Ryan Rostov: A 52-Year-Old Male With Right Ankle Pain

Ryan Rostov

Ryan Rostov is a 52-year-old roofer with the chief complaint of, “My right ankle is killing me.” Ryan went on to say that he wouldn’t have bothered coming in, but he was getting to where he was having a harder and harder time walking on roofs with a steep pitch. “Doctor, it’s getting to where I am afraid to work on some of these steep roofs. It’s not a height sort of thing, nothing like that. It’s just when I flex my right ankle to walk down the roof, I get a sharp pain. I am afraid it will hit when I am not expecting it, and I will lose my footing. I am not interested in falling off the roofs of some of the McMansions, if you know what I mean.” I asked Ryan if he had anything like this happen before. He shook his head and responded, “Just the usual aches that a guy my age comes to expect. You can’t work all day as a roofer and not have some pain. On some days I go up and down a ladder 100 times. Usually, I just take a couple of Motrin and use a heating pad. That will usually set me right after a day or so. What worries me this time is that this damn right ankle is hurting all the time. Especially, like I said, when I’m coming down a roof. I can live with the aching, but it’s that sharp pain that scares me. I’m pretty tough and I really like what I do. There’s a start and a finish to it. The roof leaks, I put on a roof, no more leaks. Kind of like being a doctor! But this ankle pain has me worried because if I don’t work, I don’t eat. In my younger days, when I should have been saving, I was playing. I really need to work if I ever want to retire, which I don’t yet! So help me get this ankle tuned up.”

I asked Ryan about any antecedent trauma, and he shook his head no. “Doc, this kind of snuck up on me. At first, my ankle had this deep ache that would get better with some Motrin and rest. Over time, the Motrin has just about quit working. But, like I said, I gotta work.” I asked Ryan what made his pain worse, and he replied, “The steeper the pitch, the worse the ankle.”

I asked Ryan to point with one finger to show me where it hurt the most. He grabbed his right ankle and said, “Doc, I can’t really point to one place because it kind of hurts all over. Although, by the end of the day, the front of the ankle is the worst. And you know, Doc, the crazy thing is, sometimes I feel like the ankle is popping.” I asked if he had any fever or chills, and he shook his head no. I continued, “What about steroids? Did you ever take any cortisone or drugs like that?” Ryan again shook his head no, then said, “You know me, I’m not one for taking pills. Pills and roofing really don’t mix.”

On physical examination, Ryan was afebrile. His respirations were 16, and his pulse was 74 and regular. His blood pressure was slightly elevated at 122/74. His head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. I did a rectal exam, which revealed no mass and a normal prostate. Visual inspection of the right ankle revealed no cutaneous lesions or obvious tumor. The ankle was cool to touch. Palpation of the right ankle revealed mild diffuse tenderness, with a mild effusion ( Fig. 1.1 ). There was tenderness at the anterior aspect of the ankle joint. There was mild crepitus, but I did not appreciate any popping or joint instability. Range of motion of the ankle joint was decreased, with pain exacerbated with flexion, extension, eversion, and inversion of the ankle. The anterior drawer test for anterior talofibular ligament instability was negative ( Fig. 1.2 ). The left ankle examination was normal, as was examination of his other major joints, other than some mild osteoarthritis in the right hand. A careful neurologic examination of the upper and lower extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not