Description of patient (type of occupation, indication of age, intensity of sport):
23 years old football player
History and previous treatment:
Trauma on the medial side of his ankle with the foot resting on the ground during a fooball match
After 6 months he continued to complain for pain during foot dorsal flexion with the foot on the ground in weight-bearing stance. If the patient try to run he feels pain on the posterior aspect of the hindfoot ( he referred pain at both side anterior to Achille's tendon).
The patient does not fell pain during forced plantar flexion
Additional investigation (CT/MRI): [Picture 1, 2, 3, 4 + 5]
At first - looking at the MRI - I hypotized it should be a posterior ankle impingenment. But I was not sure because the patient does not fell pain during forced plantar flexion. I suggested to perform a CT scan and this latter highlighed a bone fragment on the posterior aspect of the medial malleolus. The CT scan also evidenced the presence of the os trigunum.
Persisting posterior ankle pain after trauma on the medial side of his ankle with the foot resting on the ground during a fooball match
Question(s) to this case:
I kindly ask you your opinion about the tratment: Should I have to remove only the bone fragment of the medial malleolus, or should I have also to perform posterior ankle artroscopy to remove the os trigunum?
What about postoperative management?
the medial smal bomy fragment on the distal tibis is an avulsion of the PTT retinaculum. It can easily be palpated just medial to the PTT on the tibial rim. If this is recognisibly tender and the cause of his complaints then remove by small incision(open surgery)
If not tender then the deep posterior pain comes from the os trigonum which seemsto be slightly displaced posterior. This might be the reason why the post impingement test is not positive anymore.