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Sports M edicine Clinic

Sports M edicine 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

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Sports M edicine Clinic

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  1. Sports Medicine Clinic

  2. Presentation • 10 year old lacrosse player • Presented at clinic with right hind foot pain • Begin abruptly after lacrosse practice 3 weeks ago

  3. 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

  4. No relief Ice Motrin Gel heel cups crutches

  5. What is your ddx?

  6. 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

  7. How would you do the examination?

  8. 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

  9. What are the tests for ankle instability?

  10. Tests • Full rom • No instability with anterior drawer or talar tilt test • Antalgic on right

  11. What did you miss?

  12. 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

  13. Would you order Labs?

  14. lab • CBC • Sedrate • C-reactive protein

  15. 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

  16. What is your ddx?

  17. Osteoid or osteomyelitis • No linear component to suggest stress response or fracture

  18. Who would you consult?

  19. Consultations • Foot and ankle specialist • Ortho oncologist

  20. 5 weeks after symptoms started • Low-grade temp and chills • Clinical exam unchanged • Higher suspicion of osteomyelitis

  21. What would you do?

  22. Open biopsy with frozen sections • Excision of the lesion

  23. Dx Osteomyelitis

  24. What is the most common organism?

  25. Staph MRSA

  26. What is the most common organism in puncture wounds?

  27. pathology • Clindamycin 3 weeks of IV followed by 3 weeks of oral • 7 weeks back to normal

  28. osteomyelits • Pseudomonas aeruginous is the most common in puncture related cases

  29. Local • Hematogenousspread • Common in newborns heel prick for blood

  30. Increase MRSA in Sports

  31. No imaging study is 100 % dx of osteomyelitis

  32. What is the most important in care of osteomyelitis?

  33. Early dx • Isolation of the microorganism

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

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

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