Thomas M. Howard, MD, FACSM Sports Medicine Lower Leg Injuries Thomas M. Howard, MD, FACSM Sports Medicine

Differential MTSS Stress Fracture ECS Strain Tennis Leg Achilles

MTSS ECS Stress Fracture

MTSS Medial Tibial Stress Syndrome AKA Shin Splint

Theories Soleus Bridge Posterior Tibial Periostitis Medial Gastroc tightness Posterior Tibial Periostitis Tibialis Anterior fatigue

Symptoms Distal medial leg pain w impact activities

Risk Factors Too much, too soon, too fast… Pronation Running on cambered surface Poor shoes Gastoc-Soleus tightness Weak Posterior Tibialis and Anterior Tib.

Exam Tenderness along the distal med Tibial border or anterior shin No anterior cortical tenderness Foot pronation Tight Heel Cord

Management Orthotics Shoe evaluation Strengthening and stretching Shin Sleeve Activity Modification Monitor for other conditions

Stress Fractures

Epidemiology Incidence around 10% of all musculoskeletal injuries 95% of all stress fractures occur in lower extremity 46% tibia 15% navicular 12% the fibula

Usually takes at least 2-3 weeks to develop Pathophysiology Repetitive loading alters bone’s microstructure (↑ number & size microfx) Response is ↑ oseteoclastic & osteoblastic activity Usually results in a stronger bone able to withstand greater loads Initially osteoblastic activity lags behind resorptive properties of osteoclasts Process leaves bone susceptible to fatigue failure if the area is continually stressed without adequate time for repair Couple this w muscle dysfxn from overuse results in focal bending stresses exceeding structural & physiologic tolerance of bone Usually takes at least 2-3 weeks to develop

Risk Factors Too much, too soon, too fast… “out of shape” Pes Cavus, Leg length issues Thin build Vitamin D Def and hormonal Disordered Eating Poor Bone Quality Weak core…

Exam Swelling and/or percussion tenderness Fulcrum Test Single leg hop Tibial or Fibular Fulcrum Test Single leg hop

Imaging Plain Film Periosteal reaction Sclerosis CT Bone Scan MRI

…the Dreaded Black Line

Management Relative Rest Flexibility Core Strengthening Calcium ? BMD 6-12 weeks Flexibility Core Strengthening Calcium ? BMD Fix intrinsic issues Orthotics Shoes Splinting? Bone stimulator Bone graft

Exertional Compartment Syndrome

Anatomy 4 muscular compartments Fascial defects Anterior Lateral Superficial posterior Deep posterior Fascial defects

Anterior Compartment Muscles Major nerve Major vessels Tib anterior Ext. digitorum Ext. hallucis longus Peroneus tertius Major nerve Deep peroneal n. Major vessels Ant. Tibial art./vein

Lateral Compartment Muscles Major nerve Major vessels Peroneus longus and brevis Major nerve Sup. Peroneal Major vessels Branch off anterior tibial artery/vein

Deep Posterior Muscles Major Nerve Major vessels Flex. Digit. longus Flex. Hallucis longus Popliteus Tib. Posterior Major Nerve Tibial n. Major vessels Post tibial art./vein

Superficial Posterior Muscles Gastroc Soleus Plantaris Major nerve Sural n. Major vessels Branch off tibial artery/vein

Pathophysiology Normal exercise Muscle volume increases by 20% Intramuscular pressures exceed 500 mm Hg with contractions Perfusion during relaxation phase

Pathophysiology Controversial, Probably multifactorial Thickened, inelastic fascia Possible small muscle herniations Muscle hypertrophy (normal vs. other)

Clinical Presentation History One or several compartments >85% bilateral Fairly predictable and reproducible

Risk Factors Use of creatine supplementation Use of androgenic steroids Eccentric exercise in postpubertal athletes: decreases fascial compliance?

Differential Claudication Popliteal Artery entrapment Strain MTSS Buergers dz Popliteal Artery entrapment Strain MTSS Stress Fracture

Diagnostic Pressures (Touliopolous and Hershman, 1999.) POSITIVE FINDINGS: Resting pressure > 15 mm Hg 1 minute post exercise > 30 mm Hg 5 minute post exercise > 20 mm Hg **Baseline pressure does not return for > 15 minutes. (suspicious) (Garcia-Mata et al., 2001)

US Guidance?? Prob for Deep Posterior

Treatment Options Activity modification for symptom relief Correct biomechanical problems Gait retraining: Pose technique (forefoot) ? Deep Tissue Massage Surgery?

Popliteal Artery Entrapment Syndrome Claudication in young active individual Calf pain, cramping, color and temp changes

Etiology Anomalous course Muscle hypertrophy Gastroc, Soleus, Popliteus, Plantaris

Diagnosis US Angiography MRA CTA Dynamic maneuvers

Treatment

Tennis Leg Strain of Medial Gastroc

Tennis Leg Painful pop w eccentric load Neg Thompson Test Short term immobilization Rehab Recovery 2-8 weeks

Achilles Rupture Painful pop with eccentric load Palpable gap Abnormal Thompson Surgical or non-surgical mgt

Non-surgical Plantar flexed cast 6-8 weeks Rehab ~30% recurrent rupture

Surgical Open or percutaneous

Final Thoughts… Take a good history Look for training and biomechanical issues Consider dynamic assessment Judicious use of advanced diagnostic studies Cross-train and relative rest