chronic leg pain in the athlete johan myburgh may 2011 johan myburgh may 2011
TRANSCRIPT
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
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
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