CASE
A 23-year-old man presented to our emergency department (ED) complaining of pain and redness on the anterior portion of his right shin. He reported that the pain had actually started about 7 days ago and was initially in both shins.
The patient had presented to the ED at another hospital 4 days before his visit to our facility. Review of the visit note indicated that his symptoms had started after a long walk. He denied trauma or any neurologic complaints. The examination was significant for bilateral anterior shin tenderness that worsened with plantar flexion and dorsiflexion. The diagnosis was shin splints, and the patient was discharged with a prescription for ibuprofen, 800 mg.
He was seen again the next day at this same ED with right ankle pain and swelling. This visit note indicated that the patient had heard a “crack” in his ankle that morning while putting on his shoes; he noticed some swelling in the ankle shortly thereafter. This examination was significant for diffuse tenderness along the forefoot and lateral ankle on the right side with mild edema and a slight decrease in range of motion (ROM). Radiographs of the right ankle showed soft tissue swelling but no bony abnormalities. The diagnosis was an ankle sprain; he was fitted with an air cast and told to continue the ibuprofen.
At our facility's ED, the patient said that the pain in his ankle had subsided slightly but the pain in his shin was now more prominent. Earlier that morning he had noticed redness in the area as well. Aside from the long walk, he denied any recent events that could have caused his symptoms.
History The patient's medical history was significant for thyroid cancer with radical thyroidectomy in 2007, but was otherwise unremarkable. Medications included levothyroxine and ibuprofen. The patient had no known drug allergies; denied alcohol, cigarette, or illicit drug use; and lived with his family
Physical examination The patient was afebrile; heart rate, 74 beats per minute; and BP, 133/59 mm Hg. He was well-nourished, well-developed, awake and alert, and appeared to be in no acute distress. Skin examination was significant for a well-healed surgical scar on the anterior neck and a large area of mild erythema on the right anterior shin that was roughly oval in shape and approximately 20 10 cm, with diffuse borders and no streaking. No bleeding, drainage, or discharge was seen. The area of erythema was slightly warmer to the touch compared with the left leg, and he had diffuse tenderness to palpation of the right shin and ankle but no tenderness with passive ROM. Distal sensation and distal pulses were intact, and capillary refill was good at less than 2 seconds. Strength testing revealed intact plantar flexion but weak dorsiflexion on the right. Examination of the right foot and ankle was unremarkable, as was the remainder of the examination. Radiographs of his tibia and fibula were read as having no acute abnormalities.
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