Strange case

I had a pt who presented with swelling around her ankle, mainly around the lateral malleolus but also slight swelling across the anterior aspect of the ankle as well as the medial side. She had a constant 5/10 pain along the anterior aspect of her lower limb about ¾ of the way up (below the knee) and down to the ankle. Nothing she tried eased her pain but her pain increased over the course of the day especially with prolonged standing or walking. She had no history of injury, the pain just started one day and she noticed the swelling. She said she had been to the gym three days before it started but she just did her normal routine and didn’t roll her ankle or anything. She went to a doctor who thought she had just sprained her ankle so he gave her a cortisone injection (a bit weird I thought); this didn’t affect her pain or swelling at all. So she went to another doctor for a second opinion and they referred her to us. She had had an x-ray which showed nothing abnormal and the second doctor had also referred her for a bone scan (which was booked in to be done 5 days after I saw her). I assessed her and had no findings that I could make a diagnosis on. Her ankle stability tests did not show anything significant. She had pain with dorsiflexion and plantarflexion both active and passive and her inversion and eversion were pain free. She was TOP over the medial aspect of her tibial shaft but not TOP around her ankle joint. None of the subjective questions revealed red flags but because she had no findings that correlated well I decided not to try treat the swelling with ultrasound or any other modalities for fear of a more sinister pathology. All I could give her was some advice to try a compression bandage to reduce the swelling and I gave her some gentle AROM exercises. I advised her to contact us once she had got the results from the bone scan and then possibly with a diagnosis we may have been able to know how to treat her more effectively, if treatment was indicated. Unfortunately by the time I had finished my placement the pt had not got back to us which could have been because physio treatment was not indicated but unfortunately I’ll never know, it was a different presentation to what I’ve seen before so I was curious to know whether or not the scan showed anything and a diagnosis was made.
This presentation highlighted the importance to me to really be aware of red flags if the objective examination doesn’t seem to add up, even if no subjective red flags are highlighted. I don’t know if it was a red flag situation but I didn’t want to take my chances and when discussing it with my supervisor she agreed with what I had done and also found my findings didn’t point to a specific musculoskeletal diagnosis and it was a good idea to wait for further investigations. I can’t remember exactly but I think it may have been the fact that a bone scan was ordered that caused me to be a bit more aware of the possibility of a red flag situation. I would definitely take the same approach if similar situations occurred in the future and I hope I can stay alerted to the possibilities of red flags in my future practicing as a physiotherapist.