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Medial tibial stress syndrome due to methotrexate osteopathy
  1. P Alonso-Bartolome1,
  2. V M Martinez-Taboada2,
  3. A Canga1,
  4. R Blanco2
  1. 1Division of Radiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
  2. 2Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
  1. Correspondence to:
    Dr V M Martínez-Taboada
    Rheumatology Division. Hospital Universitario “Marqués de Valdecilla”, Avda, Valdecilla s/n, 39008, Santander, Spain; vmartinezt{at}

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Methotrexate (MTX) is a folate antagonist with well known side effects, which mainly include haematological and hepatic adverse events, and less frequently lung or bone toxicities. The use of MTX in high doses has been associated with an osteopathy, which is characterised by severe bone pain, osteoporosis, and insufficiency fractures of the legs.1 We present two patients with rheumatoid arthritis (RA) who developed medial tibial stress syndrome (MTSS) while taking low dose MTX.

The first patient, a 69 year old woman, had a history of RA diagnosed in 2001.2 After 1 year’s treatment with MTX (10 mg/week), she reported a 1 month history of severe pain in the medial part of the left tibia. The pain had an acute onset, prevented her from walking, and was relieved by rest. …

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