Sports Medicine Clinic

Presentation

• 10 year old lacrosse player

• Presented at clinic with right hind foot pain

• Begin abruptly after lacrosse practice 3 weeks ago

• Pain was diffuse around the heel and present in the region of the right ankle

• Symptoms have increased over the last three weeks

• Worse with weight bearing

No relief

Ice

Motrin

Gel heel cups

crutches

What is your ddx?

DDX of aldoscence heel pain

• Calcaneal apophysitis (severs disease)• Calcaneal stress reaction or stress fx• Retro-calcaneus bursitis• Achilles tendinopathy• Reactive arthritis (Reiter syndrome)• Bone tumor• osteomyeltis

How would you do the examination?

Exam

• NAD• Mild swelling• Moderate tenderness at the lateral ankle• Pain on squeezing the calcaneal • No rubor or calor in the foot or ankle• Capillary refill was normal• No strength or sensory deficits

What are the tests for ankle instability?

Tests

• Full rom

• No instability with anterior drawer or talar tilt test

• Antalgic on right

What did you miss?

Medical history

• Soft tissue infection right forefoot after a cut on the chain link fence approximately 2 months before the heel pain

• Rx with oral cephalexin 1 g x 10 days• Complete resolution of activities and was able

to return to full activities within one week of infection

• No chills, fever, or other systemic symptoms

Would you order Labs?

lab

• CBC

• Sed rate

• C-reactive protein

X-rays

• Foot and ankle – mild swelling over the lateral malleolus otherwise normal for her age

• MRI – patchy increase t2 and decrease t1 within the calcaneus

• CT - lytic lesion surrounded by sclerosis in the posterior aspect of the calcaneus

What is your ddx?

• Osteoid or osteomyelitis

• No linear component to suggest stress response or fracture

Who would you consult?

Consultations

• Foot and ankle specialist

• Ortho oncologist

5 weeks after symptoms started

• Low-grade temp and chills

• Clinical exam unchanged

• Higher suspicion of osteomyelitis

What would you do?

• Open biopsy with frozen sections

• Excision of the lesion

Dx

Osteomyelitis

What is the most common organism?

Staph MRSA

What is the most common organism in puncture wounds?

pathology

• Clindamycin 3 weeks of IV followed by 3 weeks of oral

• 7 weeks back to normal

osteomyelits

• Pseudomonas aeruginous is the most common in puncture related cases

• Local

• Hematogenous spread

• Common in newborns heel prick for blood

Increase MRSA in Sports

No imaging study is 100 % dx of osteomyelitis

What is the most important in care of osteomyelitis?

• Early dx

• Isolation of the microorganism

Summary

• Non musculoskeletal dx• Atraumatic musculoskeletal symptoms• Osteo can be present without fever or chills• Imaging studies may be misleading• Early dx and tx are keys to successful

outcomes

What is the most important lesson to learn from this presentation?