with your parents. You think you are very healthy.
You do not smoke or drink.
You currently play tennis professionally.
Generally independent at home.
Examination Findings:
When Achilles is relaxed in a dangled position, the ankle is hyper-dorsiflexed
Altered gait (weakness in pushing off with the affected left foot; worse during tiptoeing)
Tenderness is noted in the left ankle region with posteriorly localised swelling
A palpable defect in the Achilles tendon (but no rupture)
Limited movement in ankle movement due to pain.
Weakness in left ankle plantar flexion
Simmond 's calf squeeze test / Thompson test – negative in tendinopathy (but positive in rupture)
No tenderness or warmth palpating the calcaneus region. No crepitus. No obvious deformity, no nodularity or thickening on palpation of the Achilles tendon.
Differentials:
Achilles Tendinopathy
Tendon Rupture
MSK sprains and strains
Retro calcaneal bursitis
Investigations:
Clinical diagnosis
Observations
XR foot/ankle: fractures/ calcific tendinopathy / talar shift
US ankle – to rule out Achilles tendon tendinopathy /rupture
MRI ankle – if the diagnosis is unclear (to rule out tendinopathy/rupture)
Consider diagnostic arthroscopy if appropriate
Management (Achilles Tendinopathy):