Tibial Bowing

Tibial bowing is not uncommon. The direction and the apex of the tibial bow can alert the clinician to the type of the deformity, its treatment, and its prognosis. Tibial bowing can occur anteriorly, laterally, anterolaterally, and posteromedially.

Anterior bowing is often associated with fibular hemimelia. This bowing may be associated with the loss of the lateral rays of the foot, equinovalgus foot deformity, tarsal coalition, and significant leg length discrepancy.

Lateral bowing is a common variation, which occurs bilaterally. This condition is mild and not associated with other problems.

Anterolateral bowing is a serious tibial bowing that may increase and lead to a fracture as well as pseudoarthrosis of the tibia. This type of bowing occurs early in infancy. Pseudoarthrosis is usually associated with neurofibromatosis. 10% of patients with neurofibromatosis will have anterolateral tibial bowing. Neurofibromatosis is found in 50% of the patients with ALB. The patient should be carefully examined for café-au-lait spots. In this type of bowing, bone ends are usually thin and the fibula may also be involved. Treatment of anterolateral bowing is bracing with total contact orthosis. In order to treat pseudoarthosis in the tibia, surgery is usually needed. Multiple options are available for surgery, and none of these options are perfect. 50% of patients may undergo amputation due to the inability to achieve healing of pseudoarthrosis.

Posteromedial bowing is a rare calcaneovalgus deformity of the foot plus leg length discrepancy. This condition usually resolves, but may have residual leg length discrepancy.

Freiberg's Disease

Freiberg’s Disease is caused by avascular necrosis of the head of the 2^nd metatarsal. This condition is more common in patients who have a longer 2^nd metatarsal bone relative to the 1^st metatarsal. This leads to the transfer of excessive loads onto the 2^nd metatarsal, which may interfere with the blood supply. This disease tends to occur more commonly in young females during growth spurts.

Freiberg’s Disease usually presents itself as pain and swelling at the 2^nd metatarsophalangeal joint that is related to activities and walking in high heels. There may be point tenderness and swelling over the head of the 2^nd metatarsal. There may also be limited range of motion in the 2^nd metatarsophalangeal joint. Early in the disease, x-rays may only show minimal changes. Radiological evidence of the condition may only be clearly visible on an MRI and bone scan. In more severe cases, sclerosis, fragmentation, collapse of the metatarsal head, and severe arthritis, may make the condition easily visible on an x-ray.

Treatment

Conservative treatment consists of nonsteroidal anti-inflammatory medications, activity modification, orthotics, and immobilization with a short leg cast. Surgical intervention involving a joint debridement is indicated only after the failure of all conservative measures. Other procedures may be indicated depending on the complexity and severity of the case.

Pes Anserine Bursitis

Several bursa are seen around the knee area. These bursa include the suprapatellar, prepatellar, infrapatellar, and pes anserine. The pes answerine bursa is a small fluid filled sac located between the tibia and the three tendons of the Sartorius, Gracilis, and Semi-tendinosus.

These muscles are innervated by three separate nerves, the femoral, obturator, and the tibial branch of the sciatic nerve, respectively. Pes Anserine bursitis, or “breast stroke knee”, is an inflammatory condition of the medial knee at the pes anserine bursa that is common in swimmers.

What is the pes anserine?

The pes anserine is the common area of insertion for the three tendons along the proximal medial aspect of the tibia. This condition is also sometimes referred to as a “goosefoot” because the pes anserinus tendons resemble the shape of a goose foot. Pes Anserine bursitis is usually seen as causing pain, tenderness, and localized swelling after trauma or total knee replacement. The pain is seen below the joint line on the medial part of the proximal tibial with the bursa being deep to the tendons.

Treatment

Treatment consists of physical therapy, nonsteroidal anti-inflammatory medications, and injections. The physician will need to rule out meniscal tears, stress fractures, or osteonecrosis of the tibia, as these are all differential diagnosis.

Cauda Equina—Central Disc Herniation

Disc herniations usually occurs posterolaterally, but it may also be central. The cauda equina is composed of several nerves within the lower end of the spinal canal. The top of the spinal cord is a tubular bundle of nervous tissue extending from the brain.

The following section of the spinal cord is called the Conus Medullaris and is the lower end of the spinal cord. The Cauda Equina is made up of multiple nerve roots beginning at the level of L1.

The most common disc herniation is the Posterolateral Disc Herniation. This type of herniation is a nerve root injury, which will cause changes to both the sensory and motor skills as well as the reflexes. A posterolateral disc herniation usually affects the foot and ankle, and may cause unilateral leg pain and weakness. Observe for a positive straight leg raising test. These herniations are usually initially treated with conservative methods.  

A central disc herniation will cause cauda equina syndrome, which is a compression over the lumbosacral nerve roots. This compression will cause more back pain than leg pain, and bladder and bowel symptoms will be evident. This herniation is considered a surgical emergency.