Description of patient (type of occupation, indication of age, intensity of sport):
Since 1 year she has recurrent right side ankle pain and oedema after sports. No severe injury in history. Slight flat foot. Negative x-rays of foot and ankle. She had 2 weeks splint and non-weight bearing. Symptoms are hardly decreased, physiotherapy started. After 6 weeks sport rehabilitated. Pain and swelling is back.
History and previous treatment:
After many round of splint, brace, rehabilitation she has complaints, after 3 km of walking and she came to Department.
Current complaints:
After many round of splint, brace, rehabilitation she has complaints, after 3 km of walking and she came to Department.
Physical examination:
Ankle function on the right side is 5-0-20 degree, painful weight bearing, no instability, circular oedema around the ankle, might some effusion in the joint.
Radiology:
X-ray:
[Picture 1 + 2]
No pathologic sign.
Additional investigation (CT/MRI):
[Picture 3 + 4]
4 weeks later we made a MRI scan. After initial findings compared to other side. Both ankle and foot bones are oedematic, spotted appearance. No other pathology.
T1 MRI of the right side, the red circle shows the linear low signal area.
[Picture 5]
Fat suppression MRI of the right ankle.
[Picture 6]
T2 MRI of the left side.
Remarks:
Lab tests negative (basic, immun, endocrin). When asking, she tells some minimal complaints on the other side
Images:
Case summary:
Recurrent ankle oedema and pain with oedematic bone structures on both ankle and foot.
Question(s) to this case:
What is this pathology? What other tests to do with this patient? What is the treatment?
Expert:
I have no clear explanation for the symptoms. We asked our skeletal radiologist, for his opinion on the MRI images. The spotted appearance of the high signal on the fat suppression saturation and low signal on T1 can be explained by islands of red bone marrow without clinical consequences. The linear low signal area(red circle) on the right side just above the epiphyseal line cannot be explained as such. This can possibly be a stress reaction or possibly a stress fracture. A CT scan could provide more information.
The MRI of the left ankle (T2 image) shows identically to the right ankle islands of red bone marrow without clinical consequences.