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Inflammation around styloid process

Discussion in 'General Issues and Discussion Forum' started by Amanda, Jan 24, 2014.

  1. Amanda

    Amanda Member

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    Hi all,

    I wondered if anyone could offer advice on the diagnosis of a patient I saw recently.

    He presented with significant redness and swelling (no heat) around the left styloid process. The area was very swollen (including plantarly) and there was some discomfort on palpation (dorsal/laterally) but nothing excessive. Active and passive eversion was unremarkable.

    He is in 60's and very active, he likes to 'push' himself when exercising. The pain occurs after exercise, he is fine during activity. He moderately overpronates and the size of his styloid process is assymmetrical when compared to his right foot.

    There is no history of trauma, no systemic issues, he has had gout once in his 1st MPJ over a decade ago.

    I applied low dye strapping to his foot which gave him good relief immediately and will be reviewing him next week. If there is no significant improvement I will consider referral for ultrasound and xray and to the GP to check for gout (very unlikely in surrounding joints I would have thought) and inflammatory arthritis/infection.

    I have about 10 differential diagnoses in my head and I don't want to distract anyone from their inital thoughts by listing them so any ideas you have would be greatly appreciated.

    Thank you in advance,

  2. Amanda:

    The most common cause of this type of pain is peroneus brevis insertional tendinitis. I see this quite commonly, mostly in men over the age 40. With eversion against resistance, palpate firmly along the course of the PB tendon from proximal to distal. The area of maximal tenderness will be at the PB insertion.

    Other possibilities include the much less common strain of the lateral component of the plantar aponeurosis (which inserts on the plantar aspect of the styloid process in about 75% of the population) or a fracture of the styloid process which is also less likely. However, a set of radiographs would be most prudent to rule out osseous pathology.

    Hope this helps.:drinks
  3. Amanda

    Amanda Member

    Thank you very much Kevin,

    This was my inital diagnosis as well. It was the large amount of redness and swelling that made me think twice as I had never seen a tendinopathy this 'angry' before. So I am comforted by the fact that I was on the right track all along!

    Thanks again Kevin,


    NBEATON Welcome New Poster

    Hi Amanda,

    I had a case a couple of years ago which was almost identical to this which turned out to be a late presentation of Iselins disease (traction apophysitis of the tuberosity of the fifth metatarsal). He had been very active as a child and after a fairly sedentary adult life had recently returned to playing bastkeball which related to the onset of his pain. Presentation sounds identical- very enlarged styloid area compared to other foot, prominent plantarly, localised redness, no trauma etc etc. Shuld be easy to rule out following your xrays but worth adding to your differential diagnoses?

    Naomi : )
  5. Amanda

    Amanda Member

    Hi Naomi,
    Thanks so much for your suggestion.
    I had never even considered this in my differential diagnosis given his age but I will certainly add it to the list!
    I'll let you know how I go.
    Many thanks,

    NBEATON Welcome New Poster


    Yes I know- my gentleman was in his late 40's, alittle younger than yours but still well outwith normal age range. It is certainly very unusual and our Orthopods were pretty surprised! I have attatched his x-ray for your interest and i will see if I can find a picture of his foot, i know I have one somewhere!


    Attached Files:

  7. toughspiders

    toughspiders Active Member

    I would also tell him not to lie on that side in bed, my guess is he probably favours that side!
  8. Rob Kidd

    Rob Kidd Well-Known Member

    Sorry to be really painful - but I fail totally to see how one can have an apophysitis in anyone much beyond puberty. Styloid fractures, no problem, though. If there are issues here with failed unions, whatever their cause, surely they are not apophysitis. Having said that, Down syndromes (I have heard) and myxodematous cretins have chondral pathologies that span this story. I stand by to be challenged.

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