Working Diagnosis:
Pretibial Varix with Intraosseous Venous
Drainage Anomaly

Treatment:
The patient was allowed to bear weight and return to activity as tolerated on the right lower extremity. Pain exacerbation was likely due to minor trauma. She was referred to vascular surgery for evaluation. Treatment options offered to the patient included ambulatory phlebectomy, ligation and stripping, and percutaneous ablation. Patient elected conservative management with compression stocking and elevation.

Outcome:
Patient will continue to monitor her symptoms and return to the vascular surgeon if she becomes more symptomatic and/or would like to pursue interventional treatment.

Author's Comments:
The incidence of varicose veins in the lower extremities affects about 15% of the world's population. These varicose veins rarely can communicate with an intraosseous vein such as in this patient. It is hypothesized that intraosseous veins may be pre-existing vessels that enlarge over time due to elevated venous pressure caused by deep vein thrombosis, venous insufficiency, and/or venous hypertension. Pain may occur due to venous distension against the vein wall and periosteum or exacerbation due to trauma. Intraosseous drainage may also lead to venous valve impairments which can increase a patient's risk of thromboembolic events.

Editor's Comments:
As illustrated in this case, it is important to rule out high risk and more common conditions first such as insufficiency or stress fractures and deep vein thrombosis. Once these are ruled out, you can then pursue other, more rare causes of persistent tibial pain such as pretibial varix. One should keep pretibial varix in mind in an individual who presents with anterior shin pain and has evidence of varicose veins, as pretibial varix may increase intravenous pressure resulting in varicosity. There should also be increased suspicion with an X-ray finding of a small radiolucent area in the anterior tibial cortex which should prompt more advanced imaging.

References:
Boutin RD, Sartoris DJ, Rose SC, et al. Intraosseous venous drainage anomaly in patients with pretibial varices: imaging findings. Radiology. 1997;202(3):751-757. Chun S, Son JW, Ryu JW. Localized Pretibial Varicose Vein Caused by an Intraosseous Venous Anomaly. Korean J Thorac Cardiovasc Surg. 2020;53(3):147-149.

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