49-year-old male with past medical history of hypertension who presents to the sports medicine clinic with a five-year history of left lateral foot pain.https://scholarlycommons.henryford.com/merf2020caserpt/1120/thumbnail.jp

Moeller, James

Tam, Anthony C

English

Henry Ford Health System Scholarly Commons

Henry Ford Health System Henry Ford Health System Scholarly Commons Case Reports Medical Education Research Forum 2020 5-2020 Not Just An Ankle Sprain Anthony C. Tam Henry Ford Health System, atam3@hfhs.org James Moeller Henry Ford Health System, JMoelle1@hfhs.org Follow this and additional works at: https://scholarlycommons.henryford.com/merf2020caserpt Recommended Citation Tam, Anthony C. and Moeller, James, "Not Just An Ankle Sprain" (2020). Case Reports. 14. https://scholarlycommons.henryford.com/merf2020caserpt/14 This Poster is brought to you for free and open access by the Medical Education Research Forum 2020 at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Case Reports by an authorized administrator of Henry Ford Health System Scholarly Commons. History Results ReviewWorking Diagnosis49-year-old male with past medical history of hypertension who presents tothe sports medicine clinic with a five-year history of left lateral foot pain.The pain is described as aching with intermittent stabbing in a constantnature. The pain is specifically located along the lateral and plantar footthat can radiate to the fourth and fifth toe. There is associated numbness inthe same distribution. Pain is worse with walking and nothing alleviatesthe pain. He denies any specific trauma or injury to the foot. He thinks thepain may have been secondary to increased activity with racquetball. Hehad gone to multiple providers in the past for which all of them haddiagnosed him with an ankle sprain for years. He has previously received acorticosteroid injection three years ago with minimal relief. He has alsodone a course of physical therapy without relief.Initial imaging obtained at the first visit were x-rays of the foot. The finalradiology report demonstrated a deformity of the medial navicular withlinear lucency compatible with fracture of indeterminate age or possible osnaviculare. Steida process and small plantar calcaneal spur. Mild softtissue swelling about the lateral aspect of the 5th metatarsal withoutadditional acute osseous injury.Physical ExamDiscussionHT: 6’ 4”Weight: 225 lbsBMI:  27.4BP: 115/75Pulse: 76 Normal gaitFull ROM of bilateral feetNormal Thompson's test, calcaneal squeeze, metatarsal squeeze, anterior drawer, and talar tilt testingNo swelling, erythema, or ecchymosisNo muscle atrophy appreciatedNo tenderness to bony palpationTenderness along the soft tissue near base of 5th metatarsal5/5 strength dorsiflexion, plantarflexion, eversion, inversion4/5 strength 4th and 5th toe flexionDistal sensation intactNegative Tinel’s at the tarsal tunnel2+ DP/PT pulsesResults ContinuedGanglion cysts are non-neoplastic cysts that are caused by an accumulationof thick mucinous fluid. This occurs within the epineurium of peripheralnerves, which is encased in a dense fibrous capsule. The most commonpresentation of this is local and/or radiating pain. Despite having radiatingpain, numbness, and weakness, the initial EMG for evaluation wasnonrevealing. Thus, an MRI was obtained demonstrating the ganglion cystcausing chronic compression of the tibial nerve.Ganglion cysts causing damage to the tibial nerve on the medial side of theankle are relatively uncommon. Ganglia are the cause of tarsal tunnelsyndrome in up to 8% of cases (1). Surgical treatment is indicated if thesymptoms are intractable and the diagnosis is well established. Outcomespost-surgically are more favorable when there is a short history ofsymptoms, the presence of a ganglion, no sprains, and light work (2).Not Just An Ankle SprainAnthony C. Tam, MD; James L. Moeller, MD, FACSMDivision of Sports Medicine, Department of Orthopedic SurgeryHenry Ford Health System, Detroit, MIFigure 1. AP XR FootFigure 2. Lateral XR footFigure 3. MRI footDue to symptoms suggestive of neuropathic related pain, EMG wasobtained which was normal. Due to non-revealing findings, MRI of theankle was ordered, and the patient was referred to Neurology to assist incontrolling the neuropathic pain. Initially, the patient decided not to obtainthe MRI. Neurology suspected Baxter’s neuropathy and recommendedgabapentin. Medication did not alter the patient’s symptoms, and the MRIwas again advised. MRI demonstrated a ganglion cyst measuring 3.7 cmx1.1 cm x 1.6 cm along the medial aspect of the calcaneus. The ganglioncauses a mass effect on the neurovascular structures within the tarsal tunnelincluding tibial nerve. Edema and atrophy are seen within the adductordigiti minmi muscle consistent with chronic compression of the lateralbranch of the tibial nerve.The patient was referred to orthopedic foot surgeon who performed a tarsaltunnel release and removal of the ganglion cyst.The patient was pain free four days post op from surgery and has been painfree since the procedure. He has returned to normal activity without issue.Management/Outcome• Peripheral neuropathy• Ganglion CystReferences 1. Antoniadis, et al.  Posterior Tarsal Tunnel Syndrome.  Deutsches Arzteblatt International.  2008 NOV; 105(45): 776-781.2. Baba, et al.  The Tarsal Tunnel Syndrome: Evaluation of Surgical Results Using Multivariate Analysis.  International Orthopaedics. 1997 May; 21(2): 67-71.3. Lui, Tun Hing.  Endoscopic Resection of the Tarsal Tunnel Ganglion.  Arthroscopic Techniques.  2016 Otc; 5(5): e1173-e1177. Figure 4. Intraoperative photo of ganglion cyst

Not Just An Ankle Sprain

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Not Just An Ankle Sprain

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