Referred pain in the lower leg -- a cause of delayed diagnosis

Three patients presenting with ankle pain are described. In each case the pain was referred from a lesion in the proximal tibia (two osteoid osteomas; one stress fracture). There was considerable delay in diagnosis in two of these cases. It would appear that pain referred from the proximal lower leg to the ankle is not well recognized as a clinical entity. In such cases, radiography of the more proximal limb is suggested. If this proves negative, a bone scan may then be performed.