NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Week Eight: Assessment of the Musculoskeletal System

Review of case study #2: Ankle Pain

Scenario: 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 is able to

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

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will you perform? What special maneuvers will you perform? Should you apply the Ottowa

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ankle rules to determine if you need additional testing?

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Episodic/Focused SOAP Note for Throat Exam
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Patient Information: G.M. Age: 46 y.o. Sex: Female DOB: 7/5/1971

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Chief Complaint/Reason for Visit:

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“Both of my ankles hurt, but more severe on the right”

History of Present Illness:

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Ms. G.M. is a 46-year-old Asian female that works as a physical education teacher at a

local school district who presented with reports of bilateral ankle pain for the past 2 days. Patient
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reported that she was playing soccer over the weekend when she heard a “pop” sound during the
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game. The pain initially ranges from 4/10 on both ankles but after 5-10 minutes her right ankle
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pain started to increase. According to her, she was able to bear weight on both ankles but felt

more discomfort on the right side when walking or standing. Although applying cold compress

on both areas provides relief, she noticed that her right ankle seems swollen since yesterday.

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 Patient does not recall any recent accident and stated that she has been actively playing different

sports such as soccer, tennis, and volleyball all her life. The only difference that she notices

during the game is she did not have enough time to warm-up since she was running late for the

game. Upon presentation, patient reported 5/10 on her right ankle and 2/10 on her left side.

Current Medications:

 One-A-Day Women’s Multivitamins one tablet daily

 Ferrous Sulfate 325mg once daily

Allergies: Nuts-hives

Immunization History:

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 Flu Vaccine: October 2017

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PMHx:

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• Anemia (2015, managed by Ferrous Sulfate)

Fam Hx: Reported both parents are healthy and alive. Father has hypertension.
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Personal/Social History: Patient is single. Works as a physical education teacher full-

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time. Does not smoke, drink or use any illicit drugs. Physically active, exercises 5-6 time

a week.
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Review of Systems:
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Constitutional: A&O x4, pleasant and cooperative. No acute distress. Denies weight loss,
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weakness, or fatigue.
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HEENT: Denies headache, sore throat or changes in vision and hearing.

SKIN: No rash or itching.

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CARDIOVASCULAR: Denies chest pain or palpitations.

RESPIRATORY: Denies shortness of breath or cough.

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 GASTROINTESTINAL: Denies abdominal discomfort. Reported having regular daily

bowel pattern.

GENITOURINARY: Bilateral ankle pain for the past 48 hours, more severe on right

ranging 4-5/10. Swelling started past 24 hours. Able to bear weight but with discomfort.

NEUROLOGICAL: Denies focal loss of strength or loss of sensation.

MUSCULOSKELETAL: Denies focal weakness, facial droop, or joint swelling.

HEMATOLOGIC: Diagnosed with anemia 2 years ago. Regularly checked by her

primary care physician and managed by prescribed supplements. No bleeding or bruising.

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LYMPHATICS: No enlarged nodes. No cervical lymphadenopathy

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O.

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Physical exam: Vital signs: B/P 126/72, Pulse 68 (strong and regular); Temp 98.0F orally;
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RR 19; non-labored; SpO2: 98% room air;

Height: 5' 4" Weight:122 lbs.

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General: A&O x4, pleasant and cooperative. Not in any acute distress.
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HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema,

PERRLA. Oropharynx red. No lesions. Moist mucous membranes.

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Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules.

Chest/Lungs: Clear to auscultation bilaterally. No accessory muscle use.

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Heart/Peripheral Vascular: Right ankle swelling. Regular rate and rhythm noted. No
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murmurs. No palpitation. No clubbing or cyanosis; Normal capillary refill. Bilateral equal

pedal pulses.
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ABD: Soft, nontender, nondistended. No rigidity, rebound, or guarding. No palpable

hepatosplenomegaly.

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 Genital/Rectal: continent of bladder and bowel.

Musculoskeletal: Lower extremities with reports of pain. Right ankle swelling and

2x1.5cm ecchymosis on mid-lateral malleolus area with tenderness upon palpation on the

lateral side of the ankle over the anterior talofibular ligament (ATFL). Range of motion

with pain and limitation on dorsiflexion, plantar flexion, and inversion. Skin intact. Able

to bear weight on BLE, with discomforts on the right ankle. No bony tenderness,

deformity or crepitus present.

Neuro: Alert and oriented x4. Strength and sensation intact.

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Skin/Lymph Nodes: 2x1.5cm ecchymosis on mid-lateral malleolus area of the right ankle.

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Intact skin. No cervical lymphadenopathy. No rashes, or erythema. No lesions.

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Diagnostic studies:
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Anterior Drawer Test: positive

An Anterior Drawer Test is considered as a screening test in the assessment of lateral

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ankle sprain and suspected ATFL injury (Croy, Hertel, Koppenhaver, & Saliba, 2013).
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Inversion test: pain noted in the area of anterior talofibular ligament.

Imaging Studies:
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Right ankle X-ray

- According to the rule, an ankle X-Ray series is only required if there is any pain in the
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malleolar zone plus one of the following: bone tenderness along the distal 6cm of the
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posterior edge of the fibula or tip of the lateral malleolus bone tenderness along the distal

6cm of the posterior edge or tip of the medial malleolus or an inability to bear weight
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both immediately and in the emergency department for four steps (Ball, Dains, Flynn,

Solomon, & Stewart, 2015, p. 252).

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 A.

Differential Diagnoses (DD):

• Grade 2 Lateral Ankle Sprain: Sports injuries occur when running, cutting, landing from a

jump, or from direct contact which can produce an audible tear or pop causing pain and swelling

that are immediate, but ecchymosis may lag a day or two behind (American Orthopaedic Foot &

Ankle Society, 2015).

- An ankle sprain is an injury to one or more ligaments in the ankle with symptoms

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such as pain, swelling, soreness, bruising, difficulty walking, and joint stiffness

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(American College of Foot and Ankle Surgeons, 2018).
- Based on the reported symptoms and physical assessment findings, ankle sprain is the

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primary diagnosis for the patient. Anteroposterior lateral views x-ray preferably with
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weight bearing or during inversion will reveal extent of ligament injury.
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• Achilles tendinitis inflammation of the Achilles tendon producing symptoms of pain and
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swelling where the tendon inserts into the calcaneus, and patient reports of feeling of tightness

that makes walking and running difficult (Baumann, Dains, & Scheibel, 2016, p. 269).
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- The area of pain and tenderness noted with G.M. involves mid-lateral area of the
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ankle. Swelling of the Achilles tendon can be assessed in the posterior part of the
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ankle.
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• Ankle fracture: may involve the one or more of the ankle bones such as tibia, fibula, and talus

with symptoms such as severe immediate pain, swelling, bruising, tenderness, deformity, and
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inability to bear weight (American Academy of Orthopaedic Surgeons, 2013).

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 • Anterior impingement: which is also known as footballer’s ankle with presenting symptoms

such as pain and inflammation including decrease in overall ankle range of motion, mostly

affecting dorsiflexion (Stanford Health Care, 2017).

• Plantar fasciitis: affect women twice as often as men, is caused by chronic weight-bearing

stress when laxity of foot structures allows the talus to slide forward and medially, calcaneus to

drop, and plantar ligaments and fascia to stretch (Baumann, Dains, & Scheibel, 2016, p. 269).

Pain is worse on awakening and is relieved with non-weight bearing activity often involving the

heel (Baumann, Dains, & Scheibel, 2016, p. 269).

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Reference

American Academy of Orthopaedic Surgeons. (2013). Ankle Fractures. Retrieved from

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

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

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 Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to

physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Baumann, L. C., Dains, J. E., & Scheibel, P. (2016). Advanced health assessment and clinical

diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Croy, T., Hertel, J., Koppenhaver, S., & Saliba, S. (2013). Anterior Talocrural Joint Laxity:

Diagnostic Accuracy of the Anterior Drawer Test of the Ankle. Journal of Orthopaedic &

Sports Physical Therapy,43(12), 911-919. doi:10.2519/jospt.2013.4679

Stanford Health Care. (2017). Anterior Ankle Impingement (Footballer's Ankle). Retrieved from

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https://stanfordhealthcare.org/medical-conditions/bones-joints-and-muscles/ankle-

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anterior-impingement.html

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