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

2. Differential
MTSS
Stress Fracture
ECS
Strain
Tennis Leg
Achilles

3. MTSS
ECS
Stress Fracture

4. MTSS
Medial Tibial Stress Syndrome
AKA Shin Splint

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

6. Symptoms
Distal medial leg pain w impact activities

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

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

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

10. Stress Fractures

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

12. 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

13. 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…

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

15. Imaging
Plain Film
Periosteal reaction
Sclerosis CT
Bone Scan
MRI

16. …the Dreaded Black Line

17. 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

18. Exertional Compartment Syndrome

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

20. 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

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

22. 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

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

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

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

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

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

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

29. 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)

30. US Guidance??
Prob for Deep Posterior

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

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

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

34. Diagnosis US
Angiography
MRA
CTA
Dynamic maneuvers

35. Treatment

36. Tennis Leg
Strain of Medial Gastroc

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

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

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

40. Surgical
Open or percutaneous

41. 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