Left Leg Pain- Basketball

Abstract

HISTORY: 21 yo male collegiate basketball player presents to the team physician with complaints of anterior left leg pain for 1 month. One week into his pain he states he noticed an area of swelling on his shin. He experiences pain only when jumping and landing in basketball. He is pain free with jogging, weightlifting and daily activities. He denies tingling or numbness in foot. PHYSICAL EXAMINATION: Muscular African-American male. Tenderness and palpable area of induration over the anteromedial cortex of his left tibia. Mild pain with fulcrum test. Negative tuning fork test. Neurovascularly intact distally. DIFFERENTIAL DIAGNOSIS: 1.Stress fracture 2.Medial tibial stress syndrome 3.Chronic exertional compartment syndrome 4.Neoplasia: osteosarcoma TESTS AND RESULTS: X-ray: Periosteal elevation over anterior cortex of left tibia with a faint linear lucency extending perpendicularly MRI: Incomplete transverse stress fracture of the anterior mid-tibial diaphysis Vitamin D 25-OH total: 10 mg/ml (30-100 nl) Calcium, intact PTH: normal FINAL WORKING DIAGNOSES: 1) Anterior cortex tibial stress fracture, 2) Vitamin D Deficiency TREATMENT: 1.Player treated conservatively; non-weight-bearing to tall pneumatic brace to gradual return to play over four months. Started Vitamin D replacement-50,000 units twice weekly × 2 months, then maintenance dose. 2.One month after full return player admits a gradual return of pain. Re-imaging shows persistent radiolucent line. Vitamin D level is still deficient, player admits poor compliance. Player shut down for 2 weeks, bone stimulator, then gradual return to play. 3.Six months from initial presentation, pain and fracture line persist. Sent to surgeon, lateral compression plate surgically placed. FOLLOW UP: Patient was aggressively rehabbed and back in practice 8 weeks out from surgery when he jumped off his left leg, heard a crack, and fell. Player incurred comminuted tibia-fibula fractures at level of plate. Player underwent a second surgery with intramedullary nail placement in left tibia. Vitamin D levels remained slightly deficient, again due to poor compliance. At this time, the player is taking Vitamin D under direct observation in the training room. He is finishing rehabilitation and has returned to sport.