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Download the article PDF: Clinical Image Challenges September 2026
A 64-year-old woman with a history of chronic obstructive pulmonary disease, diabetes mellitus, osteoarthritis, and obesity presents to urgent care with acute right posterior ankle pain after stumbling on a curb earlier that day. She says she felt a sudden sharp pain in the back of her ankle and experienced immediate difficulty walking and climbing stairs. She reports 10 days of mild posterior ankle discomfort before this event, which she treated with ice, an elastic wrap, and intermittent crutch use. Approximately 2 weeks prior to presentation, she was treated with levofloxacin for a urinary tract infection.
On examination, there is ecchymosis along the posterior right ankle extending toward the lateral foot. She has tenderness over the distal calf, with only mild tenderness over the foot and bilateral malleoli. She is unable to actively plantarflex her foot or perform a single-leg heel raise. The Thompson test is inconclusive. Point-of-care ultrasound (POCUS) of the posterior right ankle is performed.
View the image above and consider the likely diagnosis and next steps. The resolution of the case is described on the following page.