Chronic Leg Pain in the Athlete
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Transcript of Chronic Leg Pain in the Athlete
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Chronic Leg PainChronic Leg Painin the Athletein the Athlete
Johan MyburghJohan Myburgh
May 2011May 2011
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HISTORYHISTORY
• 30 year old female
• Recreational runner
• Complains of bilateral calf pain x 4 months
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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
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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
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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
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Other HistoryOther History
• No recent long distance travel or surgery - (DVT)
• No history of lower back pain - referred pain
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EvaluationEvaluation• ObservationStanding:Anterior – (R) shoulder depressed Hyperextension (L) knee Slight internal rotation tibia Overpronation bilateral feetLateral - Flexion of trunk at hipsPosterior – Slight lumbar scoliosis
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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
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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)
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EvaluationEvaluation
• Palpation Bilateral gastrocnemius tenderness ( > medial) (R) Soleus tender and tight Posterior knee normal Superior tibiofibular joint normal
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DiagnosisDiagnosis
• CHRONIC BILATERAL CALF STRAINCHRONIC BILATERAL CALF STRAIN
Secondary to:1.Inadequate rehabilitation initial injury2.Overuse injury 1
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Three Stage AssessmentThree Stage Assessment
1.1. Biologic Biologic Intrinsic. Biomechanical abnormality2:Overpronation Core muscle weaknessExtrinsic: Aggravated running shoesInitial injury not rehabilitated
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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
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TreatmentTreatment
• Physiotherapy:Physiotherapy:Myofacial releaseStretching:Soleus and gastrocnemiusStrengthening:Intrinsic foot musclesSoleus and gastrocnemiusPelvic and core muscles
Home programHome program
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TreatmentTreatment
• Podiatrist/ Orthotist Podiatrist/ Orthotist provided: Custom made orthotics New running shoes
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OutcomeOutcome
• Pain gradually improved
• Finished Two Oceans Half Marathon with no pain
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DiscussionDiscussion
Chronic lower leg painChronic lower leg pain in the athletein the athlete
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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
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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
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Medial Tibial Stress Syndrome Medial Tibial Stress Syndrome
Diffuse pain
Medial border
Decrease with warming up
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Tibial StressTibial Stress FractureFracture
Focal uptake
Linear uptake = MTSS
Posteromedial tibiaLocalized tenderness – medial borderPain walking – rest
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CompartmentCompartment syndromessyndromes
No rest painAggravated by activityTightnessPain subside with restAnterior compartment-Most common
Lateral compartment-Numbness foot
Deep post. Compartment- Posteromedial pain
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NerveNerve entrapmentsentrapments
Deep peroneal nerveDeep peroneal nerveAnterior compartmentAnterior compartmentSuperficial peroneal nerveSuperficial peroneal nerve
Lateral Lateral compartmment
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Muscle sprainsMuscle sprains
• Gastrocnemius sprain Acute Chronic• Soleus sprain
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PAESPAES• Popliteal artery entrapment Anatomical and
functional.
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NerveNerve EntrapmentEntrapment
Sural nerve
Tibial nerve
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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
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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
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Special InvestigationsSpecial Investigations
1. X-ray: Bilateral tibia/fibula2. EMG study3. Bone scan4. MRI/ MRA5. Compartmental pressure testing
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Other special investigationsOther special investigations
• Doppler ultrasound• Ankle/brachial ratios (Pre/post exercise)• D-Dimer• Angiogram
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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
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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
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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
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Thank you