Chronic Leg Pain in the Athlete

2. Chronic Leg Painin the Athlete Johan Myburgh May 2011

3. HISTORY • 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 • 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 • 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. Evaluation • 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. Evaluation • Palpation Bilateral gastrocnemius tenderness ( > medial) (R) Soleus tender and tight Posterior knee normal Superior tibiofibular joint normal

12. Diagnosis • CHRONIC BILATERAL CALF STRAIN Secondary to: • Inadequate rehabilitation initial injury • Overuse injury 1

13. Three Stage Assessment • Biologic Intrinsic. Biomechanical abnormality2: Overpronation Core muscle weakness Extrinsic: Aggravated running shoes Initial injury not rehabilitated

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

15. Treatment • Physiotherapy: Myofacial release Stretching: Soleus and gastrocnemius Strengthening: Intrinsic foot muscles Soleus and gastrocnemius Pelvic and core muscles Homeprogram

16. Treatment • Podiatrist/ Orthotistprovided: Custom made orthotics New running shoes

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

18. Discussion Chronic lower leg pain in the athlete

19. Chronic lower leg pain • Classification4 • 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 • Classification4 • Posterior - Calf pain • Muscle sprain – gastrocnemius and soleus • Claudication-type pain: Vascular – PAES and atherosclerosis Nerve entrapments - tibial + sural nerves

21. ANTERIOR Shinpain

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

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

24. Compartmentsyndromes 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 Deep peroneal nerve Anterior compartment Superficial peroneal nerve Lateral compartment

26. Posteriorpain Calf pain

27. Muscle sprains • Gastrocnemius sprain Acute Chronic • Soleus sprain

28. PAES • Popliteal artery entrapment Anatomical and functional.

29. NerveEntrapment Tibial nerve Sural nerve

30. Differential Diagnosis Chronic Leg Pain in the Athlete3

31. Most common causes3 • Medial Tibial Stress Syndrome • Stress fractures • 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 • X-ray: Bilateral tibia/fibula • EMG study • Bone scan • MRI/ MRA • 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 No pain at rest No palpable tenderness No pain at rest Palpable tenderness MTSS Stress fracture Muscle sprains Nerveentrapment Chronic ECS PAES

36. Specialinvestigations

38. REFERENCES • 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 • 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 • 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 • Brukner and Khan, Clinical Sports Medicine 3E Rev p 578-589

39. Thank you