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Imaging Quiz: Perplexing Shin Pain

Edward G. McFarland, MD; Eva H. Kraus

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 4 - APRIL 97


[FIGURES 1 AND 2]A 19-year-old minor league baseball pitcher from South America felt pain in his left shin while pitching and presented to the trainer right after the game. He had suffered no injury to the shin, but over a period of 6 weeks, the pain became progressively worse. He had considerable nocturnal discomfort, but no fevers or night sweats. Anti-inflammatories, rest, and ice did not reduce the pain. The patient was otherwise healthy, with no other symptoms or notable history.

On physical examination at 6 weeks the patient walked with a mildly antalgic gait. On the left leg, approximately 15 cm proximal to the medial malleolus, was a warm, swollen, focal area of tenderness and pain. There was no effusion on the left knee, and the patient had full range of motion at both knee and ankle. There was no popliteal or inguinal lymphadenopathy.

Laboratory studies, including complete blood count, sedimentation rate, chemistry group, stool culture, and liver function tests, were normal. A human immunodeficiency virus test and skin testing for tuberculosis were negative.

Plain radiographs of the left tibia are shown in figure 1, and a computed tomography (CT) scan is shown in figure 2.

What is your diagnosis, and how would you confirm it?

Dr McFarland is an assistant professor in the department of orthopaedic surgery, section of sports medicine, at Johns Hopkins University in Baltimore. Ms Kraus is a medical student at the University of Freiburg in Freiburg, Germany. Address correspondence to Edward G. McFarland, MD, Johns Hopkins University, Section of Sports Medicine, 2360 West Joppa Rd, Suite 205, Baltimore, MD 21093.


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