Pinpointing The Cause Of Posterior Ankle Pain

By Babak Baravarian, DPM

Chronic posterior ankle pain is a very difficult problem for foot and ankle surgeons. Given the multiple potential tendinous and osseous causes of pain, doing a proper diagnostic workup is essential for proper care. With this in mind, let’s consider the following case of a 52-year-old Caucasian male who presents with chronic pain and weakness of the posterior ankle.
A computer salesman with an avid love for golf and tennis, the patient plays tennis on the weekends and golf at least once a week for business. Approximately two months ago, while playing tennis, he began to feel pain in the posterior right ankle region. He says the pain was worse in the morning after playing tennis, but would improve with some stretching and walking. He also notes that the right posterior ankle had developed a posterocentral mass that would get better with rest and would increase in size after a great deal of activity.
About one month ago, during a competitive tennis match, he felt pain in the posterior ankle. While he is unclear as to when the pain occurred during the match, he felt a sharp pain and then had difficulty with ambulation. He continued to play for a couple of points, but could not finish his match.

He went home and placed ice on his posterior ankle. He wrapped the ankle with an old Ace wrap and took 600 mg of Motrin three times per day for the next five days. The following morning of the injury, he felt a different pain than his usual tightness or soreness. He had a weakness upon ambulation and swelling of the posterior ankle. For the next 10 days, he tolerated some mild pain and swelling of the posterior ankle. He saw some decrease in swelling, yet he felt mild weakness during ambulation.
About one and a half months after the initial injury, he returned to play golf with some clients and felt very weak with his stroke during the finish of his swing. The right ankle was again swollen, yet he had minimal pain in the region.

What The Examination Reveals
He notes no significant past medical history except for asthma. He does not take any medications except his asthma medication, as needed, and short bouts of Ciprofloxacin as needed for upper respiratory infections, which he gets once or twice a year.
The physical exam shows a healthy and trim male with no acute distress. He has well developed lower extremities with no signs of poor muscle development. The neurological examination shows no loss of sensation on the sharp/dull and vibratory exam. Protective threshold is also intact with no region of lost sensation. The vascular exam shows bilaterally symmetrical pulses which are bounding in the posterior tibial and dorsalis pedis as well as the popliteal regions.
A dermatologic exam of the patient shows mild edema of the right posterior ankle and thigh region with the majority of the edema in the posterior aspect of the lower extremity. There is no break in the skin of the right leg and no signs of bruising or hematoma.
The muscular and skeletal examination reveal mild tenderness of the posterior ankle and distal posterior quadrant. There is pain to palpation of the Achilles distally about the insertion and slightly proximal to that region. There is no gross deficit in the region of the watershed area in the Achilles tendon. There is three out of four muscle strength with general examination of the posterior muscle group and Achilles with the patient seated.

Although there is a gross gastrocnemius equinus in the left ankle, the right ankle is easily dorsiflexed to 90 degrees with the knee locked and bent. There is minimal tenderness to dorsiflexion of the ankle. Palpation of the deep posterior ankle is difficult due to some swelling, yet there is no deep pain present upon testing it. Range of motion of the ankle is non-painful and there is no discomfort of the peroneal or posterior tibial tendons. The Thompson’s calf squeeze test is intact, yet is weak to testing.

What Is The Probable Diagnosis?
Posterior quadrant pain is likely to be due to one of several potential causes.
1. Flexor hallucis dysfunction (stenosing tenosynovitis)
2. Gastrocnemius musculotendinous junction tear (tennis leg)
3. Achillles tendon rupture
4. Osteochondral lesion of the ankle (usually posteromedial lesion)
5. Fracture of the posterior talar process (Shephard’s fracture)

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