2. Chronic Leg Pain in the Athlete Johan Myburgh May 2011 Johan Myburgh May 2011

3. HISTORYHISTORY 30 year old female Recreational runner Complains of bilateral calf pain x 4 months

4. PAIN HISTORY Starts after running fixed distance (3km), Walk – cramp like pain, Stretching afterwards painful No rest pain/ No night pain No numbness/ paresthesia Pain does not radiate

5. Exercise History New to long distance running Started training with local running club Old worn running shoes – calf discomfort (replaced) Initial running regime: 5 min. run, 1 min. walk Left sided calf sprain 3 weeks into training – No treatment Goal of training: Two Oceans Half Marathon 9 weeks away

6. Medical History No significant past medical history Medication: Oral Birth Control Surgical history: Appendectomy (age 10) Allergies: None Family history: Hypertension, No clotting disorders

7. Other History No recent long distance travel or surgery - (DVT) No history of lower back pain - referred pain

8. Evaluation Evaluation Observation Standing: Anterior – (R) shoulder depressed Hyperextension (L) knee Slight internal rotation tibia Overpronation bilateral feet Lateral - Flexion of trunk at hips Posterior – Slight lumbar scoliosis

9. Evaluation Evaluation Observation Walking: Overpronation bilateral feet Internal rotation tibia Active ankle movements – normal Passive ankle movements Dorsiflexion normal Muscle stretches – Bilateral gastrocnemius and right soleus tightness

10. EvaluationEvaluation Resisted ankle movement – normal Functional tests Pelvic stability: Bilateral Gluteus medius weakness Core muscle strength poor. Lunges poor Special test Neurological - Normal ( Slump test and SLR)

11. EvaluationEvaluation Palpation Bilateral gastrocnemius tenderness ( > medial) (R) Soleus tender and tight Posterior knee normal Superior tibiofibular joint normal

12. DiagnosisDiagnosis CHRONIC BILATERAL CALF STRAIN CHRONIC BILATERAL CALF STRAIN Secondary to: 1.Inadequate rehabilitation initial injury 2.Overuse injury 1

13. Three Stage Assessment 1.Biologic Intrinsic. Biomechanical abnormality 2 : Overpronation Core muscle weakness Extrinsic: Aggravated running shoes Initial injury not rehabilitated

14. Three Stage Assessment 2.Psychological Concerned about fitness/ readiness to compete (8 weeks left preparation) 3.Contextual Family and friends perceptions First half marathon – failure

15. TreatmentTreatment Physiotherapy: Physiotherapy: Myofacial release Stretching: Soleus and gastrocnemius Strengthening: Intrinsic foot muscles Soleus and gastrocnemius Pelvic and core muscles Home program

16. TreatmentTreatment Podiatrist/ Orthotist Podiatrist/ Orthotist provided: Custom made orthotics New running shoes

17. OutcomeOutcome Pain gradually improved Finished Two Oceans Half Marathon with no pain

18. DiscussionDiscussion Chronic lower leg pain in the athlete in the athlete Chronic lower leg pain in the athlete in the athlete

19. Chronic lower leg pain Classification Classification 4 Anterior - Shin pain Common: Stress fracture/ bone stress reaction Medial tibial traction periositis Chronic exertional compartment syndrome Popliteal artery entrapment syndrome Less common: Stress # fibula, Referred pain Nerve and vascular entrapments

20. Chronic lower leg pain Classification Classification 4 Posterior - Calf pain 1.Muscle sprain – gastrocnemius and soleus 2.Claudication-type pain: Vascular – PAES and atherosclerosis Nerve entrapments - tibial + sural nerves

21. ANTERIORANTERIOR Shin pain

22. Medial Tibial Stress Syndrome Diffuse pain Medial border Decrease with warming up

23. Tibial StressFracture Tibial Stress Fracture Focal uptake Linear uptake = MTSS Posteromedial tibia Localized tenderness – medial border Pain walking – rest

24. Compartmentsyndromes Compartment syndromes No rest pain Aggravated by activity Tightness Pain subside with rest Anterior compartment -Most common Lateral compartment -Numbness foot Deep post. Compartment - Posteromedial pain

25. Nerveentrapments Nerve entrapments Deep peroneal nerve Anterior compartment Deep peroneal nerve Anterior compartment Superficial peroneal nerve Lateral m Lateral compartment Superficial peroneal nerve Lateral m Lateral compartment

26. Posteriorpain Posterior pain Calf pain

27. Muscle sprains Gastrocnemius sprain Acute Chronic Soleus sprain

28. PAESPAES Popliteal artery entrapment Anatomical and functional.

29. NerveEntrapment Nerve Entrapment Sural nerve Tibial nerve

30. Differential Diagnosis Chronic Leg Pain in the Athlete 3 Bone/periosteum Medial tibial stress syndrome (“shin splints”) Stress fracture Vascular Popliteal artery entrapment syndrome Intermittent claudication Referred pain Peripheral Nerve entrapment Spinal/radiculopathy Knee abnormality Hip abnormality (especially in young athletes) Muscle/tendon Chronic exertional compartment syndrome Muscle strains Tendinitis/tendinosis Neoplasm Infection

31. Most common causes 3 1.Medial Tibial Stress Syndrome 2.Stress fractures 3.Chronic Exertional Compartment Syndrome Not to be missed: DVT 3. Am J Sports Med August 2005 vol. 33 no. 8 1241-1249

32. Special Investigations 1.X-ray: Bilateral tibia/fibula 2.EMG study 3.Bone scan 4. MRI/ MRA 5.Compartmental pressure testing

33. Other special investigations Doppler ultrasound Ankle/brachial ratios (Pre/post exercise) D-Dimer Angiogram

34. Diagnostic tool (Hx & PE) s Pain at Rest Palpable tenderness Pain at Rest Palpable tenderness No pain at rest Palpable tenderness No pain at rest Palpable tenderness No pain at rest No palpable tenderness tenderness No pain at rest No palpable tenderness tenderness MTSS Stress fracture MTSS Muscle sprains Nerveentrapment Nerve entrapment Muscle sprains Nerveentrapment Nerve entrapment Chronic ECS PAES PAES

36. Specialinvestigations Special investigations X-rayEMGBone scanMRI/MRACompartmental Pressure test Stress fracture ( after 2-3 weeks of Sx) Common peroneal nerve entrapment – tibial + sural n. MTSS Stress fracture PAESChronic ECS

38. REFERENCES 1.Reinking F, Exercise-related leg pain in female collegiate athletes: the influence of intrinsic and extrinsic factors. The American Journal Of Sports Medicine [Am J Sports Med] 2006 Sep; Vol. 34 (9), pp. 1500-7 2.Michael Fredericson, MD * and Cindy Wun, MD, Differential Diagnosis of Leg Pain in the Athlete, J Am Podiatr Med Assoc 93(4): 321-324, 2003 3.Peter H Edwards, MD, Michelle L Wright, and Jodi Hartman, MS, A Practical Approach for the Differential Diagnosis of Chronic Leg Pain in the Athlete. Am J Sports Med August 2005 vol. 33 no. 8 1241-1249 4.Brukner and Khan, Clinical Sports Medicine 3E Rev p 578-589

39. Thank you