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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 Medial Gastroc tightness

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Lower leg injuries

Lower Leg Injuries

Thomas M. Howard, MD, FACSM

Sports Medicine


Differential
Differential

  • MTSS

  • Stress Fracture

  • ECS

  • Strain

    • Tennis Leg

  • Achilles


MTSS

ECS

Stress Fracture


MTSS

  • Medial Tibial Stress Syndrome

  • AKA Shin Splint


Theories
Theories

  • Soleus Bridge

    • Medial Gastroc tightness

  • Posterior TibialPeriostitis

  • Tibialis Anterior fatigue


Symptoms
Symptoms

  • Distal medial leg pain w impact activities


Risk factors
Risk Factors

  • Too much, too soon, too fast…

  • Pronation

  • Running on cambered surface

  • Poor shoes

  • Gastoc-Soleus tightness

  • Weak Posterior Tibialisand Anterior Tib.


Exam

  • Tenderness along the distal med Tibial border or anterior shin

  • No anterior cortical tenderness

  • Foot pronation

  • Tight Heel Cord


Management
Management

  • Orthotics

  • Shoe evaluation

  • Strengthening and stretching

  • Shin Sleeve

  • Activity Modification

  • Monitor for other conditions



Epidemiology
Epidemiology

  • Incidence around 10% of all musculoskeletal injuries

  • 95% of all stress fractures occur in lower extremity

    • 46% tibia

    • 15% navicular

    • 12% the fibula


Pathophysiology
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 factors1
Risk Factors

  • Too much, too soon, too fast…

  • “out of shape”

  • PesCavus, Leg length issues

  • Thin build

  • Vitamin D Def and hormonal

  • Disordered Eating

  • Poor Bone Quality

  • Weak core…


Exam

  • Swelling and/or percussion tenderness

    • Tibial or Fibular

  • Fulcrum Test

  • Single leg hop


Imaging
Imaging

  • Plain Film

    • Periosteal reaction

    • Sclerosis

  • CT

  • Bone Scan

  • MRI



Management1
Management

  • Relative Rest

    • 6-12 weeks

  • Flexibility

  • Core Strengthening

  • Calcium

  • ? BMD

  • Fix intrinsic issues

    • Orthotics

    • Shoes

  • Splinting?

  • Bone stimulator

  • Bone graft


Exertional compartment syndrome
Exertional Compartment Syndrome


Anatomy
Anatomy

  • 4 muscular compartments

    • Anterior

    • Lateral

    • Superficial posterior

    • Deep posterior

  • Fascial defects


Anterior compartment
Anterior Compartment

  • Muscles

    • Tib anterior

    • Ext. digitorum

    • Ext. hallucislongus

    • Peroneus tertius

  • Major nerve

    • Deep peroneal n.

  • Major vessels

    • Ant. Tibial art./vein


Lateral compartment
Lateral Compartment

  • Muscles

    • Peroneus longus and brevis

  • Major nerve

    • Sup. Peroneal

  • Major vessels

    • Branch off anterior tibial artery/vein


Deep posterior
Deep Posterior

  • Muscles

    • Flex. Digit. longus

    • Flex. Hallucislongus

    • Popliteus

    • Tib. Posterior

  • Major Nerve

    • Tibial n.

  • Major vessels

    • Post tibial art./vein


Superficial posterior
Superficial Posterior

  • Muscles

    • Gastroc

    • Soleus

    • Plantaris

  • Major nerve

    • Sural n.

  • Major vessels

    • Branch off tibial artery/vein


Pathophysiology1
Pathophysiology

  • Normal exercise

    • Muscle volume increases by 20%

    • Intramuscular pressures exceed 500 mm Hg with contractions

    • Perfusion during relaxation phase


Pathophysiology2
Pathophysiology

  • Controversial, Probably multifactorial

    • Thickened, inelastic fascia

    • Possible small muscle herniations

    • Muscle hypertrophy

      (normal vs. other)


Clinical presentation
Clinical Presentation

  • History

  • One or several compartments

  • >85% bilateral

  • Fairly predictable and reproducible


Risk factors2
Risk Factors

  • Use of creatine supplementation

  • Use of androgenic steroids

  • Eccentric exercise in postpubertal athletes: decreases fascial compliance?


Differential1
Differential

  • Claudication

    • Buergersdz

  • Popliteal Artery entrapment

  • Strain

  • MTSS

  • Stress Fracture


Diagnostic pressures touliopolous and hershman 1999
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
US Guidance??

  • Prob for Deep Posterior


Treatment options
Treatment Options

  • Activity modification for symptom relief

  • Correct biomechanical problems

  • Gait retraining: Pose technique (forefoot)

  • ? Deep Tissue Massage

  • Surgery?


Popliteal artery entrapment syndrome
Popliteal Artery Entrapment Syndrome

  • Claudication in young active individual

  • Calf pain, cramping, color and temp changes


Etiology
Etiology

  • Anomalous course

  • Muscle hypertrophy

    • Gastroc, Soleus, Popliteus, Plantaris


Diagnosis
Diagnosis

  • US

  • Angiography

  • MRA

  • CTA

  • Dynamic maneuvers



Tennis leg
Tennis Leg

  • Strain of Medial Gastroc


Tennis leg1
Tennis Leg

  • Painful pop w eccentric load

  • Neg Thompson Test

  • Short term immobilization

  • Rehab

  • Recovery 2-8 weeks


Achilles rupture
Achilles Rupture

  • Painful pop with eccentric load

  • Palpable gap

  • Abnormal Thompson

  • Surgical or non-surgical mgt


Non surgical
Non-surgical

  • Plantar flexed cast

  • 6-8 weeks

  • Rehab

  • ~30% recurrent rupture


Surgical
Surgical

  • Open or percutaneous


Final thoughts
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


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