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i would be very grateful if anyone could guide me on a new pt today. A 12 year old boy presented with a worried mum. he has an obvious apparent bony enlargement of the medial malleoi on the right which has only been noticed since his last shoe fitting. increased by 2 sizes in 6 months. presented with tight calf muscle on the right and a slight leg differnece. right shorter. during gait extendor hallucis longus very prominent on both and marked overpronation on both. when standing the only obvious abnormality is the enlarged medial malleoi. the main problem is discomfort when wearing shoes no other pain or problems. i have prescribed an inital stretching regime and footwear advice but am a loss as to why the maleio is bigger, not swollen or bursae.??? i am recently qualified and at a loss. thank a lots for any thoughts you have. bradley

Bradley,
Welcome. There a number of "possibles" here including things like this:
http://www.ijoonline.com/article.asp... ;aulast=Gupta

You really need to get some imaging.

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Science is the antidote to the poison of enthusiasm and superstition

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Was he a normal birth? Any neurological history? Are there X-rays? Being unilateral, I'd check and see if the growth plate has been traumatized. Does he participate in soccer (football), karate, or is there a history of trauma? Going on limited information, I'd correct the leg length discrepancy, gradually, and immobilize in a CAM walker-type device. -John

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Dr. John G. Fasick
LSUHSC New Orleans
Clinical Insructor, LSU School of Medicine
jfasic@lsuhsc.edu

See also:
http://www.pedorthopaedics.com/pt/re...195628!8091!-1

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Science is the antidote to the poison of enthusiasm and superstition

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Hi Bradley:

"enlargements" in a 12 Y/O need to be assessed thoroughly, primarily to rule out any neoplasm.
History & Clinical examination (tenderness, redness, warmth, unilateral, etc...) and radiographs are first.

Assuming here that no neoplasm is present and acute trauma has been ruled out, Simon's link to apophysitis and possibly epiphysitis are your most likely diagnosis (he does have a knack for Dx things with very little information!)

Epiphysitis at the distal tibial is normally associated with some sort of acute or repetitive trauma which your history should uncover.

Accessory ossicles here are possible and I would put them under the heading of apophysitis if one is present and inflamed.

Steve

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DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Agreed. I didn't specifically mention this as it would have sent me straight into panic mode when I was newly qualified, but it was my first thought. GET SOME IMAGING PLEASE BRADLEY.

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Science is the antidote to the poison of enthusiasm and superstition

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Hi Bradley,



Did you write this on his file as the presenting complaint??!!

Cheers and good luck!

Brad

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Assuming, of course that a "medial malleoi" is similar to a medial malleoli

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Science is the antidote to the poison of enthusiasm and superstition

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I would advise in the meantime sending him to an Orthotist to Have footwear modified such as lowering of the medial quarter on footwear to alleviate pressure on the medial malleoli

OK, just for the record.......malleoli is plural; malleolus is singular.

Thank for setting us straight Steve.

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Science is the antidote to the poison of enthusiasm and superstition

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HAHA
Simon - that wasn't meant for YOU!