1. Sports Medicine Clinic

2. Presentation 10 year old lacrosse player Presented at clinic with right hind foot pain Begin abruptly after lacrosse practice 3 weeks ago

3. Pain was diffuse around the heel and present in the region of the right ankle Symptoms have increased over the last three weeks Worse with weight bearing

4. No relief Ice Motrin Gel heel cups crutches

5. What is your ddx?

6. DDX of aldoscence heel pain Calcaneal apophysitis (severs disease) Calcaneal stress reaction or stress fx Retro-calcaneus bursitis Achilles tendinopathy Reactive arthritis (Reiter syndrome) Bone tumor osteomyeltis

7. How would you do the examination?

8. Exam NAD Mild swelling Moderate tenderness at the lateral ankle Pain on squeezing the calcaneal No rubor or calor in the foot or ankle Capillary refill was normal No strength or sensory deficits

9. What are the tests for ankle instability?

10. Tests Full rom No instability with anterior drawer or talar tilt test Antalgic on right

11. What did you miss?

12. Medical history Soft tissue infection right forefoot after a cut on the chain link fence approximately 2 months before the heel pain Rx with oral cephalexin 1 g x 10 days Complete resolution of activities and was able to return to full activities within one week of infection No chills, fever, or other systemic symptoms

13. Would you order Labs?

14. lab CBC Sed rate C-reactive protein

15. X-rays Foot and ankle – mild swelling over the lateral malleolus otherwise normal for her age MRI – patchy increase t2 and decrease t1 within the calcaneus CT - lytic lesion surrounded by sclerosis in the posterior aspect of the calcaneus

16. What is your ddx?

17. Osteoid or osteomyelitis No linear component to suggest stress response or fracture

18. Who would you consult?

19. Consultations Foot and ankle specialist Ortho oncologist

20. 5 weeks after symptoms started Low-grade temp and chills Clinical exam unchanged Higher suspicion of osteomyelitis

21. What would you do?

22. Open biopsy with frozen sections Excision of the lesion

23. Dx Osteomyelitis

24. What is the most common organism?

25. Staph MRSA

26. What is the most common organism in puncture wounds?

27. pathology Clindamycin 3 weeks of IV followed by 3 weeks of oral 7 weeks back to normal

28. osteomyelits Pseudomonas aeruginous is the most common in puncture related cases

29. Local Hematogenous spread Common in newborns heel prick for blood

30. Increase MRSA in Sports

31. No imaging study is 100 % dx of osteomyelitis

32. What is the most important in care of osteomyelitis?

33. Early dx Isolation of the microorganism

34. Summary Non musculoskeletal dx Atraumatic musculoskeletal symptoms Osteo can be present without fever or chills Imaging studies may be misleading Early dx and tx are keys to successful outcomes

35. What is the most important lesson to learn from this presentation?