Diagnosing And Treating Distal Tibia Epiphysitis
- Volume 27 - Issue 9 - September 2014
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Mindful of the common presentation of growth plate injuries, these authors present insights on the diagnosis and treatment of a 12-year-old soccer player who presented with pain in the distal tibia.
Growth plate injuries in children are among the most common foot and ankle injuries that present to a foot specialist’s office. These patients are often athletes and may or may not have a traumatic accident associated with the injury. When an adolescent or teenager develops ankle pain, it is often a repetitive overuse type injury.
Ankle injuries in children may result in a fracture, osteochondral injury or sprain if trauma is involved but more commonly, children develop an injury to their growth plate or epiphysis. The distal tibia epiphysis becomes more active at the age of 12 to 14 in boys and 10 to 12 in girls.1 The distal tibia growth plate completely matures at the age of 17 to 18.2 Children who are active in soccer, baseball and football may be more predisposed to overuse injuries in the distal tibia due to the lack of support and firmness of their cleats.
The purpose of this case study is to describe a common ankle injury that we often misdiagnose and to explain treatment protocols that may be very helpful to the treating practitioner.
A Closer Look At The Patient Presentation
A 12-year-old boy presented to the office with a chief complaint of severe right ankle pain. The soccer player first noticed the pain after a game three weeks prior to his office visit. He says he may have taken a “bad step” on the grass while running toward a ball. It did not affect his play at the time but he was limping after the game. The patient described the pain as aching and throbbing, and rated the pain at 6/10 on a 10-point pain scale. Home treatment included ice and rest but the pain continued to persist.
The physical exam revealed mild edema to the anteromedial aspect of the ankle joint with severe pain on palpation over the anteromedial aspect of the distal tibia epiphysis. There was mild pain with range of motion of the ankle joint and no pain with inversion or eversion of the foot. There was pain with palpation along the distal aspect of the Achilles tendon at its insertion, which extended 2 to 3 cm proximally with the knee in a flexed and extended position. The neurovascular status was intact. No gross deformities were present.
The biomechanical exam revealed an abnormal subtalar joint axis (too medially deviated). Bilateral ankle joint dorsiflexion was 10 degrees with the knee extended and 15 degrees with the knee flexed. The resting calcaneal stance position was moderately pronated (6 to 10 degrees of eversion) and the neutral calcaneal stance position was perpendicular bilaterally.
Plain films revealed an open distal tibia epiphysis and no signs of fracture or neoplasm. The patient was non-weightbearing with crutches in a pneumatic below knee controlled ankle motion (CAM) walker. We recommended ice and Aleve bid. The pain resolved after four weeks of immobilization. We cast him for custom functional foot orthotics to help control the abnormal pronation and prevent recurrence. He returned to playing soccer without limitations six weeks later. After two years of follow-up, he did not develop a recurrence.