School

School of Health Sciences and Human Performance

Department

Exercise and Sport Sciences

ICC Theme

Other

Date

2-4-2019 12:10 PM

Abstract

Background: While an Athletic Training Student in my clinical rotation this past fall, a seemingly common condition turned out to be something far more severe and rare. In September 2018, a 21-yearold, male, Division 1 collegiate football player injured his left ankle during practice. Two weeks after the injury, he reported to his athletic trainers and presented with pain on his lateral ankle around the anterior talofibular ligament. He also reported having a history of mild pain in his left ankle for several years that did not affect his ability to play football. The athlete also reported being a type I diabetic who was currently using insulin. The patient did not present with any edema and reported mild pain only with cutting and lateral movements in practice. His ankle range of motion was within normal limits and had no functional deficits in performance. These findings indicated a mild ankle sprain. However, his pain continued to progressively worsen over the next two weeks, which prompted the athletic trainer to refer the athlete to the team physician who ordered a radiograph to rule out a fracture. Methods: Radiographic findings revealed an articular cartilage defect and spurring on the medial talar dome. Because of the abnormal radiographic findings, the physician ordered an MRI. To help with pain reduction, the physician performed an intra-articular corticosteroid injection; however, the pain reduction benefits were short-lived. The MRI revealed a large lesion on the talus with substantial loss of cartilage and bone indicating chronic arthritic changes. At this time, the patient’s pain had progressively increased where he developed an antalgic gait, and had extreme tenderness on his medial talar dome. A CT scan was then ordered and showed gas in the talocrural joint. Traction, trauma, or degenerative changes within a joint can create this gas, comprised mostly of nitrogen, that can be visible on a CT scan.1 The CT scan also revealed a large osteocondral lesion on the superior medial articular surface of the talus (1.7 cm X 1.0 cm X 0.4 cm in size), in addition to multiple small bony fragments and prominent subcondral cystic changes. The integrity of the subtalar joint space was considered within normal limits. Due to the size of the lesion, the progressively worsening pain, and the inability to walk, the patient was advised to have total rest and surgery to address the talar dome lesion. Results: Surgery included open debridement of the osteochondritis dissecans with bone graft and cartilage transplantation, microfractures of the tibia, and excision of three loose bodies. Throughout the course of his recovery, the patient was put on tight diabetic control to ensure that proper healing was not impeded by poor blood sugar control. The patient was casted for the first two weeks after surgery. Upon cast removal, the patient reported substantial calf pain, which warranted a Doppler study that revealed a deep vein thrombosis in one of his left paired peroneal veins. The patient was prescribed anticoagulation medication (Xarelto) and was progressed to a removable boot with non-weightbearing status for the next two weeks. The patient remained in the boot as he progressed to weight-bearing until he could demonstrate a pain-free gait without the boot. As of December 2018, the patient was still weight-bearing in the boot and had graduated from his University. He is no longer under the care of his athletic trainers or team physicians and currently resides in North Carolina. He is undergoing physical therapy, but his recovery status with regard to his return to full function has not yet been established. Discussion and Conclusions: I have learned a great deal from working with the athlete, athletic trainers, and team physicians in this case. What presented like the most common injury, a lateral ankle sprain, resulted in the discovery of an extremely rare injury, osteochondritis dissecans. Lateral ankle sprains have a 2/1,000 person/years incidence rate2 whereas the incidence rate of osteochondritis dissecans of the talus 2/100,000,000 person/years.3 I learned the importance of referral and imaging if an injury is recalcitrant and continues to worsen. Although this specific injury is rare, I truly appreciate the importance of having a broad perspective and exploring differential diagnoses in order to provide the best care for our athletes.

References:

1. Hood CR, Jackson WA, Floros RC, et al. The vacuum phenomenon in the ankle joint: Air bubbles on CT. The Foot and Ankle Online Journal. 2018;11(2):2.

2. Gribble PA, Bleakley CM, Caulfield BM, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016;50:1496-1505.

3. Zanon G, DI Vico G, Marullo M. Osteochondritis dissecans of the talus. Joints. 2014;2(3):11523

Comments

This is a unique clinical case that I saw on rotation as an Athletic Training Student.

Document Type

Poster

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Apr 2nd, 12:10 PM

Not Just an Ankle Sprain: The rare case of a Talar Osteochondral Lesion in a Collegiate Football Player

Background: While an Athletic Training Student in my clinical rotation this past fall, a seemingly common condition turned out to be something far more severe and rare. In September 2018, a 21-yearold, male, Division 1 collegiate football player injured his left ankle during practice. Two weeks after the injury, he reported to his athletic trainers and presented with pain on his lateral ankle around the anterior talofibular ligament. He also reported having a history of mild pain in his left ankle for several years that did not affect his ability to play football. The athlete also reported being a type I diabetic who was currently using insulin. The patient did not present with any edema and reported mild pain only with cutting and lateral movements in practice. His ankle range of motion was within normal limits and had no functional deficits in performance. These findings indicated a mild ankle sprain. However, his pain continued to progressively worsen over the next two weeks, which prompted the athletic trainer to refer the athlete to the team physician who ordered a radiograph to rule out a fracture. Methods: Radiographic findings revealed an articular cartilage defect and spurring on the medial talar dome. Because of the abnormal radiographic findings, the physician ordered an MRI. To help with pain reduction, the physician performed an intra-articular corticosteroid injection; however, the pain reduction benefits were short-lived. The MRI revealed a large lesion on the talus with substantial loss of cartilage and bone indicating chronic arthritic changes. At this time, the patient’s pain had progressively increased where he developed an antalgic gait, and had extreme tenderness on his medial talar dome. A CT scan was then ordered and showed gas in the talocrural joint. Traction, trauma, or degenerative changes within a joint can create this gas, comprised mostly of nitrogen, that can be visible on a CT scan.1 The CT scan also revealed a large osteocondral lesion on the superior medial articular surface of the talus (1.7 cm X 1.0 cm X 0.4 cm in size), in addition to multiple small bony fragments and prominent subcondral cystic changes. The integrity of the subtalar joint space was considered within normal limits. Due to the size of the lesion, the progressively worsening pain, and the inability to walk, the patient was advised to have total rest and surgery to address the talar dome lesion. Results: Surgery included open debridement of the osteochondritis dissecans with bone graft and cartilage transplantation, microfractures of the tibia, and excision of three loose bodies. Throughout the course of his recovery, the patient was put on tight diabetic control to ensure that proper healing was not impeded by poor blood sugar control. The patient was casted for the first two weeks after surgery. Upon cast removal, the patient reported substantial calf pain, which warranted a Doppler study that revealed a deep vein thrombosis in one of his left paired peroneal veins. The patient was prescribed anticoagulation medication (Xarelto) and was progressed to a removable boot with non-weightbearing status for the next two weeks. The patient remained in the boot as he progressed to weight-bearing until he could demonstrate a pain-free gait without the boot. As of December 2018, the patient was still weight-bearing in the boot and had graduated from his University. He is no longer under the care of his athletic trainers or team physicians and currently resides in North Carolina. He is undergoing physical therapy, but his recovery status with regard to his return to full function has not yet been established. Discussion and Conclusions: I have learned a great deal from working with the athlete, athletic trainers, and team physicians in this case. What presented like the most common injury, a lateral ankle sprain, resulted in the discovery of an extremely rare injury, osteochondritis dissecans. Lateral ankle sprains have a 2/1,000 person/years incidence rate2 whereas the incidence rate of osteochondritis dissecans of the talus 2/100,000,000 person/years.3 I learned the importance of referral and imaging if an injury is recalcitrant and continues to worsen. Although this specific injury is rare, I truly appreciate the importance of having a broad perspective and exploring differential diagnoses in order to provide the best care for our athletes.

References:

1. Hood CR, Jackson WA, Floros RC, et al. The vacuum phenomenon in the ankle joint: Air bubbles on CT. The Foot and Ankle Online Journal. 2018;11(2):2.

2. Gribble PA, Bleakley CM, Caulfield BM, et al. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med. 2016;50:1496-1505.

3. Zanon G, DI Vico G, Marullo M. Osteochondritis dissecans of the talus. Joints. 2014;2(3):11523

 

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