Overuse Injuries of the Lower Extremities: Keys to Diagnosis

Overuse injuries of the lower extremities are common occurrences for competitive athletes or patients who are starting new workout regimens. Magnetic resonance imaging (MRI) showed this patient’s calcaneal stress fracture (arrow), a common injury in military recruits and runners. Any disruption in training can have a serious impact on quality of life, so it is important to promptly identify the root cause of overuse injuries. Fortunately, most of these injuries can be diagnosed on clinical grounds supplemented with simple imaging studies. Can you correctly diagnose these cases?

This 35-year-old woman complains of forefoot pain that started at the end of a week-long hiking trip. Her radiograph is shown.

Which of the following choices best describes the radiograph findings?
A. Abnormal deviation of the great toe or hallux valgus
B. Tumor (either benign or malignant) at the neck of second metatarsal
C. Metatarsal stress fracture
D. Fragmentation and reactive changes at neck of the second metatarsal due to osteomyelitis or neuroarthropathy
E. No abnormality is shown on radiograph

Answer: C. Metatarsal stress fracture

The patient’s history is suggestive of a repetitive stress injury. The radiographic findings of a transverse fracture with abundant new bone formation (arrows) support the diagnosis of stress fracture. A tumor or infection would have a different history and radiographs would show destruction or expansion of bone with an abrupt transition. Charcot arthropathy involves the joint with fragmentation of bone; also, there would be a history of an underlying condition and peripheral neuropathy, usually due to diabetes.

March fractures (shown here on bone scan) are stress fractures in the metatarsals that were first described in soldiers. With heightened physical activity and prolonged cyclical submaximal loading, bone is resorbed faster than it can be replaced. Radiographs appear normal initially, but they can show periosteal reaction with callus by 3-6 weeks. Bone scans may show focal uptake in as little as 48-72 hours. Hormonal imbalance and vitamin D deficiency should be investigated. Management involves rest from the offending activity and cross-training in low-impact sports, with weight bearing as tolerated in a rigid-soled shoe. A short-leg cast for 4-6 weeks is an alternative for patients with severe pain or limp. Image courtesy of Radiopaedia.org.

A 25-year-old male athlete (shown) complains of insidious pain in the back of his lower leg. He has tenderness on palpation of the Achilles tendon. He is able to actively go up on his toes on both sides.

What is the most likely diagnosis?
A. Achilles tendon rupture
B. Insertional Achilles tendinitis
C. Haglund’s deformity
D. Noninsertional Achilles tendinitis
E. Painful os trigonum or flexor hallucis longus tendinitis

Answer: D. Noninsertional Achilles tendinitis

The fusiform swelling in the tendon is proximal to its insertion (arrow). Haglund’s deformity and insertional Achilles tendinitis present with pain and tenderness at the Achilles tendon insertion. If the Achilles tendon was ruptured, the patient would not be able to go up on his toes and the tendon contour would not be well defined. Patients with painful os trigonum or flexor hallucis longus tendinitis have tenderness deeper to the Achilles tendon; in this case, pain would be exacerbated with acute plantar flexion at ankle and resisted plantar flexion of interphalangeal joint of the great toe.

This T2-weighted MRI of the ankle is from a patient with noninsertional Achilles tendinitis. The clinical features of noninsertional Achilles tendinitis are morning pain, activity pain, diffuse edema, crepitations, and tender fusiform swelling. Patients typically have limited ankle dorsiflexion. There is relative avascularity in the Achilles tendon approximately 2-6 cm proximal from the insertion on the calcaneus. The fibers spiral 90 degrees, with the medial fibers becoming more posterior. On the MRI shown, which letter points to the diagnostic abnormality?

Answer: B. The arrow is pointing to edema within the Achilles tendon.

MRI is the best imaging modality for the evaluation of Achilles tendinopathy. Management involves control of inflammation and/or correction of any predisposing factors such as training errors, limb malalignment, or gastrocnemius contracture. Physical therapy options include eccentric stretching exercises, heat, ultrasound electric or laser photo stimulation, massage, and taping. Surgery in recalcitrant cases involves removal of degenerated tendon and (if necessary) augmentation or reconstruction with the flexor hallucis longus tendon.

A 20-year-old man started training for a marathon and presents with insidious onset of pain and swelling under the first metatarsal head with tenderness localized over the sesamoids. There is a normal range of motion.

What is the most likely clinical diagnosis?
A. Turf toe
B. Abscess under sesamoids
C. Sesamoiditis
D. Hallux rigidus
E. Gout

Answer: C. Sesamoiditis

Sesamoiditis (shown) presents with pain and swelling under the first metatarsal head and tenderness localized over the sesamoids. There may be an associated foot deformity, such as a cavus foot. Plain radiographs may show fragmentation. Management involves rest from offending activities and pressure relief with pads or molded shoe inserts. The other options have different clinical features. Turf toe is an acute traumatic event due to great toe hyperextension. An abscess is associated with fever, throbbing pain, and spreading cellulitis. Hallux rigidus is associated with dorsal osteophytes and limited range of motion. Gout usually occurs in middle-aged individuals with pain and tenderness around the metatarsophalangeal joint. Image courtesy of Radiopaedia.org.

Thickness (<8 mm) of the plantar fascia (arrow) with edema in the fascia and surrounding soft tissues are diagnostic of plantar fasciitis. Plantar fasciitis is the most common cause of heel pain in runners and accounts for 10% of running-related injuries. Thought to be caused by repetitive microtrauma to the fibrous ligament at the base of the foot, an inflamed plantar fascia can cause severe pain when walking or running. Treatment of plantar fasciitis begins with rest, icing, and anti-inflammatory medications.

A 23-year-old man increased his running distance from 2 miles to 20 miles about a week ago. He had localized pain that worsened with impact activity and point tenderness over the tibia at the junction of the middle and lower third of the tibia. His radiograph is shown. Image courtesy of the World Journal of Orthopedics.^[1]

What is the most appropriate statement?
A. Stress fracture is unlikely because radiographs are normal.
B. Stress fracture is still likely even though the radiograph is normal.
C. A bone scan is likely to be normal at this stage.
D. The radiograph shows abnormally thick cortex in the middle third of the tibia.
E. The radiograph was not necessary because the patient has compartment syndrome.

Answer: B. Stress fracture is still likely even though the radiograph is normal.

Although the radiograph is normal, it is the appropriate first-line modality to rule out any other pathology. A subsequent bone scan showed bilateral stress fractures (arrows). History of overuse, localized pain, and point tenderness over the tibia suggests the diagnosis. With compartment syndrome, pain usually occurs after a period of activity and is diffuse in the involved compartment, resolves with rest, and is not associated with localized point tenderness over bone. Management of tibial stress fractures requires rest from offending activities and cross training. Resistant cases require surgical intervention, such as intramedullary nailing or plating and bone grafting. Image courtesy of the World Journal of Orthopedics.^[1]

A 10-year-old girl started gymnastics classes 4 weeks ago. She points to an area of pain (shown). On examination, she has tenderness over the lower pole of the patella. She has active grade 5/5 extension at the knee and no tenderness at the tibial tubercle.

What is the most likely diagnosis?
A. Jumper's knee (patellar tendonitis)
B. Quadriceps tendon rupture
C. Patellar fracture
D. Osgood-Schlatter disease
E. Patellar tendon rupture

Answer: A. Jumper's knee (patellar tendonitis)

The MRI showed thickened high-signal patella tendon, particularly in the deep and proximal fibers, consistent with jumper's knee. Jumper's knee (also known as patellar tendonitis or patellar tendinopathy) is an overuse injury occurring after constant jumping, landing, and changing direction, which can cause strains, tears, and damage to the patellar tendon. Quadriceps/patellar tendon rupture and patellar fracture are unlikely because the patient has active grade 5/5 extension. Osgood-Schlatter disease is associated with tenderness over the tibial tubercle, which is distal to the site indicated by the patient. Image courtesy of Radiopaedia.org.

On ultrasound, tendinosis may manifest with thickening and hypervascularity (shown). Management involves rest or adapting a training regimen that greatly reduces any jumping or impact. Ice and nonsteroidal anti-inflammatory drugs help to reduce pain and inflammation. Wearing a knee support or strap can help minimize pain and relieve strain on the patellar tendon. Surgery for persistent pain involves removing the damaged portion of the patellar tendon, removing inflammatory tissue, and making small cuts on the sides of the patellar tendon to relieve pressure from the middle area. Image courtesy of Radiopaedia.org.

Patellofemoral syndrome (runner’s knee) is similar to jumper’s knee except it occurs in an older patient population (40-60 years). It is the most common overuse injury among runners and can result in pain under or around the patella, as well as a grating or grinding sensation during extension of the knee. It is caused by overuse, trauma, or an abnormal alignment of the patella and femur, causing damage to the underlying cartilage and resulting in irregularities, fissuring (arrows), and marked thinning of patellar cartilage. Conservative management concentrating on improving strength and flexibility deficits while controlling symptoms with rest, ice, and anti-inflammatories is successful in 80% of cases.

A man presents to orthopedic clinic with refractory lateral knee pain. He had been diagnosed with iliotibial band syndrome and on examination is noted to have a very prominent iliotibial band (shown). Conservative efforts of stretching and anti-inflammatory medications have not been successful.

Which of the following is most likely to experience iliotibial band syndrome?
A. 20-year-old body builder
B. 30-year-old sprinter
C. 40-year-old weekend warrior
D. 50-year-old new marathoner
E. 60-year-old tennis player

Answer: D. 40-year-old new marathoner

The iliotibial band (ITB) is a ligament that runs along the outside of the thigh from the iliac crest to the lateral tibia; it helps to stabilize the knee and hip during running. ITB syndrome occurs when the ligament rubs over the bones on the outside of the knee and becomes irritated, causing pain. ITB syndrome may be secondary to blunt trauma but is usually caused by overuse in sports training, specifically with running. Multiple physical examination techniques are available, such as the Thomas test (shown), which detects restriction in the iliotibial band and hip flexors by flexing one hip and looking for contralateral hip flexion.

Physical examination is typically sufficient for ITB syndrome. In refractory cases or when there is concern for additional underlying pathology, MRI will demonstrate edema (arrow) within the ITB. Treatment is usually conservative, involving rest, stretching, and strength development. Surgery is rarely indicated.

Although IT band syndrome usually localizes to the knee, it may also cause a snapping pain over the hip. What other conditions must be considered in the differential for snapping hip syndrome?
A. Loose body or joint mouse
B. Acetabular labral flap tear
C. Iliopsoas tendinitis
D. All of the above

Answer: D. All of the above

Snapping hip syndrome may be classified as external or internal, diagnosed clinically or intra-articularly, usually requiring an MRI or arthrogram. External types are due to a thickened posterior ITB passing over the greater trochanter during flexion. Internal types occur when the iliopsoas tendon snaps over the femoral head. Intra-articular causes include loose bodies (arrow) or cartilage flaps. Most cases can be treated conservatively, with surgery reserved for painful refractory cases.

More Slideshows

• Effective Reduction Techniques for Lower Extremity Dislocations
• Gait Abnormalities: Hidden Signs of Disease
• Ankle Injuries
• Typical Fractures Seen in Children
• Hand Injuries
• Other Slideshows

For more information, see the following resources:

• Overuse Injuries
• Metatarsal Stress Fracture
• Achilles Tendonitis
• Iliotibial Band Syndrome
• Patellar Injury and Dislocation
• Patellofemoral Syndrome

Contributor Information

Authors
Vinod K. Panchbhavi, MD, FACS
Professor of Orthopedic Surgery
Chief, Division of Foot and Ankle Surgery
University of Texas Medical Branch
Galveston, Texas

Disclosure: Vinod K. Panchbhavi, MD, FACS, has disclosed no relevant financial relationships.

Contributor Information

Editor
Lars Grimm, MD, MHS
House Staff
Department of Diagnostic Radiology
Duke University Medical Center
Durham, North Carolina

Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.

Contributor Information

Reviewer
Thomas DeBerardino, MD
Associate Professor
Department of Orthopaedic Surgery
New England Musculoskeletal Institute
University of Connecticut Health Center
Farmington, Connecticut

Disclosure: Thomas DeBerardino, MD, has disclosed no relevant financial relationships.