Chronic Ankle Pain - Cross-country Athlete

HISTORY: Patient is an 18-year-old female collegiate cross-country athlete who presents for evaluation of chronic right ankle pain radiating to her calf with associated hyperemia, swelling, bruising, discoloration, skin mottling, temperature variations, sensitivity, and decreased range of motion. She reports increased pain with activity and “flare-ups” after running and showering. She has a history of recurrent distal fibular fractures treated with prolonged CAM boot immobilization. She trained 30 miles per week but decreased to 10 miles per week due to pain. Patient was refractory to ankle bracing, 2 sympathetic nerve blocks, and 4 months of generic formalized physical therapy. She used ibuprofen and acetaminophen for pain as needed, and was started on amitriptyline for pain control by PCP. PHYSICAL EXAMINATION: Antalgic gait, leads with left leg and hip. Right foot medial arch collapse and hindfoot valgus. ROM: 45/45 plantarflexion, 10/20 dorsiflexion, 15/20 eversion, 30/30 inversion, 5/5 strength. Tender to palpation at tibialis posterior B/L, medial tibial shaft B/L, CFL and ATFL right leg. Sensation intact and pulses palpable B/L. Hip abduction/adduction: 3/5. DIFFERENTIAL DIAGNOSIS: Complex regional pain syndrome. Peripheral vascular disease. Erythromelalgia. Deep vein thrombosis. Chronic exertional compartment syndrome. TEST AND RESULTS: X-ray Right tibia and fibula: No acute fracture. MRI Right ankle w/o contrast: No acute process.Attenuation injury of the ATFL suggesting chronic partial injury. FINAL WORKING DIAGNOSIS: Complex regional pain syndrome TREATMENT AND OUTCOMES: Ordered a pre-/post-therapy video gait analysis showing improved running mechanics and hip stability. Completed formalized physical therapy for CRPS desensitization locally with 80% improvement of symptoms after 3 months. Reports occasional swelling in her right foot that resolves with rest. Denies current use of any OTC pain medications. Weaned lace-up ankle brace support. Continuing the home exercise program and gradual return to running with incorporation of strength and conditioning. Returned to collegiate cross-country for the fall season.