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Musculoskeletal clinical topic of the month – Peripheral Nerve Tumour presenting as shin pain

Peripheral nerve tumours

Peripheral nerve tumors (PNTs) are a heterogeneous group of mostly benign tumors that are rare in the general population. They usually develop in the peripheral nerve axonal nerve sheath and surrounding connecitive tissue. Although usually noncancerous, they still may require treatment because they can cause nerve compression, damage and/or loss of function.

Peripheral Nerve tumors can grow slowly or quickly, depending on the type. Some need no treatment or only monitoring. Rarely, nerve tumors are malignant and need aggressive treatment. Most of the time, nerve tumors are not linked to any known cause, but the risk of a PNT does increase if you have; 

  • Radiation therapy for other medical issues
  • Neurofibromatosis, a group of three nerve disorders

Neurofibromatosis types

Each type is linked to a different genetic defect. These defects can be inherited (passed down in families), or spontaneous (arising for unknown reasons).

  • Neurofibromatosis 1: This is the most common neurofibromatosis disorder, affecting up to about one in 3,000 Americans. It’s also known as NF1. It has a range of symptoms, including tumors that range from small nodules to large lumps. Most are benign tumors called neurofibromas.
  • Neurofibromatosis 2: This type, also called NF2, is linked to slow-growing nerve tumors called schwannomas. Schwannomas develop from the Schwann cells that form nerve sheaths. Most people with NF2 develop vestibular schwannomas — tumors on the vestibular nerves that link each inner ear to the brain — by age 30.
  • Schwannomatosis: This very rare neurofibromatosis disorder is linked to schwannomas that occur anywhere in the body except the vestibular nerve.

Case Presentation

Clinical history;

  • 24 year old recreational weight lifting
  • Started developing pain around inside of left thigh, lower leg and ankle for past three years ago
  • Described as a dull constant ache in inside leg
  • now had to markedly reduce exercise routines as very painful
  • Feels may have strained the area during a compound lift, but no obvious mechanism of injury
  • No bruising, swelling to the area of pain
  • Treated for tibialis posterior and achilles tendinopathy over the past few years but no real changes in symptoms
  • Sleep now disrupted, particularly when knees pressed together, therefore has to sleep with pillow between legs
  • No weight loss, no fever, no recent illness

Past Medical history;

  • BMI 22
  • Non-smoker
  • No history of ill health
  • No family history of poor health

Exercise history;

  • Recreational Olympic lifter
  • Good variation of training but now unable to perform most routine due to pain

Social history;

  • IT analyst
  • Non drinker or smoker

Clinical examination;

  • Mild non-specific tenderness across medial aspect of calf and shin
  • Tibialis Posterior activation pain free and strong
  • No myotomal or dermatomal deficit in right lower limb
  • No positive neural tension signs in lower back
  • Good pulses in foot and ankle
  • Very tender firm lump in medial thigh just superior to knee joint. Palpation and percussion of this lump reproduces local symptoms and referred pain down the medial shin (positive Tinel’s sign)

Clincial suspicions, differentials and reasoning;

  1. Peripheral Nerve tumour. The finding of a painful lump that refers pain down the leg on percussion is very suggestive of a nerve tumour. It is likely that his symptoms have been misdiagnosed as localised tendinitis and/or spinal pathology. 
  2. Spinal nerve root irritation. Unlikely as patient not had back pain and negative testing on lumbosacral neural sensitivity via slump and SLR with normal spinal examination
  3. Shin splints/Tibial stress. There could potentially be some tibial stress that has not been diagnosed, but this is unlikely given the lack of high impact training or other risk factors. Also no clinical palpable tendernes over the tibia. 
  4. Tibialis Posterior Tendinitis or calf muscle injury. Patient does not describe calf muscle injury or symptoms keep with tenditis such as localised swelling or stiffness. 

Imaging

Point of Care Ultrasound – Left ankle

Normal appearences of left tibialis posterior tendon and calf musculature. Mass in medial thigh showed sonographic appearences of a well cirumscribed 2cm x 2cm lesion adjacent to the gracilis muscle belly (left image). Lesion with neovascularisation (right image), suggestive of tumour (soft tissue or otherwise).

peripheral nerve tumour shin pain ultrasound

MRI

T2 shows 2cm x 2cm high signal lesion (with intrasubstance nerve bundles visible) adjacent to the saphenous nerve with appearences highly suggestive of Schwannoma. (Axial section left image, Coronal section right image)

peripheral nerve tumour shin pain mri

Diagnosis

Swannoma of saphenous nerve in left inner thigh causing local pain and referred pain down leg

Management

Medical

  • Patient put on anti-epileptic Pregabalin medication to reduce sensitivity of neuropathic pain as preliminary treatment
  • Patient referred to Perpheriphal Nerve Tumour unit for excision of lesion
  • Patient had only very mild ongoing symptoms post resection of tumour

Rehab

  • Desentisation programme for the of affected nerve lesion
  • Ongoing strength conditinoing training

Patient Self monitoring tools

  • LBSM pain and symptom diary
  • LBSM load monitoring diary

Key Summary and learning points

Peripheral Nerve Tumours

  • Beware of lumps and bumps that have neuropathic symptoms associated with them e.g. numbness, tingling, pain
  • Any nerve lesion can cause referred pain along is sensory distribution
  • Shin or Calf pain in particular can have neuropathic origins in the spinal or peripheral nerves. Always consider this if ongoing musculoskeletal management has failed
  • If imaging (MRI) has identified no spinal cause for lower limb neuropathic pain, always consider more distal lesions (e.g. pelvic, or local nerve lesions), neuropathies and demyelinating disease (e,g, multiple scelorsis)
  • Schwannomas are the commenest perhipheral nerve tumour and are usually benign in nature

Saphenous Nerve Anatomy

  • The saphenous nerve is the terminal branch of the femoral nerve. It travels within the subsartorial, or Hunter, canal with the femoral artery, exiting about 10 cm above the knee where it gives off an infrapatellar branch supplying the knee.
  • It then descends along the medial aspect of the tibia and medial malleolus.
  • The saphenous nerve provides sensory innervation to the medial aspect of the lower leg and the medial foot as far as the first metatarsal phalangeal joint.

Injury to the saphenous nerve

  • The nerve can be affected by injuries or procedures to the femoral artery such as catheterization within the subsartorial canal. It can also be injured as it exits the canal, particularly in individuals with genu valgus and internal tibia torsion because of exaggerated angulation as the nerve passes through the fascial layer.
  • At the knee, the saphenous nerve can be injured during arthroscopy or meniscectomy. An ill-fitting knee orthosis can cause focal compression. The infrapatellar branch of the saphenous nerve can be entrapped between the sartorius tendon and the medial femoral condyle causing anteromedial knee pain
  • In the lower leg, the nerve can be injured during saphenous vein harvesting for grafting or varicose vein stripping

Clinical presentation of saphenous nerve injury

  • Clinically saphenous neuropathy presents with sensory loss and occasionally significant neuropathic pain in the medial lower leg extending to the dorsum of the foot, sparing the toes.
  • Isolated infrapatellar branch injuries may cause medial knee pain that can be mistaken for pathology in the medial compartment of the knee. In pure saphenous nerve injury, there should be no motor weakness.
  • A Tinel sign may be elicited along the course of the nerve, and occasionally a neuroma may be palpated.
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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.