Lower Leg Injuries

Thomas M. Howard, MD, FACSMSports Medicine

DifferentialMTSSStress FractureECSStrain

Tennis LegAchilles

MTSS ECSStress

Fracture

MTSSMedial Tibial Stress

SyndromeAKA Shin Splint

TheoriesSoleus Bridge

Medial Gastroc tightness

Posterior Tibial Periostitis

Tibialis Anterior fatigue

Symptoms

Distal medial leg pain w impact activities

Risk FactorsToo much, too soon, too

fast…PronationRunning on cambered

surfacePoor shoesGastoc-Soleus tightnessWeak Posterior Tibialis

and Anterior Tib.

ExamTenderness along

the distal med Tibial border or anterior shin

No anterior cortical tenderness

Foot pronationTight Heel Cord

ManagementOrthoticsShoe evaluationStrengthening and

stretchingShin SleeveActivity ModificationMonitor for other

conditions

Stress Fractures

EpidemiologyIncidence around

10% of all musculoskeletal injuries

95% of all stress fractures occur in lower extremity46% tibia 15% navicular12% the fibula

PathophysiologyRepetitive 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 FactorsToo much, too soon, too

fast…“out of shape”Pes Cavus, Leg length

issuesThin buildVitamin D Def and

hormonalDisordered EatingPoor Bone QualityWeak core…

ExamSwelling and/or

percussion tendernessTibial or Fibular

Fulcrum TestSingle leg hop

ImagingPlain Film

Periosteal reactionSclerosis

CTBone ScanMRI

…the Dreaded Black Line

ManagementRelative Rest

6-12 weeksFlexibilityCore StrengtheningCalcium? BMDFix intrinsic issues

OrthoticsShoes

Splinting?Bone stimulatorBone graft

Exertional Compartment Syndrome

Anatomy4 muscular

compartmentsAnteriorLateralSuperficial

posteriorDeep posterior

Fascial defects

Anterior CompartmentMuscles

Tib anteriorExt. digitorumExt. hallucis

longusPeroneus tertius

Major nerveDeep peroneal n.

Major vesselsAnt. Tibial

art./vein

Lateral CompartmentMuscles

Peroneus longus and brevis

Major nerveSup. Peroneal

Major vesselsBranch off anterior

tibial artery/vein

Deep PosteriorMuscles

Flex. Digit. longusFlex. Hallucis

longusPopliteusTib. Posterior

Major NerveTibial n.

Major vesselsPost tibial art./vein

Superficial PosteriorMuscles

GastrocSoleusPlantaris

Major nerveSural n.

Major vesselsBranch off tibial

artery/vein

Pathophysiology

Normal exerciseMuscle volume

increases by 20%Intramuscular

pressures exceed 500 mm Hg with contractions

Perfusion during relaxation phase

PathophysiologyControversial,

Probably multifactorialThickened, inelastic

fasciaPossible small

muscle herniationsMuscle hypertrophy (normal vs. other)

Clinical Presentation

HistoryOne or several

compartments>85% bilateralFairly predictable

and reproducible

Risk FactorsUse of creatine

supplementationUse of androgenic

steroidsEccentric exercise

in postpubertal athletes: decreases fascial compliance?

DifferentialClaudication

Buergers dzPopliteal Artery

entrapmentStrainMTSSStress Fracture

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??Prob for Deep

Posterior

Treatment Options

Activity modification for symptom relief

Correct biomechanical problems

Gait retraining: Pose technique (forefoot)

? Deep Tissue MassageSurgery?

Popliteal Artery Entrapment SyndromeClaudication in

young active individual

Calf pain, cramping, color and temp changes

EtiologyAnomalous courseMuscle hypertrophy

Gastroc, Soleus, Popliteus, Plantaris

DiagnosisUSAngiographyMRACTADynamic maneuvers

Treatment

Tennis LegStrain of Medial

Gastroc

Tennis LegPainful pop w

eccentric loadNeg Thompson TestShort term

immobilizationRehabRecovery 2-8 weeks

Achilles RupturePainful pop with

eccentric loadPalpable gapAbnormal ThompsonSurgical or non-

surgical mgt

Non-surgical Plantar flexed cast6-8 weeksRehab~30% recurrent

rupture

SurgicalOpen or

percutaneous

Final Thoughts…Take a good historyLook for training

and biomechanical issues

Consider dynamic assessment

Judicious use of advanced diagnostic studies

Cross-train and relative rest