? Stress fracture distal tibila epiphysis

Scenario: 12 year old boy presented with a 10 day history of right ankle pain with no major history of injury. He is a boy who is heavily involved in playing 3 aports (soccer, rugby, hurling) and trains at least 3 nights per week. He originally noted ankle pain after soccer training one evening. He did not recall an injury while playing non-contact or contact.. pain just started on returning home... that night he took some painrelief and he was fine the following morning.. he rested for 1 day but went to rugby training following day.. pain started on running so he stopped.. went home, took neurofen and rested.. again he rested for a few days and tried to go back training again with no success as it brought on pain again.

Pain presents medially ankle. He has FROM ankle with 5/5 strength and no pain with resisted tests. Ligaments appear in tact and no laxity or pain noted with testing. Only positive findings are pain (VAS8-9/10) on palpation distal tibia proximal to medial malleolus. Medial malleolus intself is not tender but is notably larger than the left side. Distal tib/fib joint appeared fine. He also had a bruise and bony tenderness on thr calcaneus distal to achilles insertion.. achilles was fine on palpation and no pain provoked with stretch, rested testing, heel raises etc. Mum reports wears good boots...proper size... no heel rubbing noted by child.

I have recommended x-ray to outrule or inspect if he does have a possible stress fracture to the dustal tibia epiphysis considering this child plays +++ sport. Mother also notes he has undergone a growth spurt in last month.

Question: Just wondering has anyone any experrence in this area...? stress # distal tibial epiphysis... has anyone ever saw a similar presentation/case??

Cheers.. LohanB3