STRESS-INDUCED SPICULATED PERIOSTEAL REACTION

APPEARING AS A MALIGNANT BONE TUMOR:

A CASE REPORT
Daniel W. Haun, DC,a Norman W. Kettner, DC,b and Deanna K. Bates, DC c

ABSTRACT

Objective: The aim of this study was to describe the appearance of a rare occurrence of a spiculated periosteal reaction
caused by stress injury and the subsequent diagnostic assessments. A proposed mechanism for the etiology of stress-
induced periosteal reactions in this case is offered.
Clinical Features: A 54-year-old female had ankle pain for 1 year. Radiographs revealed a spiculated periosteal
reaction of the distal fibula. In light of the clinical history of prior breast carcinoma, the possibility of metastatic disease
was entertained.
Intervention and Outcome: Scintigraphy and magnetic resonance imaging were used in the diagnostic evaluation
of this patient. Malignancy was ruled out on the basis of the magnetic resonance imaging findings, and an etiology of a
stress reaction was proposed based on the scintigraphic findings.
Conclusion: Stress-induced spiculated periosteal reactions are a rare occurrence. This case illustrates the role
that advanced imaging plays in the assessment of a suspicious periosteal reaction. (J Manipulative Physiol Ther
2006;29:595.e1- 595.e5)
Key Indexing Terms: Periostitis; Radiology; Chiropractic; Magnetic resonance imaging

Periosteal reactions are caused by inflammation or
irritation of the periosteal membrane, resulting in the
stimulation of new bone formation.1 There are many causes
of periosteal reaction, some benign and others aggressive.2
Spiculated periosteal reactions are commonly associated
with an aggressive pathological process, most often a
primary malignant bone tumor. Stress injuries typically
produce a solid uninterrupted periosteal reaction. In a
review of the indexed literature from 1970 to the present
using the PubMed database, 2 reports of a spiculated
periosteal reaction associated with a stress injury were
found. The MANTIS database was also searched, with no
similar cases reported. Advanced imaging modalities,
a
Resident, Department of Radiology, Logan College of Chiro-
practic, Private Practice, Chesterfield, Mo.
b
Chairman, Department of Radiology, Logan College of
Chiropractic, Private Practice, Chesterfield, Mo.
c
Faculty, Chiropractic Science Division, Logan College of
Chiropractic, Private Practice, Chesterfield, Mo.
Submit requests for reprints to: Norman Kettner, DC, Logan
College of Chiropractic, Department of Radiology, PO Box 1065,
1851 Schoettler Road, Chesterfield, MO 63006-1065
(e-mail: norman.kettner@logan.edu).
Paper submitted September 23, 2005; in revised form December
12, 2005; accepted April 29, 2006.
0161-4754/$32.00
Copyright D 2006 by National University of Health Sciences.
doi:10.1016/j.jmpt.2006.07.004
namely bone scintigraphy and magnetic resonance imaging
(MRI), play a key role in the diagnosis of stress injury.3
We present a case of spiculated periosteal reaction in the
distal fibula of a 54-year-old woman. The radiographic
appearance with the patient history raised the possibility of
an aggressive process. Scintigraphy and MRI were used to
make the diagnosis of a stress-induced periostitis.
CASE REPORT
A 54-year-old woman had experienced left ankle pain
for 1 year. The initial event was described as a mild
inversion sprain. The patient did not notice significant pain
immediately after the injury. Four months later, the pain
gradually worsened, and she presented to her primary care
physician for evaluation. Radiographs taken at that time
were negative. Several months later, she presented to a
chiropractic physician for treatment. The pain was localized
to the medial side of the ankle. Physical examination
showed pronation of the left foot. The patient had under-
gone treatment of breast carcinoma 5 years earlier.
Radiography of the ankle was again performed and
revealed a spiculated periosteal reaction of the distal
metadiaphyseal region of the fibula (Fig 1). A solid
periosteal reaction with slight undulation was seen on the
tibia. The remainder of the radiographic examination was
unremarkable. A history of breast carcinoma and the

595.e1
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Speculated Periosteal Reaction September 2006

Fig 1. The AP radiograph of the ankle (A) shows a spiculated periosteal reaction on the medial margin of the metadiaphyseal region of
the distal fibula (arrows). Close-up view showing the spiculation and irregularity of the periosteum (B).

Fig 2. A T1-weighted gadolinium-enhanced axial magnetic resonance image through the distal leg (A) shows enhancement of the
periosteum (arrow) at the insertion of the IOM. T2-weighted magnetic resonance axial image (B) shows high signal intensity in the same
location, which is indicative of inflammation. The bone marrow and cortex are uninvolved.
Journal of Manipulative and Physiological Therapeutics Haun et al 595.e3
Volume 29, Number 7 Speculated Periosteal Reaction

Fig 3. Proton-density transverse magnetic resonance image through the level of the talus (A) shows inhomogeneous signal intensity
(arrowhead) in the PTT, which is indicative of tendinopathy. Also noted was an increase in fluid in the tendon sheath (arrow), which is
indicative of tenosynovitis. T2-weighted transverse magnetic resonance image through the level of the talus (B) shows high signal
intensity within the PTT (arrowhead), which is suggestive of a partial tear. An excessive amount of high signal intensity fluid is also
observed within the tendon sheath surrounding the PTT indicating tenosynovitis.

spiculated appearance of the periosteal reaction on the
fibula warranted suspicion of metastasis or another aggres-
sive process, such as osteomyelitis.
A delayed whole body bone scan revealed radiotracer
accumulation surrounding the left ankle, including the distal
fibula. The anterior surface of the left tibia showed a
nonfocal distribution of accumulation. There were no sites
of increased activity elsewhere in the skeleton. The
increased accumulation of radioisotope was attributed to
prior trauma and altered use of the tibia by the interpreting
radiologist. The radionuclide study was consistent with
stress reaction and enthesopathy; however, metastatic
disease was not fully excluded.
An MRI of the left ankle was ordered and showed
normal marrow signal intensity throughout the examination,
with no evidence of skeletal metastasis. Gadolinium
contrast administration revealed mild enhancement along
the insertion of the interosseous membrane (IOM) at the
distal fibula (Fig 2). A partial tear and tenosynovitis of the
posterior tibial tendon (PTT) were discovered incidentally
(Fig 3). The periosteal abnormality was felt to represent
a benign, stress-induced lesion of the periosteum related to
the IOM.
After serious pathology was ruled out, the patient was
subsequently treated with interferential electrotherapy and
therapeutic ultrasound. Long axis traction of the ankle was
performed. Orthotics were suggested to correct the prona-
tion of the foot, but the patient did not comply with the
recommendation. Because of unforeseen personal circum-
stances, the patient discontinued care.
DISCUSSION
Periosteal reactions are important radiographic signs in
characterizing lesions of bone. There are 4 basic types of
periosteal reactions: solid, lamellated, spiculated (sunburst),
and Codman triangle. Solid periosteal reactions are usually
associated with benign processes. The remaining types are
usually associated with more aggressive processes. Spicu-
lated (or sunburst) periosteal reactions are predominantly
caused by aggressive lesions. Common causes of a
spiculated reaction include osteosarcoma, Ewing sarcoma,
metastasis,4 and infection. Rarely, spiculated periosteal
reactions can be caused by trauma or stress.5,6 A more
detailed discussion on periosteal reactions is provided by the
review article by Wenaden et al.7
The MRI exam revealed no evidence of metastatic
disease. Metastasis causes edema within the medullary
space of bone. No such findings were present in this case.
We hypothesize that the spiculated periosteal reaction in this
case was caused by repetitive stress on the distal fibula by
the IOM. It was incidentally discovered that the patient had
a partial tear and tenosynovitis of the PTT. Weight bearing
was altered in the left lower extremity as a result. This may
595.e4 Haun et al
Speculated Periosteal Reaction
have caused abnormal stress on the fibula and IOM, which
resulted in the spiculated periostitis. Because of the insertion
of the IOM on the fibular periosteum, the periostitis took on
a spiculated appearance rather than the typical solid
appearance. In this case, the pattern of periosteal reaction
is similar to the orientation of the fibers of the IOM as they
insert on the fibula.
The source of the abnormal stresses on the IOM and the
fibula may have been the pronation of the foot and altered
weight bearing due to the partial tear of the PTT. The fibula is
thought to carry as much as 15% of the load upon the leg.8
The IOM primarily acts as a means to transfer loads from the
tibia to fibula and also to resist bowing forces on the fibula
and tibia.9 Altered position of the ankle and subtalar joints
affects how the weight is transferred through the IOM. Two
cases of stress-induced spiculated periosteal reaction have
been published.5,6 In both cases, the lesions were in the ulna
and were due to repetitive stresses caused by sports
participation. In one case, the spiculated reaction occurred
along with evidence of radioulnar IOM stress injury.5 The
authors hypothesized that pulling forces of the IOM may
have contributed to the spiculated reaction on the ulna.
In addition, PTT tears are not uncommon in this patient
population.10 Injuries to the PTT are most frequently seen in
females around the fifth to sixth decade. Most tears occur at
the musculotendinous junction, approximately 6 cm prox-
imal to its insertion on the tarsal navicular.
Imaging of stress injuries in bone is largely performed
by radionuclide scintigraphy and MRI. Scintigraphy has a
sensitivity approaching 100% for bone stress injuries.11
False-negative diagnoses have been reported. Increased
uptake in a regional or large distribution typically indicates
a stress lesion. Asymptomatic stress injuries can also be
detected, appearing as clusters of increased uptake.11 The
scintigraphic findings must be correlated with the clinical
presentation. Metastasis or other lesions of bone, such as
osteomyelitis and primary bone tumors, can have a similar
appearance on scintigraphy. In some cases, other imaging
modalities, such as MRI, are necessary to make an
accurate diagnosis.
Magnetic resonance imaging has equal, if not better,
sensitivity than radionuclide imaging for bone stress
injuries.12 MRI is also more specific than scintigraphy.13
Information about the surrounding soft tissues is obtained in
addition to the changes seen in bone. The pulse sequences
that best show stress injuries in bone are T2 and short tau
inversion recovery techniques.14 High signal areas in
cortical bone, periosteum, and bone marrow typically
indicate edema. If radiographs are negative and scintigraphy
is positive, MRI can provide useful additional informa-
tion.15 Advantages over 3-phase bone scintigraphy include
lack of ionizing radiation and less imaging time.16 As with
any diagnostic procedure, there is never 100% sensitivity.
Compared with other modalities, such as computed tomog-
raphy and skeletal scintigraphy, MRI imaging has a high
Journal of Manipulative and Physiological Therapeutics
September 2006
sensitivity for detection of osseous metastasis. The lack of
marrow involvement on the MRI and the pattern of uptake
on the radionuclide images speak toward a benign etiology.
A radiographic appearance similar to the case presented
is seen in acute traumatic injuries to the IOM of the leg.
These syndesmosis sprains are uncommon and require a
longer recovery period than typical ankle sprains.17,18
Calcification and ossification of the IOM often follow these
sprains and can become symptomatic.19 This ossification
can have the appearance of a periosteal reaction along the
margins of the distal tibia and fibula.
CONCLUSION
Periosteal reactions can be caused by many pathological
processes. Stress injury commonly causes a solid periosteal
reaction. In rare instances, a spiculated periosteal reaction
can be elicited, and advanced imaging should follow. The
stress-induced response can mimic a more aggressive
process and complicate the diagnostic process. Scintigraphy
and MRI are very sensitive in the detection of stress injury.
MRI is more specific than scintigraphy and may provide
valuable additional information as occurred in this case.
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