Fibula head pain and enlargement

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Can anyone help with this one?

I am dealing with a patient in conjunction with a Physio, who is a runner and Ice Hockey player. He complains of left fibula head pain, and, intially, ITB pain.

We have done:

FFOs
Strapping (mainly patellar and fibula head)
ITB etc stretching +++++
Core stability
Proprioception
Localised treatment (friction, U/S, mobilisation)
RICE
NSAIDs
Analgesics

He has ++ internal femoral torsion and when observing him standing with his orthoses in, his 'alignment' is excellent from the foot up, but the knees don't follow and he remains internally rotated at the hips.

The head of the fibula appears to be increasing in 'boney' density.

Can anyone suggest:

a) Any further treatment
b) Any 'diagnosis'?

We are sending for MRI and an orthopaedic opinion.

Thanks!

 

Sorry to beat Craig here but check for trigger points

 

Hi Nicola

I presume your physio may well have done this but short of being able to give a diagnosis here is reasonably safe option.

Peripheral joint mobs to both the distal and proximal fibula head. I certainly do not mobilise one without the other. You may also wish to mob the knee by ensuring the internal and external glide element of its function is ok. They are simple techniques but often overlooked and can be quite effective.

Again, a bit of acupuncture to area may be helpful, but I would try the mobs first.

Cheers
Ian

 

Sorry guys,

Everything in sight has been mob'd, both distal and proximal.

Acupuncture and trigger points have been addressed. Both of these techniques helped to reduce the associated symptoms from the knee and ITB (which perhaps I didn't make clear)!

The concerning element is that the fibula head is visibly enlarged (boney) and I wondered if it's possible to get e.g. exostoses, cysts etc of a certain kind in this area?

Or if it's possible to ?steroid inject in this area?

Also, despite all the external hip rotator work in the world (we've done a lot), the knees aren't following the lower kinetic chain.

Therefore, my suspicion was that this may be a localised phenomenon that is not in fact biomechanical, but pathophysiological? Is it possible to get ? boney growths in this area / cysts?

Sorry guys, good suggestions, but already done (basically every physio technique available done!)!

thanks for any other info if any could suggest!

 

Certainly, if there is obvious deformity of the fibular head, radiographs of the knee should be performed to rule out any suspicious lesions. http://www.mypacs.net/cgi-bin/repos/mpv3_repo/wrm/repo-view.pl?cx_subject=801534&cx_repo=mpv4_repo

Also consider insertional tendinitis of the biceps femoris tendon, lateral collateral ligament strain of the knee and especially a dislocation of the proximal tibiofibular joint.
http://www.wheelessonline.com/ortho/proximal_tibiofibular_joint_injuries

Hope this helps.

 

Thanks Kevin,

I suspect that the details hilighted in the second link would probably be more applicable as it fits some of the patterns of symptoms.

Presumably the tumour would give pain in non-weight-bearing? Currently he only gets pain with running.

I've suggested x-rays as a baseline whilst waiting for MRI and surgical consult.

Thanks!

 

Hi Nicola,

A current patient of mine had a multilobulated cyst around/under (all over the place) his fibula head. Prominence in the area increased with activity more recently but not in the past (the problems he had been experiencing resulted in having an anterior compartment release, which was of no benefit, of course and it didn't address the pain around the fibula head anyway!!!!!!!). The cyst was only found after he started to develop foot drop.
Surgical excision of the cyst was performed and it was reported as being extensive and complex. Pain post surgical was significant and was only relieved after 6 weeks by acupuncture.
Cheers
Shane