Willis Paull, PhD

A 16-year-old boy complains of right lower leg pain that began 2 weeks earlier, after his first week at a summer basketball conditioning camp. Before he left for the camp, he was jogging off and on, averaging a few miles a week. At camp he began running 7 miles a day and doing sprints 3 times a week.

The leg pain initially began at the end of a run and quickly disappeared. It now is present as soon as he starts his run, and after 15 to 20 minutes it is so intense that he cannot continue. The pain persists for 1 to 2 hours after a run. It is located on the posteromedial aspect of the right tibia, covering an area that starts about 1 inch above the medial malleolus and extends upward about 4 inches (

). He does not note any numbness or dragging of his right foot. He is in good health and has never had a similar problem.

Physical examination reveals no gross difference in appearance between the 2 lower extremities. The patient pronates when he walks. Both plantar flexion against resistance and standing on tiptoes reproduce the pain in his right leg. The result of a tuning fork test is negative, and he exhibits no pinpoint tenderness. He has no neurologic or vascular deficit. His shoes are 2 years old and were used by his brother for a full season. They provide minimal support medially, and the soles are significantly worn.

Given the patient's age, the lack of acute trauma, the gradual onset of symptoms, and the recent initiation of intense physical activity, this is most likely an overuse injury. All 4 choices represent overuse injuries that can occur in runners.

The location of the pain and the lack of symptoms of neurologic or vascular compromise (such as numbness or footdrop) make compartment syndrome (B) less likely. Compartment syndrome associated with running is usually located in the anterior or lateral portion of the leg (

Posterior tibial tendinitis or tendinopathy (C) follows the path of the posterior tibial tendon, posterior to the medial malleolus. The pain associated with this injury is usually located behind the medial malleolus (

) and is typically accompanied by swelling. The lack of swelling and of pain in the location of the medial malleolus makes this diagnosis unlikely.

The location of the pain over the area of the posterior medial tibia is characteristic of both stress fractures (A) and MTSS (

). Although stress fractures are usually located in the medial posterior region of the tibia, the area of pain is typically much smaller than that seen in this patient. 

The tuning fork test can help rule out a stress fracture. With the fork vibrating, place the blunt end superior to the area of pain. Feeling increased pain in the area previously described as painful is considered a positive result. However, this test is of more diagnostic value when the result is negative (ie, when there is no increase in perceived pain). The negative result on a tuning fork test and the lack of pinpoint tenderness both make a stress fracture unlikely here.

Pronation--which this patient exhibits--predisposes the posterior musculature of the lower leg to pull excessively on the tibia. This pull or stretch causes a periosteal reaction on the tibia at its posterior medial border. Because this boy's shoes provide minimal medial support, they aggravate the medial tibial stress. These clues, in conjunction with the location of the pain, point to 

Compartment pressures (C) are not indicated because compartment syndrome seems unlikely. An MRI scan (B) is overkill at this point: it is not indicated and thus would add considerable unnecessary expense. Many clinicians would order a plain radiograph as a precaution, to check for stress fracture; however, this, too, is an additional expense. If the patient does not respond to treatment, a radiograph would then be indicated. At this time, however, no further testing is recommended.

This overuse syndrome is caused by a mismatch between overload and recovery. Repetitive overload on tissues that are not able to adapt to new or increased demands leads to tissue breakdown. Specifically, MTSS results from traction of the posterior tibial, flexor digitorum longus, and soleus muscles on the periosteum of the tibia (

). The traction produces an overload stress, which leads to an inflammatory response in the tibial periosteum (periostitis).

 The pain of MTSS is located over the posteromedial tibia beginning just above the medial malleolus and extending superiorly for 3 to 5 inches (see 

). It is activity-related, and chronic neurologic symptoms, such as numbness and footdrop, are usually absent. Diffuse pain and tenderness along the posteromedial border of the tibia that are aggravated by plantar flexion are characteristic findings. Pronation of one or both feet may be present.

 Multiple factors can contribute to or increase the risk of overload. A prior injury or lack of conditioning may lead to muscle imbalance, inflexibility, weakness, and instability. Other factors that can contribute to the development of MTSS include poor exercise technique, improper equipment, and changes in the duration or frequency of activity (training errors). Some persons seem to be more vulnerable to MTSS than others. This boy was not well conditioned when he began camp, his equipment (footwear) was faulty, and he pronated. His anatomy predisposed him to overload his posterior leg musculature, and his lack of conditioning contributed muscle weakness and lack of flexibility.

Treatment of MTSS is conservative. Running needs to be stopped for a short period, but alternative activities, such as swimming or use of a stationary bicycle, can be substituted. Additional treatment options include NSAIDs to reduce inflammation, orthoses to correct pronation, and exercises to strengthen the calf muscles.

 This patient's treament included all of these options. He began a 10-day course of ibuprofen, 600 mg tid. An orthosis was prescribed to correct his pronation. (He also obtained new shoes that had strong medial support.) He refrained from competitive basketball for 2 weeks and from weight-bearing exercise for 1 week. He used a stationary bicycle for 1 week; then he began to alternate walking/jogging with riding the stationary bike. The camp's trainer oversaw a program of gradually increasing activity. He did very well, and within 4 weeks had returned to full play.

Articles

Musculoskeletal Clinics: 16-Year-Old Camper With Tibial Pain

A 17-year-old boy with no history of foot problems decided to try some new moves with his skateboard on a steep ramp. Midway down the ramp, he tumbled head over heels and landed with most of his weight on his plantar-flexed right foot. He does not think he twisted his ankle. He felt fine until he tried to stand up. At this point he felt pain on the top of his right foot and could not bear weight on that foot.

Friends took him to the local emergency department. Standard radiographs revealed no fracture. The foot was immobilized with a soft cast, and he was advised to use crutches. The next day he noticed increasing pain and swelling in the injured foot.

Three days later, the patient sees his primary care physician because the pain and swelling have continued to worsen. Examination of the left foot reveals no abnormalities. Examination of the right foot (after cast removal) reveals significant swelling from the dorsum of the midfoot to the toes, with significant ecchymosis over the same area. Marked tenderness is noted over the second and first tarsometatarsal joints in the midfoot (

). Palpation reveals no tenderness on the plantar surface, lateral or medial malleolus, or fifth metatarsal head.

Pedal pulses are present, and the patient is able to dorsiflex his foot fully to 30 degrees against resistance (similar to the left foot). Active inversion and eversion of the ankle--both unresisted and against resistance--are uncomfortable but accomplished with ease. Plantar flexion is limited and painful, and the patient is unable to bear weight on his right foot without significant pain. No neurologic deficits are noted.

WHAT IS YOUR PRESUMPTIVE DIAGNOSISAT THIS POINT?

None of the 4 injuries proposed is a likely diagnosis. Lack of tenderness over the head of the fifth metatarsal on palpation makes a fifth metatarsal fracture (A) unlikely.

 An anterior talofibular ligament tear (lateral ankle sprain) (B) is usually associated with tenderness over the anterior portion of the lateral malleolus and a decreased ability to dorsiflex the foot.

 Moreover, both fifth metatarsal fractures and anterior talofibular ligament tears usually occur with inversion; this does not seem to have been the mechanism of injury in this case.

Rupture of the posterior tibial tendon (C) usually occurs with chronic tibial tendonitis rather than secondary to trauma; also, inversion of the ankle is not possible if the tendon is ruptured. This patient has no history of chronic foot problems and is able to invert his foot; thus, posterior tibial tendon rupture is not likely.

Acute navicular fractures (D) occur when eversion stress causes a bony avulsion of the medial deltoid ligaments from the navicular bone. Tenderness is located closer to the medial malleolus, over the navicular area--not over the dorsum as it is in this patient (

). Moreover, navicular fractures are usually evident on radiographs. This patient's films revealed no fractures.

WHICH OPTION IS MOST APPROPRIATE AT THIS POINT?

 Continue to treat the patient with crutches and avoidance of weight bearing for another2 weeks.

 Have him start a rehabilitation program with a physical therapist.

 Obtain non-weight-bearing radiographs of the right foot.

 Obtain weight-bearing radiographs of the right foot.

The lack of a diagnosis makes both continued conservative treatment (A) and starting rehabilitation (B) inappropriate. The patient may have a problem that is made worse by delaying specific treatment. Additional imaging studies are indicated to help with diagnosis.

A CT scan (E) is expensive and is best considered only if the less expensive plain films prove unhelpful. Because of this patient's initial statement that he first experienced pain with weight bearing and his continued difficulty with weight bearing, ordering weight-bearing films (

Anteroposterior (AP), lateral, and oblique weight-bearing radiographs are obtained; they reveal a 3- to 4-mm diastasis between the base of the first and second metatarsals. This is evidence of a Lisfranc joint injury.

 The Lisfranc joint is composed of the medial articulation of the first and second metatarsals with the medial (first) and middle (second) cuneiforms (

 The joint is named after a French field surgeon, Jacques Lisfranc, who described an amputation performed through this joint because of gangrene that had developed after a soldier fell off his horse and caught his foot in a stirrup.

The Lisfranc joint is susceptible to separation and dislocation dorsally because no intermetatarsal ligament runs between the bases of the first and second metatarsal (see 

). There are strong intermetatarsal ligaments between the bases of the second through fifth metatarsals that provide a significant amount of dorsal stability (see 

). A strong ligament (called the Lisfranc ligament) runs between the medial cuneiform and the base of the second metatarsal. This ligament, which runs in a plantar direction, stabilizes the second metatarsal in its mortise. However, the joint capsule and dorsal ligaments provide minimal--and the only--support on the dorsal surface of the Lisfranc joint. The bony architecture of this joint is the focal point that supports the entire tarsometatarsal articulation. Its anatomy constitutes a "weak link" that with stress is prone to injury.

 Lisfranc joint injury can occur as the result of a direct external force striking the foot or as the result of an indirect force being transmitted to a stationary foot. The indirect force can be the weight of the body, which produces a compression or rotary force. With the foot in extreme plantar flexion, a significant axial load in a downward direction displaces the second metatarsal at its base. This situation occurs in falls, in which the axial load may be 2 to 3 times body weight (depending on the height of the fall) and in automobile and motorcycle accidents, in which the velocity at the moment of impact may be great. 

The most common type of Lisfranc injury (type 1) is a sprain that results from a simple fall or a sports- related injury. Type 1 injuries are associated with pain and swelling but no instability or diastasis. Higher height or velocity injuries (types 2 and 3) produce more pain, swelling, and disability and are associated with diastasis (as seen in this patient) and fracture dislocations.

 Lisfranc joint injuries are rare and often misdiagnosed. Early diagnosis and proper treatment improve the chance of successful healing and reduce the likelihood of post-injury arthritis and difficulty in walking.

If you suspect Lisfranc joint injury, order radiographs that include weight-bearing AP, lateral, and oblique views of both feet so that you can compare the 2 sides. In a normal foot, a weight-bearing AP view shows the lateral margin of the first metatarsal base lined up with the lateral edge of the medial (first) cuneiform, and the medial margin of the second metatarsal base lined up with the medial edge of the middle (second) cuneiform; both the AP and oblique weight-bearing views in a normal foot show the medial border of the fourth metatarsal lined up with the medial border of the cuboid. If there is misalignment of these edges, suspect a Lisfranc joint injury. With significant misalignment between the metatarsals, a separation or diastasis may be evident, as in this case.

Look for the presence of small avulsed fragments ("fleck sign"), which are indications of ligamentous injury and probable joint disruption. Dislocation may be demonstrated on the lateral view by a "step off" of the second metatarsal. This indicates that the dorsal surface of the proximal second metatarsal is higher than the dorsal surface of the middle (second) cuneiform and is diagnostic of Lisfranc injury.

 Refer the patient to an orthopedic surgeon.

 Place a non-weight-bearing cast on the footfor 6 week

 Refer the patient to a physical therapist forrehabilitation.

Type 1 Lisfranc injuries can be treated with avoidance of weight bearing for 4 to 6 weeks, but type 2 and type 3 injuries require surgery. Treatment with a non-weight-bearing cast (C) would be acceptable if no diastasis were present on the radiograph. Because diastasis is present between the base of the first and second metatarsals, this patient has a type 2 injury and thus requires surgery (

A CT scan (A) may be helpful in diagnosing difficult cases of Lisfranc joint injury and in formulating a surgical treatment plan. However, the weight-bearing films provide sufficient information for those decisions a primary care physician is called on to make. The orthopedic surgeon will decide whether a CT scan will help with his management decisions. Although rehabilitation (D) is not indicated at this time, it will be of value postoperatively.

 Compartment syndrome and disruption of the dorsalis pedis artery are 2 complications to watch for in patients with Lisfranc joint injuries. Excessive swelling can lead to compartment syndrome. The dorsalis pedis artery is located near the Lisfranc joint, and joint disruption may compromise the artery. A bounding dorsalis pedis pulse and lack of neurologic deficit rule out both complications.

 The patient was treated surgically with open reduction and internal screw fixation and is now doing well.

 Shahady EJ, Paull W, Brotherton S. Foot pain that causes a runner to limp. 

 Shahady EJ, Paull W, Hemrajani R. Acute ankle pain in a runner. 

 Burroughs KE, Reimer CD, Fields KB. Lisfranc injury of the foot: a commonly missed diagnosis. 

 Mullen JE, O'Malley MJ. Sprains--residual instability of subtalar, Lisfranc joints, and turf toe. 

 Shahady EJ, Paull W, Bass D. Lower leg pain in a runner. 

A 17-year-old boy with no history of foot problems decided to try some new moves with his skateboard on a steep ramp. Midway down the ramp, he tumbled head over heels and landed with most of his weight on his plantar-flexed right foot.

Musculoskeletal Clinics: Foot Pain After Skateboarding Accident

A 12-year-old girl complains of left knee pain and swelling that resulted from a collision with another player while she was playing kickball the day before. Her left foot was planted as she tried to catch a ball, and she was hit on the outside of the left knee. She fell to the ground and was unable to walk on the injured leg; overnight, the knee became more swollen and painful.

Flexion of the left knee is limited to 60 degrees, and there is an extension lag of 10 degrees. Results of a Lachman test are negative, but application of valgus stress to the knee produces some medial laxity and increased pain. Examination of the right leg reveals 	normal extension (to 0 degrees), flexion to 	145 degrees, and no laxity or discomfort 	during a Lachman test or a valgus stress test.

What is your presumptive diagnosis at this point?

Swelling and the inability to bear weight indicate a significant injury, such as a fracture or a ligament tear. The mechanism of injury--being hit on the lateral side--is consistent with a medial collateral ligament tear; pain and laxity on examination make this diagnosis even more likely.

However, in a child of this age, the growth plate is weaker than the ligaments and will fracture before a ligament will tear. Thus, an 

) is the most likely diagnosis. A medial collateral ligament tear (C) would have been most likely in a child whose growth plates had closed--but that typically does not happen until at least age 16 years.

 The growth plate is divided into 3 layers:

The physis--the cartilaginous layer between the epiphysis and the metaphysis--represents the weakest biomechanical link in the growth plate and is the most susceptible to shear forces. Physeal injuries can completely disrupt the physeal blood supply, leading to premature closure of the physis and avascular necrosis of the epiphysis.

 About 15% to 30% of bone injuries in children involve the growth plate. The upper extremities are involved more commonly than the lower extremities. The distal radial physis is the site of one third of all growth plate injuries. The phalangeal physes are, collectively, the second most common site, followed closely by the distal tibial physis. Physeal injuries of the knee are rare, representing about 2% of all growth plate injuries; however, half of all growth arrests that require surgical correction result from physeal injuries of the knee.

The peak incidence of physeal injuries coincides with the rapid growth period of early adolescence; this occurs at about age 11 years in girls and at age 12 to 13 years in boys. The incidence of physeal injuries in boys is twice that in girls. The later closure of the physis in boys largely explains this disparity.

Physeal injuries can result from overuse as well as from acute trauma. For example, the excessive training that young gymnasts sometimes engage in can cause physeal overuse injuries. Repetitive, rapid, high-loading exercises--which may generate stress on the wrist equal to 3 times an athlete's body weight--can produce physeal changes and growth arrest in the distal radius.

) is required in every child in whom a growth plate injury is suspected. The Ottawa knee rule, which is used to help determine when knee radiographs are required in children (

), also indicates a need for radiographs in this patient. Two of the four conditions listed in the rule are present (she is unable to flex her knee beyond 90 degrees, and she cannot bear weight).

If a routine (nonstress) film reveals no suspicious findings, obtain a stress film to determine whether the physis opens with valgus stress. Although most physeal fractures are visible on both stress and nonstress films, those that involve only transphyseal separation produce no fracture lines and thus cannot be seen on nonstress radiographs. In this patient, a stress film would proba-bly demonstrate physeal opening, given the results of her valgus stress test.

Always obtain radiographs of the contralateral extremity; these can minimize confusion between normal physeal lines and fractures.

MRI, CT, and bone scanning have limited value in the assessment of growth plate injuries. The struggle involved in performing these studies in children without the use of sedation, their cost, the possibility of false-positive interpretations of results, and major discrepancies among the interpretations of different radiologists limit the usefulness of these studies in patients whose skeletal system is immature.

The patient's radiographs reveal a transphyseal separation with extension through the metaphysis.

The Salter-Harris classification system serves as a guide for both diagnosis and treatment of growth plate fractures. Salter-Harris type I injuries involve a purely transphyseal separation; no osseous fracture lines are visible. Type II fractures (

), the most common type of physeal injury, consist of transphyseal separation and extension through the metaphysis. This is the category of this patient's injury. Almost all Salter-Harris type I and type II fractures can be treated with closed reduction and immobilization.

Salter-Harris type III fractures involve a partial separation through the physis that extends through the epiphysis and beyond the joint surface. A type IV Salter-Harris fracture extends from the joint surface through the epiphysis and physis and into the metaphyseal bone. Salter-Harris type III and IV injuries require anatomic reduction. Salter-Harris type V fractures result from a crush injury of the epiphyseal plate and also require anatomic reduction. Radiographs obtained at the time of injury often appear normal in type V fractures.

Most physeal injuries in children heal without growth disturbance. However, significant growth disturbances occur in about 10% of such injuries. Thus, follow-up examinations are required to search for any signs of altered physeal growth. Almost all cases of growth arrest occur within 1 year of injury.

This patient is treated with immobilization for 4 weeks and does fairly well. There is no evidence of growth arrest after 1 year. Over the next 3 years, however, she begins to experience periodic swelling of her knee and a feeling that her knee is giving way. Eventually, she seeks medical attention for these symptoms. Examination reveals atrophy of the vastus medialis muscle of her left knee (

), positive results of a patellar push test (

), and positive results of a Lachman test (presence of a soft end point) (

). Results of the remainder of the knee examination are normal.

Which of these conditions are now in your differential?

A positive result on a Lachman test and periodic swelling are consistent with an anterior cruciate ligament tear (

). Vastus medialis atrophy, a positive result on a patellar push test, and a history of buckling can occur with patellar femoral tracking syndrome (

). Medial meniscus injury is a possibility even with examination results that are negative for this condition (

). Meniscal damage often develops in knees in which there is an injury of the anterior cruciate ligament, because of the excessive external rotation that occurs in this setting.

The growth plate is probably now closed, and there is no history of trauma. Thus, a new injury to the growth plate is unlikely. A medial collateral ligament tear is also unlikely without a history of recent valgus stress to the knee.

Because the patient's skeleton is now more mature (and because she is older and more likely to cooperate during the examination), MRI is a more reliable imaging modality than it was at the time of her earlier knee injury.

An MRI scan was obtained; it revealed a partial disruption of the anterior cruciate ligament and some disruption of the medial meniscus. This patient probably sustained both a physeal injury and an anterior cruciate injury initially. Results of her initial Lachman test were negative, but that is not unusual the day after an injury. Within 1 to 2 hours of an injury, the hamstring spasm stabilizes the forward location of the tibia, giving the false impression that the anterior cruciate ligament is intact. The excessive swelling she initially experienced also suggested an anterior cruciate ligament injury. Physeal fractures alone do not usually produce that much swelling.

 The presence of a growth plate fracture does not rule out concomitant ligamentous injury. To detect such injuries, follow-up examination is important. Ligamentous injury will usually become evident within 3 to 4 months of the initial trauma if the clinician is alert to the possibility. The significant swelling that this patient initially experienced is more common with an accompanying anterior cruciate ligament injury than with a growth plate injury alone. Thus, in her case, evaluation for a possible anterior cruciate strain or tear would have been especially important. However, this may not have been done because, in the past, this type of injury was thought to be less likely than a simple growth plate fracture and was commonly missed.

 monitored 30 children with growth plate injuries and found that 14 had evidence of ligament instability. Eleven had anterior cruciate ligament laxity, and 5 had medial collateral ligament laxity. Thus, it is important to maintain a high index of suspicion for coexisting ligamentous injury in all children with physeal injuries of the knee. Periodic follow-up with reexamination of the knee is the most efficient way to discover a ligamentous injury accompanying a growth plate injury.

 Dorizas JA, Stanitski CL. Anterior cruciate ligament injury in the skeletally immature. 

 Stiell IG, Wells GA, McDowell I, et al. Use of radiography in acute knee injuries: need for clinical decision rules. 

 Bulloch B. Validation of the Ottawa Knee Rule in children: a multicenter study. 

 Perron D, Miller M, Brady W. Orthopedic pitfalls in the ED: pediatric growth plate injuries. 

Author | Willis Paull, PhD

Articles

Musculoskeletal Clinics: 16-Year-Old Camper With Tibial Pain

Musculoskeletal Clinics: Foot Pain After Skateboarding Accident

Musculoskeletal Clinics: 12-Year-Old With Knee Pain From Kickball Injury