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Age / Sex : 35 / M
C.C.: Chronic pain in right lower leg (runner)
1) What is your impression?
Courtesy : Jong Kyu Han, MD., Soonchunhyang University College of Medicine
Diagnosis: medial tibial stress SD
Discussion
Findings:
- negative finding on radiography
- radionuclide activity in the distal tibial shaft of right leg on bone scan
- MR findings show bone marrow and surroung soft tissue edema in direct contact with medial tibial cortex with anteromedial to posteromedial extension
Differential diagnosis :
Stress fracture of the tibia, Deep vein thrombosis, Gastrocnemius-Soleus strain, Cellulitis, Osteomyelitis
Discussion:
Although the highest incidence of Medial tibial stress syndrome(MTSS) occurs in runners, MTSS also may developed in athletes involved in jumping sports, such as basketall, tennis, and volleyball. A typical clinical presentation of this condition involves pain, palpable tenderness, and , in rare cases, swelling. Pain associated with MTSS frequently presents as a recurring dull ache over the distal one-third posteromedial cortex of the tibia. During the early development of this condition, patients may experience pain at the beginning of a workout or run, which may be relieved with continued activity, only to recur at the conclusion of the activity. Pain caused by MTSS usually is alleviated with rest and typically does not occur at night. However, as this syndrome progresses, pain often may ensue throughout training or during low activity and also may continue at rest. The physical examination should confirm the presence of pain along the medial border of the distal tibia. Palpable tenderness along the posteromedial edge of the distal one third of the tibia is the most common physical finding in MTSS. Radiographs and 3-phase bone scans are recommended to differentiate between MTSS and other causes of chronic leg pain, such as stress fractures. Although radiolographs of the leg typically produce negative results in patients with MTSS, the films should be obtained to exclude abnormalities associated with other conditions, including stress fractures and tumors. A bone scan result demonstrating a longitudinal uptake pattern along the distal one third of the tibia is indicative of MTSS. The best diagnostic clue of MR imagings are hyperintense edema and fluid signal at medial tibial border on T2WI. Linear hyperintense periosteal edema/fluid in direct contact with meidal tibial cortex which shows anteromedial to posteromedial extension. Hyperintense edema/fluid extends to origin of soleus posteromedially(Soleus bridge).
Grading – Grade I : periosteal edema(T2WI), Grade II : Periosteal and marrow edema(T2WI), Grade III : Marrow edema(T1 and T2WI), Grade IV : fracture line
References:
1. Edwards PH, Wright ML, Hartman JF. A practical approach for the differential diagnosis of chronic leg pain in the athlete. Am J Sport Med 2005;33:1241-9
2. Mattila KT, Komu ME, Dahlstrom S, Koskinen SK, Heikkila J. Medial tibial pain: a dynamic contrast-enhanced MRI study. Magn Reson Imaging. 1999;17(7):947-54
3. Stoller DW, Tirman PFJ, Bredella MA. Diagnostic imaging Orthopaedics. A medial reference publishing company. 2004, 6-98-101
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