Lower leg injuries
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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

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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


Lower leg injuries

MTSS

ECS

Stress Fracture


Lower leg injuries

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.


Lower leg injuries

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


Stress fractures

Stress Fractures


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…


Lower leg injuries

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


The dreaded black line

…the Dreaded Black Line


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


Treatment

Treatment


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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