Child gymnast with 1.5 months heel pain, asked to assess Os Trigonum, MRI, Please Help

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Several questions.
Is it even possible to evaluate an Os Trigonum in an 8 year old?
There is tremendous Posterior subtalar effusion…I cannot see the cause.
I don’t see distention of the FHL tendon sheath, a low lying FHL muscle
belly or thickening of the retrotalar pulley.
Is this posterior ankle impingement?
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Recently back from vacation….OCAD consult cases piling up—it’s not that
I’ve run out of questions…just short on time.
Just as confused as ever.

Hilary

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3 thoughts on “Child gymnast with 1.5 months heel pain, asked to assess Os Trigonum, MRI, Please Help”

  2. ocad-msk

    The posterior talar tuberosity seems to be large enough to cause posterior ankle impingement. It is not ossified, but may be an os trigonum or an Stieda process. Physical examination data can help with proper diagnosis.

    Marcelo Pires Prado
    Medicina e Cirurgia do pé e tornozelo

    Hospital Israelita Albert Einstein
    Rua Ruggero Fasano s/n- Morumbi – SP
    Bloco A1 – 3o. andar – sala 322
    Fone (11) 2151.1315

    ________________________________
    De: ocad-msk@googlegroups.com <ocad-msk@googlegroups.com> em nome de hilary umans <hilary.umans@gmail.com>
    Enviado: quarta-feira, maio 12, 2021 18:05
    Para: ocad-msk@googlegroups.com
    Assunto: Re: Child gymnast with 1.5 months heel pain, asked to assess Os Trigonum, MRI, Please Help

    ATENÇÃO: este e-mail tem como origem um remetente que não é do EINSTEIN.
    NÃO CLIQUE em links e anexos de remetentes desconhecidos ou que não tenha certeza de que o conteúdo é seguro.
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    Several questions.
    Is it even possible to evaluate an Os Trigonum in an 8 year old?
    There is tremendous Posterior subtalar effusion…I cannot see the cause.
    I don’t see distention of the FHL tendon sheath, a low lying FHL muscle belly or thickening of the retrotalar pulley.
    Is this posterior ankle impingement?
    [1.jpg]
    [2.jpg]
    [3.jpg]
    [4.jpg]
    [5.jpg]
    [6.jpg]
    Recently back from vacation….OCAD consult cases piling up—it’s not that I’ve run out of questions…just short on time.
    Just as confused as ever.

    Hilary

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  3. hilary.umans

    Thank you for the many comments.

    I have discussed this case with the referrer who primarily treats
    dancers….he said she is an elite level gymnast and dancer.
    (I suppose if she doesn’t have posterior ankle impingement as yet, she is
    destined to develop it)

    1. Both Hamza Alizai and Caio Nery pointed out marrow edema at the
    posteromedial talus (first set of axial images), which I
    missed….suggested that it might indicate posterior impingement.
    2. Not surprisingly, most agreed that we cannot report “os trigonum”
    syndrome at this age, as the posterior talus is not yet ossified.
    3. Dr. Prado suggested that the posterior talar tuberosity seems large
    enough to cause posterior impingement and that physical exam data could
    help with the proper diagnosis. (I am curious about that, given the degree
    of subtalar capsular distention, which will be symptomatic)
    4. It was pointed out that the capsular distention is more likely synovitis
    than bland effusion—I agree….and the current plan is to proceed with
    subtalar steroid injection.

    –A few suggested Calcaneal Apophysitis. In my opinion, the apophysis
    looks pristine (see that Sag T1); there is no reactive marrow edema or
    irregularity of the growth plate.

    Hilary

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