50 YO Male with 4 Months History of Right Proximal Fibular Pain

Abstract

HISTORY: A 50 yo white male referred from the ER with 2 months history of insidious onset localized sharp pain over the proximal lateral lower right leg. He first felt the pain after working with a shovel for about 4 hours in his garden. No direct trauma. Pain is present during rest and walking. Prevents him from sleep at night. No complaint of back pain. No radiation distally. Aggravated by weight bearing, and direct pressure over the painful area. He visited the ER twice, one month apart. Had negative X-rays, and minimal improvement with NSAIDS. Recently had increasesd numbness on the dorsum of foot. Denied any fever, chills, nausea, or weight loss. PMH of back surgery 1990, multiple oral and dental abscesses, and a recent abscess behind the ear that drained extensively. EXAMINATION: FROM of knee, hip and ankle. No effusion of knee or ankle, no soft tissue swelling. 5/5 strength testing bilaterally and no pain with isometric testing of knee flexion or extension; Ankle plantar flex ion, dorsiflexion, eversion or inversion. Sensation to fine touch was intact and equal bilaterally on leg, foot, first and second web spaces. (-) Tinel's over the peroneal nerve. +2 pulses. He was apprehensive when an attempt we examined the painful area. (+) Tenderness over an area about 1 cm on the fibula starting about 2 inches distally from the proximal end. (-) Tenderness on medial and lateral joint lines. No palpable mass or deformity. Negative straight leg raise test, lachman, McMurray, varus and valgus laxity. Fibular subluxation with knee flexion, and with walking which reproduces discomfort. Manually subluxing the fibula causes the pain shooting distally. Left fibula exam was normal. DIFFERENTIAL DIAGNOSIS: Fibular fracture. Proximal tibiofibular instability. Peroneal nerve entrapment. Osteomyleitis of proximal fibula. TESTS & RESULTS: CBC, ESR WNL. Xrays revealed no fracture or periosteal changes to suggest osteomyletis or tumor. MRI of the knee was negative. (-) Venous Doppler study for DVT. Normal velocity of peroneal nerve on conduction study above and below the fibular head, and (-) EMG. FINAL WORKING DIAGNOSIS: Right Proximal tibiofibular instability with Chronic Subluxing Fibular head. TREATMENTS: Ace wrap & crutches was given in ER with inadequate relief. Patient received a custom made brace to help hold the fibular head in place which initially relieved his discomfort almost completely. A week later it stopped working and patient was back to pain medications. Cylinder cast with strapping was tried aiming at 3 weeks application, however, the patient developed peroneal nerve dysesthesias and the cast was discontinued. The patient was referred for a ligament reconstructive procedure.