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Lower Leg Injuries

Lower Leg Injuries. Thomas M. Howard, MD, FACSM Sports Medicine. Differential. MTSS Stress Fracture ECS Strain Tennis Leg Achilles. MTSS. ECS. Stress Fracture. MTSS. Medial Tibial Stress Syndrome AKA Shin Splint. Theories. Soleus Bridge Medial Gastroc tightness

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Lower Leg Injuries

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  1. Lower Leg Injuries Thomas M. Howard, MD, FACSM Sports Medicine

  2. Differential • MTSS • Stress Fracture • ECS • Strain • Tennis Leg • Achilles

  3. MTSS ECS Stress Fracture

  4. MTSS • Medial Tibial Stress Syndrome • AKA Shin Splint

  5. Theories • Soleus Bridge • Medial Gastroc tightness • Posterior TibialPeriostitis • Tibialis Anterior fatigue

  6. Symptoms • Distal medial leg pain w impact activities

  7. Risk Factors • Too much, too soon, too fast… • Pronation • Running on cambered surface • Poor shoes • Gastoc-Soleus tightness • Weak Posterior Tibialisand Anterior Tib.

  8. Exam • Tenderness along the distal med Tibial border or anterior shin • No anterior cortical tenderness • Foot pronation • Tight Heel Cord

  9. Management • Orthotics • Shoe evaluation • Strengthening and stretching • Shin Sleeve • Activity Modification • Monitor for other conditions

  10. Stress Fractures

  11. Epidemiology • Incidence around 10% of all musculoskeletal injuries • 95% of all stress fractures occur in lower extremity • 46% tibia • 15% navicular • 12% the fibula

  12. Pathophysiology • Repetitive 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

  13. Risk Factors • Too much, too soon, too fast… • “out of shape” • PesCavus, Leg length issues • Thin build • Vitamin D Def and hormonal • Disordered Eating • Poor Bone Quality • Weak core…

  14. Exam • Swelling and/or percussion tenderness • Tibial or Fibular • Fulcrum Test • Single leg hop

  15. Imaging • Plain Film • Periosteal reaction • Sclerosis • CT • Bone Scan • MRI

  16. …the Dreaded Black Line

  17. Management • Relative Rest • 6-12 weeks • Flexibility • Core Strengthening • Calcium • ? BMD • Fix intrinsic issues • Orthotics • Shoes • Splinting? • Bone stimulator • Bone graft

  18. Exertional Compartment Syndrome

  19. Anatomy • 4 muscular compartments • Anterior • Lateral • Superficial posterior • Deep posterior • Fascial defects

  20. Anterior Compartment • Muscles • Tib anterior • Ext. digitorum • Ext. hallucislongus • Peroneus tertius • Major nerve • Deep peroneal n. • Major vessels • Ant. Tibial art./vein

  21. Lateral Compartment • Muscles • Peroneus longus and brevis • Major nerve • Sup. Peroneal • Major vessels • Branch off anterior tibial artery/vein

  22. Deep Posterior • Muscles • Flex. Digit. longus • Flex. Hallucislongus • Popliteus • Tib. Posterior • Major Nerve • Tibial n. • Major vessels • Post tibial art./vein

  23. Superficial Posterior • Muscles • Gastroc • Soleus • Plantaris • Major nerve • Sural n. • Major vessels • Branch off tibial artery/vein

  24. Pathophysiology • Normal exercise • Muscle volume increases by 20% • Intramuscular pressures exceed 500 mm Hg with contractions • Perfusion during relaxation phase

  25. Pathophysiology • Controversial, Probably multifactorial • Thickened, inelastic fascia • Possible small muscle herniations • Muscle hypertrophy (normal vs. other)

  26. Clinical Presentation • History • One or several compartments • >85% bilateral • Fairly predictable and reproducible

  27. Risk Factors • Use of creatine supplementation • Use of androgenic steroids • Eccentric exercise in postpubertal athletes: decreases fascial compliance?

  28. Differential • Claudication • Buergersdz • Popliteal Artery entrapment • Strain • MTSS • Stress Fracture

  29. 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)

  30. US Guidance?? • Prob for Deep Posterior

  31. Treatment Options • Activity modification for symptom relief • Correct biomechanical problems • Gait retraining: Pose technique (forefoot) • ? Deep Tissue Massage • Surgery?

  32. Popliteal Artery Entrapment Syndrome • Claudication in young active individual • Calf pain, cramping, color and temp changes

  33. Etiology • Anomalous course • Muscle hypertrophy • Gastroc, Soleus, Popliteus, Plantaris

  34. Diagnosis • US • Angiography • MRA • CTA • Dynamic maneuvers

  35. Treatment

  36. Tennis Leg • Strain of Medial Gastroc

  37. Tennis Leg • Painful pop w eccentric load • Neg Thompson Test • Short term immobilization • Rehab • Recovery 2-8 weeks

  38. Achilles Rupture • Painful pop with eccentric load • Palpable gap • Abnormal Thompson • Surgical or non-surgical mgt

  39. Non-surgical • Plantar flexed cast • 6-8 weeks • Rehab • ~30% recurrent rupture

  40. Surgical • Open or percutaneous

  41. Final Thoughts… • Take a good history • Look for training and biomechanical issues • Consider dynamic assessment • Judicious use of advanced diagnostic studies • Cross-train and relative rest

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