Running Up That Hill: A Case of Nighttime Arm Pain in a High School Cross-Country Runner

Document Type

Conference Proceeding

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Publication Title

Clin J Sport Med


History: A 16 year-old male cross-country runner presents to the sports medicine clinic with right upper arm pain that began 10 months prior. No history of injury or traumatic event. Describes the pain as achy, present throughout the day, but it is much more significant at night and has been interfering with sleep. The pain has been stable since it's onset and is neither improving nor worsening. Lifting weights will mildly aggravate the pain. He has not tried any medications for treatment. He was evaluated at an urgent care shortly after the pain began. X-rays were performed that showed a periosteal reaction, and he was referred to our department. He denied any fever, chills, malaise, fatigue, weight loss.

Physical Exam: Inspection: No erythema or lesion noted bilaterally. Palpation: Tenderness to palpation in the right mid-humerus. ROM: Full active ROM bilaterally. Muscle strength: 5/5 in biceps, triceps, and rotator cuff bilaterally. Pain reproduced with manual muscle testing of biceps, triceps, and rotator cuff on right side. Neurovascular: Intact, no deficits. Differential Diagnosis: 26. Ewing Sarcoma 27. Chronic Recurrent Multifocal Osteomyelitis 28. Osteoid Osteoma 29. Osteomyelitis 30. Stress Fracture Test Results: XR: Periosteal reaction of the mid shaft of the R humerus. MRI: Marked periosteal thickening and edema of the posteromedial aspect of the R humeral diaphysis. CT: Long segment of periosteal reaction surrounding the diaphysis of the humerus with thickening of the bone cortex. Bone Scan: Area of increased radiotracer uptake at the site of the periosteal reaction. No other lesions are noted. Path: Fragments of reactive woven bone with associated fibrosis and inflammation. Negative for malignancy. Final Diagnosis: Chronic Recurrent Multifocal Osteomyelitis (CRMO).

Discussion: CRMO, also described in the literature as Chronic Non-bacterial Osteomyelitis (CNO), is a rare condition with reported prevalence of 0.4/100 000 worldwide. Typical presentation includes insidious onset nighttime bone pain with or without fevers, and 1 to 20 active bone lesions- most commonly affecting the metaphysis of long bones. Histologic hallmarks of this disease process are bone inflammation in the absence of infection or malignancy. NSAIDs are first line treatment, however some patients require methotrexate, TNF inhibitor and/or bisphosphonate therapy. The IL-1 inhibitor, anakinra, has also been reported as a successful treatment option.

Outcome: Our patient underwent a bone biopsy to rule out malignancy/infection and confirm the diagnosis of CRMO. Due to the rarity of this disease, a second opinion was obtained from an outside pathologist, who confirmed the diagnosis of CRMO. NSAID therapy was initiated with resolution of his pain.

Follow-Up: Four weeks after bone biopsy he was cleared to return to running. He will be evaluated by rheumatology as approximately 25% of patients diagnosed with CRMO have an associated autoimmune disorder, including skin disorders and chronic inflammatory bowel disease. Due to an average reported remission rate of 40% (with common recurrence) he will be followed closely by orthopedic oncology.





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