Pediatric Problem in an Adult Ankle

Document Type

Conference Proceeding

Publication Date

3-1-2024

Publication Title

Clin J Sport Med

Abstract

History: A 52-year-old male presented to the Sports Medicine clinic for evaluation of 6 months of left ankle pain. He denied any history of injury or trauma. He first noticed the pain while running a half-marathon, and it became severe enough that he could not finish the race. His pain was reported as a dull ache with an insidious onset. Pain did not improve with conservative measures such as rest, ice, compression, elevation, and over-the-counter pain-relieving medications. The patient reported increased pain with activities such as running and skiing. He denied ankle instability, swelling, or radiation of symptoms to his foot or knee. He denied constitutional symptoms such as fevers, chills, night sweats, and unintentional weight loss. Physical Exam: Fifty-two-year-old male in no acute distress and with normal gait. No skin changes or swelling. Patient reported a deep-seated pain in his left fibula, proximal to the lateral malleolus, with no bony tenderness upon palpation. Full range of motion with dorsiflexion and plantarflexion. Negative anterior drawer test. 5/5 strength with inversion, eversion, dorsiflexion, and plantarflexion. Neurological exam revealed 21 deep tendon reflex at Achilles, and sensation of the lower extremities was intact to light touch. Normal distal pulses. Differential Diagnosis: 311. Peroneal tendinitis 312. Stress fracture 313. Ankle sprain 314. Sinus tarsi syndrome 315. Primary bone tumor Test Results: X-rays of the left ankle revealed no fracture, arthritis, or soft tissue calcifications. There was a subtle cortical irregularity of the medial fibula. MRI without contrast of the left ankle revealed erosion of the cortex of the medial distal fibular diaphysis with extension into an associated 3 × 2 cm soft tissue mass. Biopsy of the mass in the distal fibula was positive for sarcoma. PET scan was positive for malignancy with no evidence of metastasis. Final Diagnosis: Ewing's Sarcoma. Discussion: Ewing's Sarcoma is a rare bone malignancy that occurs in the diaphysis of long bones such as the femur, tibia, and humerus. Incidence is reported to be 3 per 1,000,000. It is primarily found in young adults under the age of 25 and is the second most common primary malignant bone tumor in children. It may be caused by a de novo genetic translocation of t(11;22). Biopsy is required for diagnosis, and metastasis frequently occurs to lungs, bone, and bone marrow. Ewing's Sarcoma in a patient in their 50's is extremely rare, but this case did fit the typical presentation with a prolonged course of symptoms before diagnosis. Outcome: The patient was referred to orthopedic oncology for further management. He subsequently underwent resection of the distal fibular diaphysis and chemotherapy. Follow-Up: Following surgery and chemotherapy, the patient developed a foot drop and deficits in sensation of his left foot. Weight-bearing activities, recreational sports, and ambulation were limited due to pain. He used an ankle brace for support. He was referred to physical therapy for functional rehabilitation.

Volume

34

Issue

2

First Page

e36-e37

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