Dr. Vivek Chail
General Practitioner
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Patient's Query
Hello doctor,
Magnetic resonance imaging (MRI) scan on right ankle following a climbing fall of 3.89 yd and hitting the ground, inversion rolling on impact. This was a year back ongoing pain and issues. The pain is around anterior talo-fibular ligament (ATFL), joint and occasional swelling after heavy activity. I am a rock climber and train in the gym. I work part-time personal trainer so spend a lot of time on my feet, and also studying physio. The report and scan are attached, would like a second opinion as the scan is slightly subjective. I work in the sport and rehab industry. Please see scan images to see any issues, impressions are high grade 2 sprain of ATFL and calcaneofibular ligament (CFL) large tibiotalar joint effusion lateral malleolus trabecular fractures. I would like a new report, please. I need a second opinion 20 years old, 5.18 ft tall, 114.64 lb. Currently, I am taking Fluoxetine 20 mg daily for anxiety and depression.
Hi,
Welcome to icliniq.com. The magnetic resonance imaging (MRI) scan images (attachment removed to protect patient identity) of your right ankle confirm the following findings: 1. The ATFL (anterior talofibular ligament) and CFL (calcaneofibular ligament) are indeed showing signs of a sprain. However, the attachments are relatively intact. There is no tear. 2. The effusion in the ankle joint is significant and visualized surrounding the talotibial joint area and the fluid collection is more in the lateral part of the joint. There is fluid anterior to the joint as well and posterior to the talocalcaneal joint in the Kagers fat pad area. 3. There is mild fluid surrounding the long and short fibular tendons (peroneus longus and brevis). 4. The lateral malleolar trabecular fracture and subchondral changes of the superior lateral talar dome are visualized. 5. You might get a computed tomography (CT) scan done should your doctor recommend a detailed evaluation of the fractures.
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