Pediatric Unilateral Lower Leg Pain - Cross Country

Abstract

HISTORY: A 13 year-old male presented with gradually worsening unilateral lower leg pain for 3 weeks. Pain was located on the right, slightly distal and lateral to the knee. Pain worsened with running and pivoting activities, and eventually walking caused pain. He became a member of the cross country team with no distance running prior to the season's start, but does play basketball. Pain began 1-2 weeks after the start of cross country. He denied the following: specific injury, knee complaints, fevers, numbness, tingling, and weakness. Family history is negative for bone and musculoskeletal problems. PHYSICAL EXAMINATION: Exam revealed a well appearing thin male with a normal gait. No bruising, effusion, or swelling at or around the knee. There was tenderness to palpation over proximal right fibula. Knee exam revealed no tenderness, normal testing of ligaments, special tests, and patella. Examination of the hip, foot/ ankle, distal strength, sensation, and pulses were all normal. DIFFERENTIAL DIAGNOSIS: Proximal fibular stress fracture Peroneal muscle strain Iliotibial band syndrome Tumor TESTS AND RESULTS: Tibia/Fibula Radiographs, 2 Views: - open growth plates and vague sclerosis of proximal diaphysis of the fibula, without distinct fracture line. MRI of tibia/fibula was obtained at 2 week follow-up: -complete nondisplaced transverse fracture of the proximal fibula with reactive marrow edema and periosteal reaction. FINAL WORKING DIAGNOSIS: Proximal fibular stress fracture. TREATMENT AND OUTCOMES: Originally treated with avoiding any painful activities. At 2 week follow-up pain was worse and present with any weight bearing. Treatment of strict non-weight bearing with cast boot for 2 weeks was instituted, followed by gradually increasing weight bearing and activity. Follow-up at 4 weeks showed a palpable bony callus of the proximal fibula. No pain with walking, so cast boot was removed and activity was advanced. Repeat radiographs showed healing callus without displacement. 7 weeks after original visit, he was pain free and had returned to running without recurrence of pain.