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Monday, December 3, 2007

A 39-Year-Old Man with Ankle Pain and Stiffness

Test your diagnostic skills...


A 39-year-old man presents to his primary care physician with a 6-month history of pain in his right ankle. The pain has been insidious, and it is accompanied by stiffness and swelling of the ankle joint. The patient cannot move his ankle well. Additionally, despite using a crutch, he cannot perform his daily activities. The patient has no history of trauma to the affected joint. There is no history of fever, back pain, or any other joint involvement. He has no history of sexually transmitted diseases, and his family history is negative for arthritis.

On physical examination, the patient has normal vital signs. The cardiac findings are negative for murmurs or rubs. No rash or penile discharge is observed. Examination of the right ankle elicits discomfort with passive range of motion, revealing limitations with inversion and eversion and with flexion and extension. On palpation, the patient has mild tenderness. There is obvious swelling of the joint, which feels firm. There is no warmth or redness over the joint. The remainder of the physical examination is unremarkable.

A plain radiograph of the ankle is obtained (see Image 1). After the results of the plain radiograph are interpreted, the primary care physician orders a follow-up magnetic resonance imaging (MRI) scan of the joint (see Images 2 through 4).

What is the diagnosis?

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