2ND ANNUAL PODIATRIC SPORTS MEDICINE
CONFERENCE
LONDON – 5TH JULY 2013
EXERCISE INDUCED LEG PAIN IT IS ALL IN THE HISTORY
Dr Nat Padhiar MSc PhD FCPodS FFPM RCPS(Glas)
Consultant Podiatric Surgeon & Honorary Reader
[email protected]
ACADEMIC - http://www.whri.qmul.ac.uk/sportsmed/
http://www.grandround-e-med.com
PRIVATE - http://www.londonsportscare.com
http://www.londonsportscare.co.uk
HISTORY
A doctor who cannot take a good
history and a patient who cannot
give one are in danger of giving
and receiving bad treatment.
SHIN SPLINTS
 ‘Shin Splints’ – An umbrella or basket term to
describe a number of differing conditions
affecting the lower leg.
 AMA(1968) Pain and discomfort in the leg
from repetitive running on hard surfaces or,
forcible extensive use of flexors…………
The diagnosis should be limited to musculotendinous inflammation excluding a stress
fracture or, ischaemic disorder.
EILP - DIFFERENTIAL DIAGNOSIS
1.
2.
3.
4.
MEDIAL TIBIAL STRESS SYNDROME.
CHRONIC COMPARTMENT SYNDROME.
STRESS FRACTURE.
SUPERFICIAL PERONEAL NERVE
ENTRAPMENT SYNDROME.
5. SURAL NERVE ENTRAPMENT SYNDROME.
6. RADICULOPATHY.
7. SPINAL STENOSIS.
8. POPLITEAL ARTERY ENTRAPMENT
SYNDROME.
9. POPLITEAL ARTERY STENOSIS.
10. MUSCLE HERNIA.
11. AV FISTULA.
12. OSTEOID OSTEOMA.
13. OSTEOCLASTOMA.
14. DIABETIC NEUROPATHY & ISCHAEMIA.
15. McARDLE SYNDROME.
16. DUCHENNE MD.
17. BECKER MD.
18. EOSINOPHILIC FASCIITIS.
19. TARUIS DISEASE.
20. DI MAURO’S DISEASE.
21. TOXIC OIL SYNDROME.
22. HPOA.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
SICKLE CELL ANAEMIA.
POPLITEAL CYST RUPTURE.
GUILLAIN-BARRE SYNDROME.
SARCOMA OF THE SOLEUS.
BARTTER’S SYNDROME.
GITELMAN’S SYNDROME.
TIBIALIS ANTERIOR MUSCLE SYNDROME.
ACCESSORY SOLEUS SYNDROME.
ACCESSORY FHL SYNDROME.
MUSCLE TEAR.
MYOFASCIAL TEAR.
INFECTION.
DELAYED ONSET MUSCLE SORENESS.
CECS FOLLOWING ACUTE COMPARTMENT
SYNDROME.
37. MYOSITIS OSSIFICANS.
38. HAEMATOMA.
EXERCISE INDUCED LEG PAIN
DIAGNOSIS
 HISTORY
 EXAMINATION
 INVESTIGATIONS
HISTORY
• DITRIBUTION – BILATERAL OR UNILATERAL
•
SITE OF PAIN
• ONSET OF PAIN OR SYMPTOMS
• WHAT BRINGS OR PROVOKES THE PAIN OR SYMPTOMS
• DOES THE REST MAKE THE PAIN OR SYMPTOMS BETTER
• TIGHTNESS, CRAMPS, SWELLING, PARAESTHESIA, NUMBNESS ETC.
• NOCTURNAL PAIN OR SYMPTOMS.
• FAMILY HISTORY
• SYSTEMS REVIEW
CASE HISTORY – SHIN SPLINTS
 Active lady engaged in competitive and endurance
sport. Marathon PB 2:42.
 Complains of pain in the legs during exercise.
 Has to stop.
 Relieved within minutes of rest.
 Can start again.
 Pain is specific over the anterior compartment.
 Examination is unremarkable.
 Other symptoms include feeling of tightness, tenderness,
ache and sometimes paraesthesia in the foot.
 Bilateral symptoms.
 No nocturnal or pain at rest.
HISTORY OF TREATMENT
 GP
Ice, Rest and NSAIDS. Back running.
No better.
 Physio
Various treatment modality.
10 week programme. Back running.
No better.
 Podiatrist 3 Different pairs of orthoses. No better
if anything made worse.
 Osteopath + Acupuncture + Sports masseur. No better.
 London SportsCare, London Independent Hospital
Diagnosis – Chronic Exertional Compartment
Syndrome
DICP – Confirmed the diagnosis > Superficial
fasciotomy > Back running within 6 weeks.
CHRONIC EXERTIONAL COMPARTMENT
COMPARTMENT SYNDROME (CECS)
DEFINITION
A condition in which increased pressure within
a closed anatomical space compromises circulation
and the function of the tissues within the space.
INVESTIGATIONS
 Dynamic intra-compartmental Pressure (DICP) study
 NIRS
 MRI scan
INVESTIGATION
INTRA-COMPARTMENT PRESSURE STUDY
Padhiar N, King JB. Exercise induced leg pain-chronic compartment syndrome. Is the increase in intracompartment pressure exercise specific? Br J Sports Med. 1996 Dec;30(4):360-2.
Aweid O, Del Buono A, Malliaras P, Iqbal H, Morrissey D, Maffulli M, Padhiar N. Systematic review
and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional
compartment syndrome of the leg. Clinical journal of sport medicine: official journal of the Canadian
Academy of Sport Medicine. 05/2012; 22(4):356-70.
TREATMENT?
ENDOSCOPIC RELEASE
Lohrer H, Nauck T. Endoscopic release of fascia in
CECS. Br J Sports Med 2011;45:e2 .
CHRONIC EXERTIONAL
COMPARTMENT
SYNDROME
FOREARM
FOOT
LOWER LIMB
HISTORY

PAIN WITH ACTIVITY + HAS TO STOP + RELIEF WITHIN MINUTES +
CAN RESTART + TIGHTNESS (NOT CRAMP) + NORMAL
EXAMINATION + BILATERAL + ANTERIOR COMPARTMENT
 = CHRONIC EXERTION COMPARTMENT SYNDROME
 UNILATERAL + MIMICS CECS + ANTERIOR COMPARTMENT
 = SUPERFICIAL PERONEAL NERVE ENTRAPMENT SYNDROME

UNILATERAL/BILATERAL + MIMICS CECS + SUPERFICIAL POSTERIOR
COMPARTMENT
 = POPLITEAL ARTERY ENTRAPMENT SYNDROME, MYOPATHY,
ACCESSORY SOLEUS SYNDROME, FHL ACCESSORY SYNDROME, CECS

PAIN WITH ACTIVITY + CAN RUN THROUGH PAIN + WORSE PAIN AT
REST + TAKES HOURS TO DAYS TO GET RELIEF + BONE TENDERNESS
USUALLY MEDIAL TIBIA + SOMETIMES NOCTURNAL SYMPTOMS + SLEEP
DISTURBED + UNILATERAL/BILATERAL
 = TIBIAL STRESS INJURY ( PERIOSTITIS-MTSS, STRESS #)
EXERCISE INDUCED LEG PAIN
1.
2.
3.
4.
5.
6.
MEDIAL TIBIAL STRESS SYNDROME
CHRONIC EXERTIONAL COMPARTMENT
SYNDROME
STRESS FRACTURE
NERVE ENTRAPMENT SYNDROME
RADICULOPATHY
POPLITEAL ARTERY ENTRAPMENT
SYNDROME
DIAGNOSIS
 HISTORY
 INVESTIGATIONS
HISTORY
• Diagnosis
• Pot luck that treatment will be effective
• In some cases unnecessary surgery
• Time wasting and therefore delay in return to sport
• Costly
THANK YOU VERY MUCH