Table 24 Laura Butz, Natalie King Chris Minning, Fred Roepcke Case 4 Table 24 Laura Butz, Natalie King Chris Minning, Fred Roepcke

15 y/o female complaining of pain in anterior left leg History Decided to go out for school’s cross-country team A couple days after workouts she started complaining of pain in anterior left leg Coach told her it was probably “shin splints” and that she’d probably be fine if she kept running She kept running and pain worsened Pain got worse throughout the night and she went to the ER

Vital Signs All vitals are normal

Physical Exam Musculoskeletal Neurological Left leg red and swollen Anterior aspect of leg sensitive to palpation and felt harder and warmer than other parts of leg Dorsiflexion of foot and toes severely limited Dorsalis pedis pulse was weak and sensory loss was noted between 1st and 2nd Neurological Normal

Dorsiflexion vs. Plantarflexion

Questions What muscles dorsiflex the foot? Tibialis anterior Extensor Hallicus Longus Extensor Digitorum Longus To which compartment do these muscles belong Anterior compartment What is the innervation and blood supply to this compartment Deep fibular n. and anterior tibial a.

Course of Deep Fibular N. and Anterior Tibial Artery

Questions What are the other two compartments of the leg? Lateral Compartment Posterior Compartment Divided into Superficial and Deep Layers

Lateral Compartment of Leg What muscles make up this compartment? Fibularis Long Fibularis Brevis Blood supply and innervation? Fibular artery Superficial fibular n. Actions Eversion and plantarflexion

SF Posterior Compartment of Leg What muscles make up this compartment? Gastrocnemius Soleus Plantaris Blood supply and innervation? Posterior tibial a. Tibial n. Actions Plantarflexion

Deep Posterior Compartment of Leg What muscles make up this compartment? Popliteus Flexor Hallicus Longus Flexor Digitorum Longus Tibialis Posterior Blood supply and innervation? Posterior tibial a. Tibial n. Actions Plantarflexion and inversion

Question What do you think happened to the girl's leg in this case? Overexertion of muscles caused them to swell – no space to expand within anterior compartment Chronic exertional compartment syndrome (CECS) Acute typically caused by trauma What clues would indicate paralysis of anterior compartment muscles? Inability to dorsiflex foot – foot drop

Anterior Tibial Artery What would explain the weak pedal pulse? Anterior tibial artery compression If the artery were completely closed would there still be any blood flow to the dorsum of the foot? Yes, due to the collateral flow through the deep plantar artery

Question How does one explain the sensory loss in the girl’s foot? Injury to the Deep fibular n. Deep fibular n. provides sensory innervation to the adjacent sides of the 1st and 2nd metatarsal

Questions How was the deep fibular nerve compromised? Due to the sudden increase in exercise, the muscles in the anterior compartment swelled, increasing the pressure in the anterior compartment. This may compress the nerve

Questions What else is innervated by the Deep Fibular Nerve? In addition to all muscles in the anterior leg compartment, the Deep Fibular nerve supplies motor innervation to the Extensor Digitorum Brevis. We could test to see if there is motor loss to this muscle to confirm the diagnosis.

Diagnosis Objective pressure measurements are the gold standard for diagnosis The primary characteristic distinguishing the chronic condition is pressure elevation during exercise and a slower return to resting value at the end of exercise

Treatment Rest from activity that is causing the pain Once pain subsides slowly re-introduce stressful exercises Wear proper shoes for athletic activities If “shin splints” are recurring shoe inserts may correct any foot variation causing the pain 18

Treatment In severe cases, fasciotomy may be necessary Cut open compartment to relieve pressure and remove necrotic muscle