Persistent Knee Pain in a Recreational Runner
Persistent Knee Pain in a Recreational Runner
Primary bone cancers are rare and affect fewer than 2500 people yearly in the United States. Osteosarcoma, the most common malignant primary bone tumor, has an annual incidence of 2 cases per million people. Advances in surgical and medical therapies have dramatically improved the prognosis of osteosarcoma during the last few decades. Early detection by primary care physicians remains a cornerstone of treatment, because locally advanced or metastatic disease has a substantially worse prognosis. This report describes a recreational athlete who complained of persistent knee pain and was subsequently diagnosed with high-grade tibial osteosarcoma.
A 25-year-old recreational runner presented to her family physician for evaluation of chronic right knee pain. The discomfort had been present for 2 months and started after an episode of falling onto her knee. She had struck her flexed knee on cement while avoiding a dog and noted moderate anterior knee pain. She sustained a few superficial abrasions but did not hear a "pop" or recall swelling of the affected knee. She felt no regional weakness or numbness and did not seek care at the time. The pain subsided over the ensuing 3 weeks, and she resumed athletic activities. Five weeks before evaluation, she noticed increasing pain in the anterior right knee that awakened her from sleep and forced her to discontinue running. She noted no catching, locking, or instability of her knee. She denied any fevers, chills, night sweats, or weight loss. No similar symptoms were present in other joints. Her medical history was otherwise unremarkable, and her only medication was ibuprofen. She smoked half a pack of cigarettes daily, used no illicit substances, and had no relevant family history.
Her temperature was 99.1°F on initial examination, and she seemed healthy. Physical examination of her knee revealed no gross deformity, effusion, crepitus, or regional muscle wasting. She was tender over the medial proximal tibia and the anteromedial joint line of her right knee. The knee range-of-motion was 5° to 140°. Strength testing of the right lower extremity was normal, and she had normal peripheral pulses and sensation. Ligamentous and meniscal tests were normal. She walked with a normal gait, and the remainder of her physical examination was normal.
The patient's atypical symptoms, including progressive discomfort and night pain in association with localized bony tenderness, prompted her family physician to obtain radiographs of her right knee. These radiographs revealed an abnormal bony architecture with a mottled lucency and cortical irregularity affecting the medial tibial plateau (Figure 1). Magnetic resonance imaging (MRI) showed a large (5 cm) focus of pathologic marrow replacement at the medial tibial plateau with disruption of the posterior cortex and extension into the adjacent soft-tissue (Figure 2). A radionuclide bone scan demonstrated increased activity in the medial proximal right tibia, but no other areas of abnormal uptake were noted. The patient's family physician promptly discussed the case with an orthopedic oncologist who recommended and performed a biopsy of her right tibia that revealed a high-grade osteosarcoma.
(Enlarge Image)
Plain knee radiographs of a 25-year-old recreational runner with chronic right knee pain. The radiographs reveal an abnormal bony architecture with a mottled lucency and cortical irregularity affecting the medial tibial plateau.
(Enlarge Image)
MR images of the patient's right lower extremity show a large (5 cm) focus of pathologic marrow replacement at the medial tibial plateau with disruption of the posterior cortex and extension into the adjacent soft-tissue (arrows).
Under the direction of a medical oncologist working with the orthopedic and primary care teams, the patient received 3 cycles of preoperative chemotherapy with doxorubicin and cisplatin. Her orthopedic surgeon subsequently performed a wide tibial resection with endoprosthetic reconstruction. After a brief course of physical therapy, she received 2 postoperative cycles of chemotherapy with ifosfamide. She developed burning on the soles of her feet consistent with chemotherapy-induced neuropathy. She returned to her family physician to treat postoperative symptoms of depression and insomnia, but she had no other complications. Extensive testing revealed no recurrent disease 18 months after her initial presentation, and she became pregnant.
Primary bone cancers are rare and affect fewer than 2500 people yearly in the United States. Osteosarcoma, the most common malignant primary bone tumor, has an annual incidence of 2 cases per million people. Advances in surgical and medical therapies have dramatically improved the prognosis of osteosarcoma during the last few decades. Early detection by primary care physicians remains a cornerstone of treatment, because locally advanced or metastatic disease has a substantially worse prognosis. This report describes a recreational athlete who complained of persistent knee pain and was subsequently diagnosed with high-grade tibial osteosarcoma.
A 25-year-old recreational runner presented to her family physician for evaluation of chronic right knee pain. The discomfort had been present for 2 months and started after an episode of falling onto her knee. She had struck her flexed knee on cement while avoiding a dog and noted moderate anterior knee pain. She sustained a few superficial abrasions but did not hear a "pop" or recall swelling of the affected knee. She felt no regional weakness or numbness and did not seek care at the time. The pain subsided over the ensuing 3 weeks, and she resumed athletic activities. Five weeks before evaluation, she noticed increasing pain in the anterior right knee that awakened her from sleep and forced her to discontinue running. She noted no catching, locking, or instability of her knee. She denied any fevers, chills, night sweats, or weight loss. No similar symptoms were present in other joints. Her medical history was otherwise unremarkable, and her only medication was ibuprofen. She smoked half a pack of cigarettes daily, used no illicit substances, and had no relevant family history.
Her temperature was 99.1°F on initial examination, and she seemed healthy. Physical examination of her knee revealed no gross deformity, effusion, crepitus, or regional muscle wasting. She was tender over the medial proximal tibia and the anteromedial joint line of her right knee. The knee range-of-motion was 5° to 140°. Strength testing of the right lower extremity was normal, and she had normal peripheral pulses and sensation. Ligamentous and meniscal tests were normal. She walked with a normal gait, and the remainder of her physical examination was normal.
The patient's atypical symptoms, including progressive discomfort and night pain in association with localized bony tenderness, prompted her family physician to obtain radiographs of her right knee. These radiographs revealed an abnormal bony architecture with a mottled lucency and cortical irregularity affecting the medial tibial plateau (Figure 1). Magnetic resonance imaging (MRI) showed a large (5 cm) focus of pathologic marrow replacement at the medial tibial plateau with disruption of the posterior cortex and extension into the adjacent soft-tissue (Figure 2). A radionuclide bone scan demonstrated increased activity in the medial proximal right tibia, but no other areas of abnormal uptake were noted. The patient's family physician promptly discussed the case with an orthopedic oncologist who recommended and performed a biopsy of her right tibia that revealed a high-grade osteosarcoma.
(Enlarge Image)
Plain knee radiographs of a 25-year-old recreational runner with chronic right knee pain. The radiographs reveal an abnormal bony architecture with a mottled lucency and cortical irregularity affecting the medial tibial plateau.
(Enlarge Image)
MR images of the patient's right lower extremity show a large (5 cm) focus of pathologic marrow replacement at the medial tibial plateau with disruption of the posterior cortex and extension into the adjacent soft-tissue (arrows).
Under the direction of a medical oncologist working with the orthopedic and primary care teams, the patient received 3 cycles of preoperative chemotherapy with doxorubicin and cisplatin. Her orthopedic surgeon subsequently performed a wide tibial resection with endoprosthetic reconstruction. After a brief course of physical therapy, she received 2 postoperative cycles of chemotherapy with ifosfamide. She developed burning on the soles of her feet consistent with chemotherapy-induced neuropathy. She returned to her family physician to treat postoperative symptoms of depression and insomnia, but she had no other complications. Extensive testing revealed no recurrent disease 18 months after her initial presentation, and she became pregnant.
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