Chronic Leg PainChronic Leg Painin the Athletein the Athlete

Johan MyburghJohan Myburgh

May 2011May 2011

HISTORYHISTORY

• 30 year old female

• Recreational runner

• Complains of bilateral calf pain x 4 months

PAIN HISTORYPAIN 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

Exercise HistoryExercise 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

Medical HistoryMedical History

• No significant past medical history• Medication: Oral Birth Control• Surgical history: Appendectomy (age 10)• Allergies: None• Family history: Hypertension, No clotting

disorders

Other HistoryOther History

• No recent long distance travel or surgery - (DVT)

• No history of lower back pain - referred pain

EvaluationEvaluation• ObservationStanding:Anterior – (R) shoulder depressed Hyperextension (L) knee Slight internal rotation tibia Overpronation bilateral feetLateral - Flexion of trunk at hipsPosterior – Slight lumbar scoliosis

EvaluationEvaluation• ObservationWalking: Overpronation bilateral feet Internal rotation tibia• Active ankle movements – normal• Passive ankle movements Dorsiflexion normal Muscle stretches – Bilateral gastrocnemius

and right soleus tightness

EvaluationEvaluation

• Resisted ankle movement – normal • Functional tests Pelvic stability: Bilateral Gluteus medius

weakness Core muscle strength poor. Lunges poor • Special testNeurological - Normal ( Slump test and SLR)

EvaluationEvaluation

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

DiagnosisDiagnosis

• CHRONIC BILATERAL CALF STRAINCHRONIC BILATERAL CALF STRAIN

Secondary to:1.Inadequate rehabilitation initial injury2.Overuse injury 1

Three Stage AssessmentThree Stage Assessment

1.1. Biologic Biologic Intrinsic. Biomechanical abnormality2:Overpronation Core muscle weaknessExtrinsic: Aggravated running shoesInitial injury not rehabilitated

Three Stage AssessmentThree Stage Assessment

2.2. PsychologicalPsychologicalConcerned about fitness/ readiness to compete(8 weeks left preparation)3.3. ContextualContextualFamily and friends perceptionsFirst half marathon – failure

TreatmentTreatment

• Physiotherapy:Physiotherapy:Myofacial releaseStretching:Soleus and gastrocnemiusStrengthening:Intrinsic foot musclesSoleus and gastrocnemiusPelvic and core muscles

Home programHome program

TreatmentTreatment

• Podiatrist/ Orthotist Podiatrist/ Orthotist provided: Custom made orthotics New running shoes

OutcomeOutcome

• Pain gradually improved

• Finished Two Oceans Half Marathon with no pain

DiscussionDiscussion

Chronic lower leg painChronic lower leg pain in the athletein the athlete

Chronic lower leg pain Chronic lower leg pain

• ClassificationClassification4

• Anterior - Shin painCommon: 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

Chronic lower leg pain Chronic lower leg pain

• ClassificationClassification4

• Posterior - Calf pain1.Muscle sprain – gastrocnemius and soleus2.Claudication-type pain:Vascular – PAES and atherosclerosisNerve entrapments - tibial + sural nerves

ANTERIORANTERIOR

Shin pain

Medial Tibial Stress Syndrome Medial Tibial Stress Syndrome

Diffuse pain

Medial border

Decrease with warming up

Tibial StressTibial Stress FractureFracture

Focal uptake

Linear uptake = MTSS

Posteromedial tibiaLocalized tenderness – medial borderPain walking – rest

CompartmentCompartment syndromessyndromes

No rest painAggravated by activityTightnessPain subside with restAnterior compartment-Most common

Lateral compartment-Numbness foot

Deep post. Compartment- Posteromedial pain

NerveNerve entrapmentsentrapments

Deep peroneal nerveDeep peroneal nerveAnterior compartmentAnterior compartmentSuperficial peroneal nerveSuperficial peroneal nerve

Lateral Lateral compartmment

PosteriorPosterior painpain

Calf pain

Muscle sprainsMuscle sprains

• Gastrocnemius sprain Acute Chronic• Soleus sprain

PAESPAES• Popliteal artery entrapment Anatomical and

functional.

NerveNerve EntrapmentEntrapment

Sural nerve

Tibial nerve

Differential Diagnosis Chronic Leg Pain Differential Diagnosis Chronic Leg Pain in the Athletein the Athlete33

Bone/periosteumMedial tibial stress syndrome (“shin splints”)Stress fracture

Vascular Popliteal artery entrapment syndromeIntermittent claudication

Referred painPeripheral Nerve entrapmentSpinal/radiculopathyKnee abnormalityHip abnormality (especially in young athletes)

Muscle/tendon Chronic exertional compartment syndromeMuscle strainsTendinitis/tendinosis

Neoplasm

Infection

Most common causesMost common causes33

1. Medial Tibial Stress Syndrome2. Stress fractures3. Chronic Exertional Compartment Syndrome

Not to be missed: DVT

3. Am J Sports Med August 2005 vol. 33 no. 8 1241-1249

Special InvestigationsSpecial Investigations

1. X-ray: Bilateral tibia/fibula2. EMG study3. Bone scan4. MRI/ MRA5. Compartmental pressure testing

Other special investigationsOther special investigations

• Doppler ultrasound• Ankle/brachial ratios (Pre/post exercise)• D-Dimer• Angiogram

Diagnostic tool (Hx & PE)Diagnostic tool (Hx & PE)

• sPain at Rest Pain at Rest Palpable Palpable tendernesstenderness

No pain at rest No pain at rest Palpable Palpable tendernesstenderness

No pain at restNo pain at restNo palpableNo palpable tendernesstenderness

MTSSMTSSStress fractureStress fracture

Muscle sprainsMuscle sprainsNerveNerve entrapmententrapment

Chronic ECSChronic ECSPAESPAES

SpecialSpecial investigationsinvestigations

X-ray EMG Bone scan MRI/MRA Compartmental Pressure test

Stress fracture( after 2-3 weeks of Sx)

Common peroneal nerve entrapment –tibial + sural n.

MTSSStress fracture

PAES Chronic ECS

REFERENCES1. 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

Thank you