January 14, 2020 at 6:28 pm #8300lacarrollParticipant
Hey everybody! I had an interesting eval last week during residency that was something I hadn’t come across before, so I thought I would share the case and get some feedback/thoughts from y’all.
– 18 yo female collegiate rower with L distal tibia/medial ankle pain that started around late November 2019; no MOI, just increasing symptoms
– Aggs: running, biking, rowing, erging, plyometric activities, walking
– Eases: rest, Advil
– Immobilized in walking boot for 6 weeks –> seemed to increase her pain
o (-) for stress fracture
o (+) for “Eccentric, well-circumscribed to lucent lesion with sclerotic margins in the lateral aspect of the distal tibial diaphysis, consistent with a non-ossifying fibroma”
– Increased pronation of L rearfoot/midfoot in standing, decreased arch height on L foot; increased L foot pronation with B and SL squat
– P! with:
o Single leg heel raise, single leg hop, percussion on medial distal tibia, palpation of posterior medial malleolus along Post tib tendon, palpation along post tib into muscle belly area
I came to the conclusion that she most likely has posterior tibialis tendinopathy during the course of the eval, but the presence of the non-ossifying fibroma in her distal tibia really threw me off during the subjective portion. Do you guys have any experience with a similar situation with a space occupying lesion like that in the region of pain? Or would y’all have asked other questions/looked at other tests to help you feel more confident in your diagnosis? I’m attaching a couple of articles I found afterwards that helped me understand this condition a little bit better and what it may mean going forward with treatment.
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January 18, 2020 at 10:57 am #8309helenrshepParticipant
Interesting case, Lauren! I don’t have any experience with NOF in patients. I think it’s good her sport is low impact, and I would maybe limit the amount of impact exercises I gave her just since there is an increased risk of fracture.
Other questions – how big is the NOF? Any idea how long it’s been there? (wondering if it’s new and therefore more related to her current symptoms, or it’s been there for years so it’s possible for her to be asymptomatic) Do you know the stage of lesion?
I’d want to know more about the aggravating factors – I feel like there’s no way her symptoms are the exact same degree/location of aggravation with both biking and running. If so, it’s not a weight bearing/load sensitivity issue I suppose. Specific to rowing – which part of the motion is bothersome? On the erg, is the forward position with increased dorsiflexion or pushing back or another part? I think getting more details on what part of the activities are aggravating and in what way would be helpful. And how much rest is needed for symptoms to subside?
Did you test resisted inversion? And what about neural tension in the medial ankle like a SLR with a tibial nerve bias?
Hope some of that is helpful! Good luck!
January 19, 2020 at 10:20 pm #8314breynoldsParticipant
Very interesting, I have yet to encounter a case similar to this that I know of.
Along the same lines as Helen, I would have asked a little more about the aggravating factors:
-Does time of day affect her symptoms?
-how long it took for symptoms to increase for each activity and
-how long for the symptoms to dissipate once she was resting.
-In the article it states that there are stages of the NOF, so I wonder which stage hers is as some of the stages are more prone to fx. It seems from the description that it is less likely stage A and probably late stage B or stage C.
-Was the imaging taken prior to or after being immobilized?
-I am sure you tested it but are there any changes with strength, motion, etc?
-Has she ever had a previous injury of the leg or any imaging of the leg before?
-Was the pain always localized to the medial aspect of the tibia or has the pain moved around (I only wonder because of the location of the NOF, could she have been compensating because of pain and then then the medial symptoms arose)?
If all things point towards posterior tibialis tendinopathy and there are impairments to address, I would focus on those and keep the NOF in consideration when creating the program and tailor it towards the patient and how she presents to you.
Good luck and thanks for sharing, hopefully this was somewhat helpful
January 20, 2020 at 7:18 pm #8318awilson12Participant
My only experience with a bony lesion was in a younger male with an osteoid osteoma near his femoral neck. His main complaint was severe night pain (he already had an ortho appointment lined up for a few days later so that made it easy to refer out), but he also had some myofascial contributions and patterns of hip weakness that were consistent with an overuse injury. Me and my CI ended up treating him some to get him back to prior level of activity and they were exploring if any further steps were needed to address the osteoma (it was super small).
A few questions for you about this patient-
Any increase or change in activity leading up to the onset of symptoms?
What is her level of understanding about non-ossifying fibromas and her affect/outlook on this?
More out of curiosity…
1) Did y’all have any theories on why the boot increased symptoms?
2) What did your education look like day 1, and does reading these articles and being more familiar with the diagnosis change education in future visits?
January 24, 2020 at 10:01 am #8325lacarrollParticipant
These are some great questions/points!
Helen: We aren’t very sure how long it’s been there, she just recently had imaging (12/19/2019), but it is a smaller lesion (5 x 4 x 12 mm) with no cortical breakthrough or increased bone marrow signal on the imaging. As far as the official stage, there is no mention of that in the imaging report. As far as aggravating factors, running > erging > biking. So all three were aggravating, but running and plyometric activities were the most aggravating. With erging, I don’t think she was very certain about the part that was painful, so that didn’t help much, but I also didn’t do a good job of clarifying. I did test resisted/passive ankle motions, but none of them reproduced her symptoms which was a little weird. I did not test SLR with the tibial bias, but that’s a good idea.
Brandon: Symptoms were worse with/after activities, not really time specific. Her symptoms would typically resolve after resting or by the next morning when we saw her. And again, I’m not 100% sure about the staging and where she fell based on my limited knowledge. Imaging was taken after 6 weeks immobilization. No previous injuries/imaging prior to this incident. Pain has always been over medial aspect of lower leg.
Anna: No real change in activity other than she was in the middle of her season when the pain started, and we were seeing her after the end of the season. She couldn’t really pinpoint any changes in activity leading up to the onset of pain. She was aware of the lesion, but was very concerned that she was still having pain in the area and was more concerned about making it worse with returning to her normal activities. As far as the boot, we weren’t really sure why that seemed to increase symptoms honestly. Have any good thoughts on that? She was interesting because I only saw her for the evaluation. We educated her on a return to activity progression, but we also put a rearfoot wedge in her L shoe which immediately helped her foot posture. As far as therex, we did some foot intrinsic strengthening and SL balance/strengthening activities for her to progress to since she would only have the 1 visit.
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