History: Trauma

What's going on around the lateral malleolus? Acute, chronic, developmental?

What's the verdict?

Real History: Playing basketball with popping sensation that felt like a kick to the heel (this was all in the first sentence of the triage note). ¯\_(ツ)_/¯

What a difference that makes.

The deep margin of the normal Achilles tendon should be smooth and linear as it leaves the myotendinous junction to its insertion at the calcaneus - shouldn't get thicker distally. Focal bulging and fat stranding in the retrocalcaneal (AKA Kagers) fat pad is abnormal.

Check out this normal case for comparison with my poorly drawn lines for delineation of the normal Achilles tendon (posterior), distal triceps surae myotendinous junction (superior), and flexor myotendinous structures (anterior).

Teaching Points:

Radiographs are more than bones. Fat pads and planes are often the clue to the diagnosis.
The history is not always a history. If it's too brief, check the EMR. The triage or first RN note often has the least amount of filler.
Os subfibulare!

https://radiopaedia.org/articles/os-subfibulare?lang=us

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