Disclosures: Haruki Ishii, MD: No financial relationships or conflicts of interest

Case Diagnosis: Proximal Soleus Enthesopathy

Case Description: A 33-year-old male long-distance runner, with one year of right posterior calf pain, was initially found to have lipomas over the medial head of his gastrocnemius. After surgical excision symptoms improved for 3 months. Then, his right calf pain returned, and a tibial stress reaction was found on MRI. Pain resolved after twelve weeks of rest. Six months later, the patient presented with recurrent exercise-induced right calf pain, not improving with physical therapy. Physical exam revealed a firm mass along the insertion of the soleus onto the proximal tibia. Extensive work up including rheumatologic studies, compartment pressure testing, and vascular studies were all negative. Both ultrasound and MRI showed focal enthesopathy at the proximal insertion of the soleus onto the tibia. CT illustrated a broad, cortically based ossification along the posterior tibial cortex. The patient received ultrasound-guided trigger point injections of the soleus without improvement. Given this, he underwent surgical excision of the ossification.

Setting: OutpatientAssessment/

Results: One-month post-op, the patient had no calf pain and was returning to his running routine.

Discussion: Exercise related leg pain is common in runners but can be challenging to clinicians given the broad differential diagnosis. Medial tibial stress syndrome (MTSS) is one of the most painful overuse injuries and encompasses several pathologies including medial tibial periostitis, soleus enthesopathy, and shin splints. Soleus enthesopathy in MTSS usually presents at the distal two-thirds of the tibia. Interestingly, our patient presented with focal enthesopathy at the proximal tibia. Conservative management is the initial approach for MTSS given lack of evidence based optimal treatments. In this case, surgery was a successful alternative for refractory calf pain.

Conclusion: MTSS has multiple etiologies and limited treatment options. A thorough workup is essential to discover the underlying etiology and to guide alternative interventions for successful treatment and safe return to play.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-never-ending-story-of-calf-pain-in-a-recreational-long-distance-runner-a-case-report/