Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

HPI: The patient is a 33-year-old-male who presents with persistent pain about the lateral aspect of the right ankle which, he states has been getting worse over the last several years. He states that approximately six years ago and that following a course of conservative care, he underwent a right ankle arthroscopy. At that time, he was noted to have a talar osteochondral defect that was treated with arthroscopic microfracture techniques. He relates that following this surgical intervention, his pain symptoms did not significant improve.

PMH: Hyperlipidemia

SHx: Right ankle arthroscopy with microfracture of a lateral talar OCD

FMHx: Noncontributory       Meds: Lipitor       ALL: NKDA

PE: Vital signs: BP 124/74, pulse 68, respirations 18, saturation 99% on room air. The patient is a AAOX3, NAD, and demonstrates appropriate mood and effect.  He is well nourished and demonstrates appropriate body habitus.  Upon focused physical exam to the right lower extremity, the patient demonstrates palpable pedal pulses with CFT>3 seconds.  There are no varicosities or telangectasias noted.  Protective sensation is grossly intact along the distal distribution of the L4, L5, S1 and nerve roots.  Proprioception and vibratory sensation is intact DTR are assessed and graded +2/4 at the achilles and patella to the right lower extremity.  Muscle strength is assessed and noted to be +5/5 in dorsiflexion, plantarflexion, inversion and eversion with pain noted with ankle range of motion, particularly in dorsiflexion.  There is no significant instability noted about the right ankle, there is a negative drawer test at the ankle.  With weight-bearing, the patient demonstrates an appropriate angle and base of gait and he is noted to demonstrate an antalgic gate.

Imaging Studies: Plain film radiographs of the ankle were obtained which demonstrated radiolucency along the anterior lateral should of the talar dome. Subsequent MRI was obtainedwhich a demonstrated a large talar lesion with underlying subchondral cyst formation.

Considering the clinical, radiographic, and MRI findings described above, how would you proceed in the management of this patient? You can share your thoughts on this topic, as well as all of your pearls and experiences in the e-Talk forum on podiatry.com.

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