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Periostitis is a condition that describes inflammation of the periosteum which is a layer of dense connective tissue enveloping the bones. Periostitis may appear in various conditions, but trauma and infections are the most common causes. The diagnosis can be made through patient history, radiography, and magnetic resonance imaging.


The clinical presentation of periostitis may depend on the underlying cause but in most cases, local pain and swelling of the adjacent tissue are present. Additional symptoms of fever, chills, and profound tenderness are suggestive of an infectious etiology, most notable being osteomyelitis, secondary syphilis, actinomycosis (when periostitis of the mandible is seen) or odontogenic infections [1]. In the setting of medial tibial stress syndrome (MTSS) (known as "shin splints”), inflammation of the periosteum leads to the appearance of vague and diffuse pain in the lower extremity, usually in the middle or distal tibia, which is provoked by exertion [2]. In the early stages, pain is worse when starting the exercise and then gradually decreases during training and within minutes of stopping the exercise. However, as the injury progresses, pain occurs with less activity and may even occur at rest. [2]. A similar clinical course can be observed in malignant or autoimmune diseases involving the skeletal system (e.g. leukemia, reactive arthritis, lung cancer with metastatic dissemination in the bones) [1] [3]. In rare cases, multifocal periostitis involving more than one extremity (or even the axial skeleton) and diffuse pain can be seen in patients who are receiving long-term prophylaxis of voriconazole, as this antifungal drug contains fluoride, which is known to induce a periosteal reaction [4] [5].

  • Idiopathic myelofibrosis, a chronic myeloproliferative disorder of unknown origin, is characterized by splenomegaly, extramedullary hematopoiesis, leukoerythroblastosis, teardrop erythrocytes, and myelofibrosis. It is a rare disorder in childhood.[ncbi.nlm.nih.gov]
Bone Pain
  • Awareness of this potential syndrome, which manifests as bone pain, elevated serum alkaline phosphatase and a bone scan suggestive of periostitis, is necessary in LT recipients on long-term voriconazole.[ncbi.nlm.nih.gov]
  • We review the previous literature regarding syphilitic bone pain and periostitis.[ncbi.nlm.nih.gov]
  • A 39-year-old man presented with severe bone pain in the tibiae and forearms in the wake of a poststreptococcal sepsis complicated with pneumonia and erysipelas 4 months earlier.[ncbi.nlm.nih.gov]
  • A 66-year-old man with a history of heart transplant for idiopathic dilated cardiomyopathy presented with progressive bone pain and myalgias. He has been on voriconazole for a pulmonary Aspergillus infection for 9 months.[ncbi.nlm.nih.gov]
  • In 1966, Goldbloom et al. described two children who developed a peculiar clinical picture characterized by intermittent daily bone pain in the lower limbs, fever spikes, increased acute phase reactants and dysproteinaemia.[ncbi.nlm.nih.gov]
Medial Tibial Stress Syndrome
  • Medial tibial stress syndrome: conservative treatment options, Curr Rev Musculoskelet Med, 2009; 2 : 127-133. 3 Hamstra-Wright KL, et al..[kinatex.com]
  • It can be caused by excessive physical activity as well, as in the case of medial tibial stress syndrome (also referred to as tibial periostalgia, soleus periostalgia, or shin splints).[en.wikipedia.org]
  • Ato Ampomah Brown, “Medial Tibial Stress Syndrome: Muscles Located at the Site of Pain,” Scientifica, vol. 2016, Article ID 7097489 (2016). doi:10.1155/2016/7097489 Beck, BR., & Osternig, LR. “Medial tibial stress syndrome.[bouncerehab.com.au]
  • In the setting of medial tibial stress syndrome (MTSS) (known as "shin splints”), inflammation of the periosteum leads to the appearance of vague and diffuse pain in the lower extremity, usually in the middle or distal tibia, which is provoked by exertion[symptoma.com]
  • Medial Tibial Stress Syndrome RE: Chronic Periostitis Treatment 7/2/2009 11:33AM - in reply to NY09 Medial Tibial Stress Syndrome I've battled with chronic medial tibial stress syndrome for nearly 3 years now.[letsrun.com]
Lower Leg Pain
  • All medical data were gathered from enrolled adults with sports-related lower leg pain. A total of 54 patients underwent triple-phase bone scans using skeletal nuclear scintigraphy, which confirmed periostitis in their lower limbs.[ncbi.nlm.nih.gov]
  • There are a number other causes of lower leg pain that can mimic periostitis.[painfreefeet.ca]
Bone Disorder
  • The book details the pathologic and radiologic characteristics of all bone and joint diseases, including arthritis, metastatic bone disease, osteoporosis, trauma, osteomyelitis, developmental bone disorders, and tumor-like lesions.[books.google.com]
Saber Shin
  • shins), but it is a far less common finding in acquired disease. 9 Bone involvement often occurs in the long bones and can also be found in the skull. 9 Patients present with pain over the bony regions.[jucm.com]


Patient history is quite important in evaluating the etiology and course of the disease-causing the symptoms reported by the patient, especially when information such as recent voriconazole use or presence of malignant diseases are obtained. The diagnosis of periostitis as an isolated finding, however, can only be made through imaging studies. Radiography is an easy, effective and quick method to detect some of the key features that support the diagnosis. Irregular nodular calcifications along the interosseous membrane, edema of the periosteum, the presence of exostoses (an exuberant growth of periosteal bone due to inflammation), gross thickening of the affected bones, and a periosteal reaction of various types (single layer, onion skin, sunburst type, etc) are the main findings [2] [5] [6]. In fact, the type of periosteal reaction can be helpful, as "onion skin" type is typical for periostitis ossificans, a type of non-suppurative osteomyelitis [7], and for malignant neoplasms (Ewing's sarcoma, for example), whereas "sunburst" reaction is primarily encountered in benign tumors, such as osteoblastoma [3] [8]. More advanced imaging studies - magnetic resonance imaging (MRI) or computed tomography (CT), or nuclear bone scanning, can be useful for determination of the cause, and to assess the state of the surrounding soft tissue [2].


  • Dermatologists must be attentive to the possibility of autoimmune blistering diseases during ustekinumab treatment.[ncbi.nlm.nih.gov]
  • Therefore, we consider a TNF-blocking strategy as promising for treatment of POPP.[ncbi.nlm.nih.gov]
  • The mycologist recommended long-term treatment with voriconazole after initial recovery. After 7 months of treatment, the patient complained of joint pain and swelling in his hands.[ncbi.nlm.nih.gov]
  • We describe a case of development of painful periostitis deformans in a 39-year-old woman who was receiving long-term voriconazole treatment for Aspergillus infection as a complication of orthotopic liver transplant.[ncbi.nlm.nih.gov]
  • The POPP treatment is debated, and side effect risk of therapies may not be offset by their benefits. We report on a successful treatment with carnitine in a 15-year old boy suffering from POPP.[ncbi.nlm.nih.gov]


  • The prognosis for returning to perform at her previous level of activity without ongoing lameness problems in the right forelimb remained fair to guarded.[cal.vet.upenn.edu]
  • It needs no pharmacological or surgical treatment and has an excellent prognosis. References 1. Rana RS, Jim SW, Ronald LE. Periosteal reaction. AJR Am J Roentgenol 2009; 193:259-72. 2. James HB, Charles AR, James RK. Basic principles.[wajradiology.org]
  • Prevention and prognosis of periostitis Prognosis for periostitis is good as long as treatment is completed. For those with acute periostitis, surgery may be performed and antibiotics administered through IV.[belmarrahealth.com]
  • Prognosis : guarded to good. Pathogenesis Etiology Interosseous ligament tearing. Metacarpal or metatarsal 2 or 4 injury from direct trauma. Metacarpal or metatarsal 2 or 4 fracture MC / MT 2 and 4: fracture . Unknown causes in some cases.[vetstream.com]


  • Mandibular cases were already described for an infectious dental cause, often with an "onion skin" radiographic aspect, but some rare reported cases showed no obvious etiology.[ncbi.nlm.nih.gov]
  • Additional symptoms of fever, chills, and profound tenderness are suggestive of an infectious etiology, most notable being osteomyelitis, secondary syphilis, actinomycosis (when periostitis of the mandible is seen) or odontogenic infections.[symptoma.com]
  • Therefore, histologic evaluation is a must for distinguishing this benign lesion from malignant and infectious etiologies. We present 2 patients with florid periactive periostitis of the phalanges who were treated in our clinic.[ncbi.nlm.nih.gov]
  • Histologic evaluation is commonly required to distinguish this benign lesion from clinically indistinguishable malignant and infectious etiologies.[ncbi.nlm.nih.gov]
  • These were also combined with the text words cancer, rheumatic disease, etiology, pathogenesis, hypothesis, transplant, and treatment. Only the English language literature, with pertinent information, was included.[ncbi.nlm.nih.gov]


  • Epidemiology The number of syphilis cases peaked in the United States in the late 1980s and early 1990s.[jucm.com]
Sex distribution
Age distribution


  • Pathology and Pathophysiology of this disease are described in a clear way. All therapeutic modalities from surgery to antibiotic and hyperbaric oxygen therapy are comprehensively outlined and discussed.[books.google.com]
  • Pathophysiology Injury to interosseous ligament due to instability between MC/MT 2 and 4 and MC/MT 3 desmitis and proliferative new bone formation.[vetstream.com]


  • Early recognition of this condition could prevent inappropriate therapies and reduce morbidity.[ncbi.nlm.nih.gov]
  • Early recognition of this phenomenon is important to prevent unnecessary tests and procedures. Prompt discontinuation of voriconazole should result in improvement of symptoms.[ncbi.nlm.nih.gov]
  • By treating minor injuries right away, you can prevent chronic periostitis from occurring. Prevention of chronic periostitis involves preventing overuse injuries.[belmarrahealth.com]
  • Get informed about the condition, and know about its causes, prevention, symptoms and treatment options.[hxbenefit.com]



  1. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  2. Galbraith RM, Lavallee ME. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009;2(3):127-133.
  3. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
  4. Wermers RA, Cooper K, Razonable RR, et al. Fluoride excess and periostitis in transplant patients receiving long-term voriconazole therapy. Clin Infect Dis. 2011;52(5):604-611.
  5. Skaug M, Spak C, Oza U. Painful periostitis in the setting of chronic voriconazole therapy. Proc (Bayl Univ Med Cent). 2014;27(4):350-352.
  6. Shah KM, Karagir A, Adaki S. Chronic non-suppurative osteomyelitis with proliferative periostitis or Garre's osteomyelitis BMJ Case Rep. 2013;2013: bcr2013009859.
  7. Kannan SK, Sandhya G, Selvarani R. Periostitis ossificans (Garrè's osteomyelitis) radiographic study of two cases. Int J Paediatr Dent. 2006;16(1):59-64.
  8. Sharma V, Chew FS, Hoch B. Periosteal osteoblastoma: Multimodal imaging of a rare neoplasm. Radiol Case Rep. 2009;4(4):329.

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Last updated: 2017-08-09 17:39