Tib Ant Spasm with Painful os Trigonum??

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Hi All,

I’m currently seeing a 10y/o Indian boy with 6 month history of pain in both ankles. Right much greater than left especially after playing sports (he currently plays football and tennis 3-4x p/w) which he described as an aching.

The patient indicates the pain is on the anterior aspect of the right ankle and the posterior medial aspect of the same ankle just behind the medial malleolus.

On examination he has a very restricted right ankle range of motion and appears to have spasm in the tibialis anterior, long extensors and peroneus tertius. With some myofascial release work the right ankle ROM improves but on plantar flexion he displays a bony end feel at approximately 45 Degrees.

On palpation he is very sore on the posterior medial ankle joint line and the anterior ankle appears slightly oedematous and painful on the long extensor tendons in the region of the retinaculi. The anterior muscle group in this right leg is in spasm and is painful along the course of the muscles. The peroneals are fine.. no peroneal spasm or pain on palpation of the brevis and longus muscles.

X-rays (attached below) show a reasonable size Os Trigonum on the right ankle and do not indicate tarsal coalition (which they probably wouldn’t as the coalition shouldn’t have ossified at this stage).

He has quite a flat footed gait however the right foot doesn’t appear to move as freely as the right. Shortish stride length.

My thoughts for the pain is that the Os Trigonum is causing a posterior ankle impingement which is causing the pain and as such I have prescribed (a week ago) OTC orthotics to try to reduce the arch drop thus reducing pronation and so how much the calcaneum dorsiflexes during pronation. The insoles have helped reduce the pain by about 50% (still not wearing them for football). Today I increased the control in the insoles a little and if this illicits further improvement I will probably look to move to casted insoles with a fairly high arch profile.

For further treatment I have asked his Mum to help with some massage on the right anterior leg and Ice the right anterior ankle to help reduce the swelling and pain associated with the long extensor tenosynovitis.

My questions are:

- why does he have spasm in the tib ant and long extensors? Is it the body trying to dorsiflex the foot to reduce the compressive forces of the posterior impingement?
- Should I be suspicious of a Tarsal Coalition (which by the way, as a Pt pointed out to me a while back is a great name for a Rock band)? And if so should I send for CT? The reason I am unsure is because of the unusual (?) location of the spasm.
- Has anyone seen spasm in this muscle group and not the peroneals in such a case?

 

Hello Sam,

I do not think this sounds typical of os trigonum pathology. The x-ray does not show any obvious coalition. Rather than CT, you would be better requesting an MR scan if you are concerned regarding possible fibrous or cartilaginous coalitions. Having said that, your MR scan may also shows signs of AVN of the navicular as it appears slightly flattened and sclerotic on the lateral view you have posted.

Os trigonum is usually most painful when a patient tiptoes. Does he get any pain on resisted plantarflexion of the hallux with the ankle dorsiflexed or plantarflexed? I would expect pain associated with os trigonum to be more lateral and posterior, rather than medial.

 

Thanks very much for the input Bob.

Here is DP view of both feet and oblique view of the right.

The Navicular in the right foot is clearly narrower on the lateral aspect than the left.. I did see this as fairly unusual but due to the lack of symptoms coming from the area I was more inclined to attribute it to anatomical variation. Could this be Navicular AVN?

I don't recall any pain on resisted hallux plantar flexion. There is pain in the ankle on full passive dorsiflexion and inversion and that is where I reach the bony end feel in ankle plantar flexion (the plantar flexion gives the bony end feel, the inversion gives the pain in posterior medial ankle), once I have managed to get the tib ant and long extensors to relax and allow me to move the foot.

So working DDx at the moment are:

- Tarsal Coalion
- Navicular AVN
- Painful Os Trigonum

I think next step MRI for a better look at this foot.

What is really throwing me is the Tib ant spasm. Any more input would be very gratefully received.

For those who are interested I've also done a quick search on Tibialis Anterior Spasm and interestingly only get 9 hits in total from google, and only 2 of them are medical journals. Here are links to the abstracts:

http://www.sciencedirect.com/scienc...1a4e38d90f29a940e4c76a82376b5420&searchtype=a showing two atypical tarsal coalitions one with spasm, the other with overactivity of the tib ant.

http://www.ncbi.nlm.nih.gov/pubmed/12838065 showing tib ant spasm with calcaneal osteoid osteoma.

Nothing really on google scholar or Japma. Didn't have time to do a wider search yesterday.. will try to do today and post any thing useful I find.

Regards,

Sam

 

Hi Guys,

I'm finding this case quite interestin so I will assume that some of you guys are as well. As such I will post periodic updates on here to keep you updated with how the case is going.

After searching for about an hour on various standard and medical websites yesterday I found nothing more on tibialis anterior spasm. So, I am assuming it is a fairly rare phenomenom. If any one has any experience in this condition, please feel free to pitch in.

I've decided to request an MRI for my patient to look for AVN or atypical tarsal coalition. I'll post the results when I have them, plus any more info I get when I get it.

Kind Regards,

Sam R

 

Is there an increase in pain when you have the patient actively plantarflex and dorsiflex the hallux while you palpate deeply within the retro talar space? Motion of the FHL gliding on the posterior process of the talus in close proximity to the os-trig can be source of pain and inflamm. Anterior ankle pain is common and can be referred from the area. Never saw ant. tib spasm from this kind of problem. It does sound like something else is going on along with poor mechanics. child should discontinue football...rest.

Steven

 

Os Trigonum is very common in footballers 5-10%, it develops on the posteromedial border of the talus, it forms part of the grove for the tendon of flexor hallucis longus, fracture or irritation to the spur formed will cause local tenderness and limited plantarflexion. It will usually resolve with rest.

:drinks

 

Sorry Jon,
But you need to read your anatomy book the right way around I think. Os trigonum is posterior and lateral (the very few that I have excised have been too). It is though to develop at the most posterior and lateral part of the talus - around Steida's process and has been cited to be a separate ossification centre of the talus. You need to differentiate it from a fracture to this prominence (Shepard's fracture) and it is more prevalent in foot ballers and ballerinas. It does however form part of the groove for FHL at the back of the talus (hence my previous questions to the original poster). If rest/ immobility doesn't settle it, you can try guided injections or excision.
http://www.ncbi.nlm.nih.gov/pubmed/16458810
http://www.springerlink.com/content/y42081h4636wu288/

 

I was going by my Introduction to podopediatrics second edition, Ill certainly look at the papers youve suggested, Thanks Bob

 

Image from Google.

Looks like its the lateral aspect of the most posterior aspect of the talus which kinda sits right in the centre line of the foot if this MR image is any thing to go by.

 

Haven't read through ALL the posts here, but just looking at the initial post and Bob's response, I'd have to agree.
Your initial lateral shows early talar beaking and certainly an unusual shaped navicular.
Spasms would be the norm.

Os Trig...maybe, but I'd put my $ on a STJ coalition.

Steve

PS

OS Trigonum or posterior process is lateral/posterior. When you excise these the easiest way to remove is through an incision along the
lateral border of the tendo Achilles then straight down. It's always right there.

 

Sam I don´t know if this helps you might help others .

The Os trigonum syndrome : Pictorial essay