A 20 year old elite female player presented with localised medial (right) ankle pain. She reported having sustained an “ankle sprain” while playing football five months prior. She reports having difficulty walking for more than a week after her acute injury. Two months after the injury she had an MRI scan which was reported to show a deltoid ligament injury with localised oedema in the medial talus. At this stage she was managed with a further period of rest but has since been unable to return to football due to ongoing, activity-related medial ankle symptoms.
On examination there was very little to find. She had pain hopping but could walk normally. She had some modest, localised swelling over the medial ankle. The most significant finding was of localised tenderness around the medial talus and medial malleolus region. There was no evidence of ligamentous laxity.
An x-ray series of the ankle taken both at the time of injury, and again at the time of her MRI, did not show any significant bony abnormality. The MRI images (from two months after the injury) show abnormal T2 hyperintensity in the medial body of the talus. This is associated with moderate T2 hyperintensity in the anterior fibres of the deep deltoid ligament in keeping with a significant sprain. The superficial deltoid fibres appear to be intact. A SPECT conducted five months after the injury shows focal radiotracer uptake at the medial aspect of the right talus on the delayed static images. This has a similar distribution to the bone marrow oedema seen on the MRI. A tiny 4 x 2 x 1 mm bony fragment is seen in this region and is in keeping with a small avulsion fracture.
At the time of their presentation, this player had already experienced quite a prolonged period of pain. This had not responded to an appropriate period of rest and a progressive re-introduction of activity. As a result a decision was made to excise the ossicle. This was done without complication. Following surgery she was able to progressively return to football over a two month period. At this point there was a substantial improvement in her preoperative symptoms, she was able to return to competitive football and she was pleased with the outcome.
Injuries to the deltoid ligament are far less common than injuries to the lateral ligament complex with isolated deltoid ligament injuries accounting for less than 5% of all ankle ligament injuries. The most common injury mechanism injury involves forced eversion combined with external rotation. Patients generally present with localised medial ankle pain and have tenderness about the medial gutter. In general, the management of this type of injury is similar to lateral ankle sprains, however, the rehabilitation period is often protracted.
Avulsion fractures like those seen in this case are very common following injuries to the ankle. In most cases these do not require any specific treatment and reflect an injury to the ankle ligaments or other stabilising structures around the ankle. Usually no specific treatment is required and patients are able to return to sport predictably after being treated for a ligamentous injury. As this case illustrates however this is not always the case. Imaging modalities demonstrating bone activity, such as MR imaging and SPECT, can be very useful diagnostic tests and can help guide treatment decisions.
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