Os Trigonum Syndrome In a Collegiate Football Athlete

Title: Os Trigonum Syndrome In a Collegiate Football Athlete
Name: Jared Traver
Primary Presenters: Jared Elijah Traver
College of Health Sciences
Masters
Faculty Sponsor(s): Dr. Hayley Erickson

Os Trigonum Syndrome in a Collegiate Football Athlete: A Level 4 Case Study
Traver JE*, Kelly A†, Ericksen HM*: * University of Wisconsin-Milwaukee, † University of Wisconsin-Whitewater

Background: This case presents an 18-year-old male offensive line football player injured in fall camp. The patient reported another player landed on the back of his ankle and it rolled in inversion. The pain was most intense around the anterior talofibular ligament and the calcaneofibular ligament. During the initial evaluation, percussion, tuning fork, and bump tests were positive, leading to a possible fracture diagnosis but x-rays were negative. The patient’s pain level (6/10) continued for two weeks. After a week of rest and pain management, the patient RTP and randomly reported posterior pain near the Achilles tendon. With this change in reported pain, the athletic trainer started to question the x-ray report of the ankle. The orthopedic surgeon obtained the x-rays and determined the presence of the Os Trigonum bone. An MRI was ordered to evaluate stability of the bone. The patient was scheduled for a MRI, but was rescheduled due to insurance failure to pre-authorize, and another date was delayed due to insurance. The patient may not be able to get an MRI for several months. The patient is still participating in conditioning with pain at 2/10, with occasional hits and falls that cause 6/10 increase in pain.

Differential Diagnosis: Grade 2 inversion ankle sprain, tibia/fibula fracture, Achilles tendinopathy, talar dome contusion
Treatment: Treatment included a Game Ready designed to facilitate cooling and compression with an ankle attachment and Ace wrap compression. After initial pain and swelling diminished, the patient performed ROM exercises including alphabet writing along with rocker board exercises. The patient was placed on the underwater treadmill to help with conditioning and running without lower extremity strain. The patient was returned to play while continuing minor strengthening, swelling, and pain control.

Uniqueness: The case is unique in the fact that only about 20% of the entire population may have the presence of an Os Trigonum. The Os Trigonum is an extra formed bone in the ankle which can typically present bilaterally, however bilateral presentation is unknown in this case. The Os trigonum bone can become mobile resulting in Os trigonum syndrome. Mechanisms to induce mobility include any ankle sprains, ankle fractures, or impacts to the ankle. The bone becomes mobile and causes catching, pain, and limited ROM. Typical occurrence of this syndrome is in the ballet population due to constant strain and injury to the ankle. Evaluation of mobility of the Os Trigonum is only available through a MRI, but without insurance preauthorization the full syndrome cannot be diagnosed. This roadblock has delayed further intervention based on the surgeon’s and patient’s goals. Depending on the current mobility of the bone, there are multiple different rehabilitation techniques including normal ankle rehabilitation programs, conservative pain management, and surgical removal. Patients with Os Trigonum can continue to participate in activity with managed pain. Outside of this case management depends on the patient and their desired outcomes. The goal with his patient is to manage pain through conservative management until diagnostic imaging is performed.

Conclusion: The presence of the Os Trigonum bone is in around ⅕ of the population and can be overlooked on an initial evaluation. Following rehabilitation for a suspected ankle sprain, the change of pain location and positive fracture tests led to referral for further diagnostic imaging, and the discovery of the bone. The current case was challenging because despite insurance issues, and lack of MRI to properly diagnose this injury, the athlete was able to play through the season. Treatment with the athlete was from preventing pain and inflammation. From the information that we have were given, we treated the patient centered on the patient’s goal to continue playing at a high level.
Word Count: 600

https://sites.uwm.edu/healthresearchsymposium-2022/files/formidable/2/References-41fe1e.pdf