Ten Years of Lower Leg Pain

Abstract

HISTORY: Ten years ago, a 21 year-old healthy college student who was active in cycling and running presented to another physician with three months of left leg pain. He described it as a constant pressure localized to the proximal posterior calf with radiation to the posterior lateral calf and foot. The pain worsened with vigorous activity and ankle plantar-flexion. X-rays were normal. Given his regular involvement in intense physical activity and the chronicity of his pain, the preliminary diagnosis of gastrocnemius strain was made. He had symptomatic improvement with four weeks of biweekly physical therapy. Ten years later, he presented to us with continued intermittent left lower extremity pain. PHYSICAL EXAMINATION: Left lower extremity examination demonstrates tenderness over the left anterior and lateral aspects of the proximal calf. Thompson's Test produced diffuse calf pain. The left knee and ankle have full range of motion, normal strength, and normal ligamentous stability. Normal gait, reflexes, and sensation, with 2+ pedal pulses and negative Homan's sign. DIFFERENTIAL DIAGNOSIS: Left gastrocnemius or peroneus longus strain Chronic exertional compartment syndrome Stress fracture Mass / Tumor TESTS AND RESULTS: X-Ray (2009): Subtle areas of cortical thickening of the mid-tibia and fibula. Small enchondroma in the mid-fibular shaft. Six weeks of physical therapy with only mild improvement. An MRI was ordered for further evaluation. MRI (2009): Multi-loculated high T2 signal lesion within the tibialis posterior muscle compatible with a hemangioma. It does not extend into adjacent muscles but abuts the tibial nerve and posterior tibial artery. Small areas of high T1 signal within the muscle consistent with blood. Chronic cortical thickening of the adjacent tibia. FINAL WORKING DIAGONSIS: Symptomatic hemangioma of the tibialis posterior muscle TREATMENT AND OUTCOMES: Orthopedic Oncology was consulted and surgical options discussed. Due to potential surgical complications, initial treatment is activity modification, avoiding vigorous exercise, and conservative management. If unsuccessful, surgical intervention will be considered. Follow-up scheduled in 6 months with repeat MRI.