Discussion: Assessing Musculoskeletal Pain

Discussion: Assessing Musculoskeletal Pain

Discussion: Assessing Musculoskeletal Pain

Patient Information:

Initials: C.A, Age: 46 years, Sex: Female, Race: African American


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CC (chief complaint): Bilateral ankle pain

HPI: C. A is a 46 is African American aged 46 years old. She presents with complaints of pain in her bilateral ankle, especially on the right side. She claims to have heard a “pop” while playing soccer over the weekend. She can tolerate weight, but it is painful. Her major worry is her right ankle.

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Location: Bilateral ankle

Onset: Abrupt

Character: Sharp but not radiating pain

Associated signs and symptoms: Ankle enlargement and inadequate right ankle movement.

Timing: The pain has lasted for two days. It is irregular with each episode taking about 15-20 minutes.

Exacerbating/ relieving factors: Pain is intensified by walking, tolerating weight, or sitting. Pain is momentarily eased by cold compresses.

Severity: Pain is worse on the right ankle at about 5/10 compared to the left ankle which is about 2/10.

Current Medications: None

Allergies: No identified drug and food allergies

Past Medical History: No history of chronic medical conditions, blood transfusion, or previous surgeries. Flu vaccine: December 2020

Social History: She is a professional teacher and the team’s soccer captain. She likes playing soccer on weekends. She does not take alcohol, smoke tobacco, or use illicit drugs.

Family History: Her parents are all alive. Her mother is diabetic but effectively managed by metformin. She is not living with her husband because they separated two years ago. She has a 20-year-old college-going daughter.


GENERAL:  No fever, chills, night sweats, or changes in weight

HEENT:  Eyes:  Refutes loss of vision, blurred vision, or yellow sclera. Ears, Nose, and Throat: Refutes ear discharges, hearing loss, dysphagia, nasal congestion, or sore throat.

SKIN:  Reports no rash, itching, or skin discoloration.

CARDIOVASCULAR: No paroxysmal nocturnal dyspnea, palpitation, chest pain, or orthopnea.

RESPIRATORY:  No cough, shortness of breath, sputum, or difficulty in breathing. GASTROINTESTINAL: No alteration in changes in abdominal distention, or bowel routines.

GENITOURINARY:  Refutes hematuria, frequency, or dysuria. The last menstrual period was on 07/09 /2022.

NEUROLOGICAL:  Denies convulsion, headache, syncope, or alterations in the functions of bowel and bladder.

HEMATOLOGIC:  No anemia, bruising, or bleeding.

LYMPHATICS:   No record of splenectomy. No lymphadenopathy.

PSYCHIATRIC:  Refutes anxiety, depression, hallucinations, or delusions.

ENDOCRINOLOGIC:  No cold, polydipsia, polyuria, and heat intolerance.

ALLERGIES: No history of asthma, eczema, or hives.


Physical exam

Vital Signs: P 78 RR 19 Temp 98.4 F, BP 123/74 mmHg, Weight 128 lbs., Height 5′ 5″

General: A middle-aged female adult of African American origin. She has a minor discomfort. She is oriented and alert.

Respiratory: Vesicular breath sounds in entire lung zones, a symmetric chest that budges with respiration. No crackles or wheezing.

Cardiovascular: No murmurs. PMI in the fifth intercostal space, normoactive precordium, midclavicular line. S1 and S2 detected. Ecchymosis measuring 2 cm by 2 cm was noted around the lateral malleolus. Tenderness of the lateral malleolus was observed, particularly above the anterior talofibular ligament. Restricted range of motion of the right ankle, especially on plantar flexion, inversion, and dorsiflexion. Bilateral skin intact. No noted erythema or edema on the left ankle. The usual range of motion was noted on the left ankle. Noted bilateral constructive dorsalis pedis. Bilateral intact sensation, No noted deformity, crepitus, or bony tenderness.

Neurological: GCS 15/15, oriented to person, place, and time. Cranial nerves are intact, sensation in every dermatome is intact, and typical bulk, typical tone, and reflexes in all joints. Regular functions of bladder and bowel.

Diagnostic results:

The prone anterior drawer test: This test evaluates the reliability of the ankle’s lateral ligamentous complex. The test is crucial for the patient’s case.

Talar tilt test: This test focuses on the calcaneofibular ligament. The patient suffered pain around the ligament area.

Eversion test: This test is conducted to assess the reliability of the deltoid ligament. It is negative in the patient’s case.

Imaging: Based on the Ottawa Ankle rules, conducting a series of X-rays is crucial is necessary where the pain is noted in the malleolar area alongside any of the following signs; tenderness above the posterior periphery of the distal 6 cm or medial malleolus’ tip, tenderness above the posterior periphery of the distal 6 cm or lateral malleolus’ tip, and incapacity to tolerate weight shortly following an injury (Murphy et al., 2020). The patient, C.A, met the Ottawa rules. As a result, a right lateral X-ray was conducted, which indicated swelling in the soft tissue. There is a need for an MRI of the ankle or more perspectives to effectively describe the ligaments involved.


Differential Diagnoses

Lateral Ankle Sprain: This pain is a frequent injury associated with sports. It occurs majorly with the ankle inversion and entails the lateral ligamentous complex, which comprises the calcaneofibular and posterior talofibular ligament, and anterior talofibular ligament that are damaged in reducing order (Martin et al., 2021). Patients with this condition often have a hematoma, tenderness above the sprained ligament, inadequate range of motion, and soft tissue swelling. These characteristics are common with the patient in this case. The “pop” sound she reported is an indication of a clear ligament tear.  As such, lateral ankle sprain is the primary diagnosis in this patient.

Ankle Fracture: This condition characterizes one or more ankle joint bones including the tibia, talus, and fibular. It presents as a cute immediate pain, tenderness, incapacity to tolerate weight, limited movement, pain, skin abnormalities, and swelling (McKeown et al., 2020). It is not the major diagnosis since ankle fractures are normally high-energy injuries but the patient can tolerate the weight.

 Syndesmotic Ankle Injury: This condition is also called a high ankle sprain. It characterizes an injury to a minimum of one of the ligaments that encompass the distal tibiofibular syndesmosis (Raheman et al., 2022). It is also attributed to injuries associated with sports with an abrupt twisting force. It leads to more proximal pain above the ankle.

Anterior Impingement: This condition connotes strapped structures down the tibiotalar joint’s anterior margin in terminal dorsiflexion (Chen et al., 2019). It often characterizes ankle pain and restricted movement. It is also linked to considerable abnormalities in the osseous and soft tissues.

Achilles Tendinitis: This condition characterizes Achilles tendon inflammation. It manifests with swelling, pain, and erythema at the point of tendon placement into the calcaneus. It also manifested in incapability to move and tightness (Lee & Lee, 2018). In the case at hand, the patient reported pain and tenderness in the ankle’s lateral area. However, in Achilles tendinitis, the pain should manifest in the posterior area of the ankle.

This section is needless in this course. However, it will be necessary for future courses.


Chen, L., Wang, X., Huang, J., Zhang, C., Wang, C., Geng, X., & Ma, X. (2019). Outcome comparison between functional ankle instability cases with and without anterior ankle impingement: a retrospective cohort study. The Journal of Foot and Ankle Surgery, 58(1), 52-56. https://doi.org/10.1053/j.jfas.2018.07.015

Lee, Y. K., & Lee, M. (2018). Treatment of infected Achilles tendinitis and overlying soft tissue defect using an anterolateral thigh free flap in an elderly patient: A case report. Medicine, 97(35). Doi: 10.1097/MD.0000000000011995

Martin, R. L., Davenport, T. E., Fraser, J. J., Sawdon-Bea, J., Carcia, C. R., Carroll, L. A., … & Carreira, D. (2021). Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 51(4), CPG1-CPG80. https://www.jospt.org/doi/10.2519/jospt.2021.0302

McKeown, R., Kearney, R. S., Liew, Z. H., & Ellard, D. R. (2020). Patient experiences of an ankle fracture and the most important factors in their recovery: a qualitative interview study. BMJ open, 10(2), e033539. http://dx.doi.org/10.1136/bmjopen-2019-033539

Murphy, J., Weiner, D. A., Kotler, J., McCormick, B., Johnson, D., Wisbeck, J., & Milzman, D. (2020). Utility of Ottawa ankle rules in an aging population: evidence for addition of an age criterion. The Journal of Foot and Ankle Surgery, 59(2), 286-290. https://doi.org/10.1053/j.jfas.2019.04.017

Raheman, F. J., Rojoa, D. M., Hallet, C., Yaghmour, K. M., Jeyaparam, S., Ahluwalia, R. S., & Mangwani, J. (2022). Can weightbearing cone-beam CT reliably differentiate between stable and unstable syndesmotic ankle injuries? A systematic review and meta-analysis. Clinical Orthopaedics and Related Research®, 10-1097. Doi: 10.1097/CORR.0000000000002171

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Discussion: Assessing Musculoskeletal Pain

• By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

Case 2: Ankle Pain

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She can bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?

With regard to the case study you were assigned:
• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study you were assigned.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

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