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It’s not all shin splints

Learn about chronic exertional compartment syndrome, its symptoms, diagnosis, treatment options, and outcomes for athletes. Discover how forefoot running and the Pose Technique can help alleviate leg pain.

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It’s not all shin splints

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  1. It’s not all shin splints Marc Silberman, M.D. Gillette, New Jersey

  2. Disclosure I declare no conflict of interests I do not have any financial disclosures

  3. Exercise induced leg pain 1. CECS 34% 2. Tibia Stress Fracture 25% 3. MTSS 13% Clanton T, Solcher B. Chronic leg pain in the athlete. Clin J Sport Med. 1994;13:743-759

  4. Chronic Exertional Compartment Syndrome (CECS)

  5. CECS • Pain, tightness, cramping, numbness, burning, swelling with exertion • Pathophysiology not understood • High pressure within myofascial space resulting in decrease tissue perfusion • Historical treatment is fasciotomy

  6. The Compartments

  7. . Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada. Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

  8. Pedowitz Criteria • At rest > 15 mm Hg • 1 minute post exercise > 30 mm Hg • 5 minutes post exercise > 20 mm Hg Pedowitz RA, Hargens A, Mubarak SJ. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35-40

  9. Continuous Pressure Measurement Anterior Compartment Phase 1 Military 15kg backpack walking 6.5km/hour Phase 2 Military 15kg backpack walking incline 5% Phase 3 No backpack running 9.5km/hour incline 5% Elevated pre-exercise standing state in subjects Diagnostic cut off of 105 mm Hg Roscoe et al. Am J Sports Med 2015.

  10. Surgical Outcomes • Packer reports a 19% failure rate • Post college age satisfaction of 66% • 50% military symptomatic, 25% failed to return to full duty • 17% had to be discharged • Success rates of 30% to 65% for posterior compartment

  11. . Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada. Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

  12. . Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada. Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

  13. . Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada. Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

  14. . Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada. Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

  15. . Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada. Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

  16. . Silberman MR . 2004 Annual Meeting of AMSSM, Vancouver, Canada. Research Poster Presentation: A Follow-up of athletes tested for chronic exertional compartment syndrome of the lower leg and outcomes of returning to play.

  17. Forefoot Running • Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. Int J Sports Phys Ther. 2011;6:312-321. • Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40:1060-1067. • Helmhout et al. The Effectiveness of a 6-Week Intervention Program Aimed at Modifying Running Style in Patients With Chronic Exertional Compartment Syndrome. The Orthopaedic Journal of Sports Medicine.

  18. Diebel et al • 10 patients enrolled in a 6 week running program • Running distance significantly increased by 300%, from 1400 ± 600 m to 4800 ± 500 m • Mean post exercise anterior pressure decreased by 51%, from 78.4 ± 32.0 to 38.4 ± 11.5 mm Hg • Improvements of 81% for SANE, 21% for LLOS, 96% for VAS; scores higher at 1 year follow-up • Vertical ground reaction force decreased • Decreased step length and increased step rate

  19. Helmout et al. • 19 participants in the Dutch Military • 6 weeks learning Pose Technique • Running distance increased by 43% • Post exercise ICP decreased by 36% • Self reported outcomes increase in SANE, LLOS, and PSC of 36%,18%, 60% • 74% had no elevation of pain • Decreased step length and increased step rate

  20. Helmout et al.

  21. Pose Technique The support foot is pulled from the ground to allow the body to fall forward, while the other foot drops down freely, in a change of support

  22. Reduced Eccentric Loading with Pose Technique • Shorter stride lengths • Smaller vertical oscillations of the sacrum and heel • Neutral ankle joint at impact • Lower magnitude of vertical impact forces • Lower eccentric work at the knee • Greater eccentric work at the ankle Arendse et al. MSSE. 2004.

  23. Vertical Ground Reaction Force • Higher loading rates are found in those who sustained stress fractures • Higher loading rates are found in those who sustained all running related injury types, studies are limited • Hank van der Worp et al. BJSM 2015.

  24. Botulinum toxin A • 16 patients • 25 anterior compartments • 17 lateral compartments • Follow-up lasted 3 to 9 months • 15 patients pain was eliminated • 5 patients the strength remained normal Isner-Horobeti ME. Am J Sports Med. 2013;41:2558–2566.

  25. Botulinum toxin A Isner-Horobeti ME. Am J Sports Med. 2013;41:2558–2566.

  26. Onabotulinum toxin A • 20 year old, left anterior-lateral CECS • Onabotulinum toxin A 20 units proximally and 20 units distally • Within one week, pain 1/10 with no paresthesias, jogging within 2 weeks • 14 month follow-up • Neuromuscular junction affect lasts 2 – 6 months • Known antinociceptive effects independent of its neuromuscular action Barria at al. Clin J Sport Med 2016;0:1–3.

  27. CECS References • Arendse et al. Reduced eccentric loading of the knee with the Pose running method. MSSE 2004; (36)2 272-277. • Barria MR. Botulinum Toxin for Chronic Exertional Compartment Syndrome: A Case Report With 14 Month Follow-Up. Clin J Sport Med 2016;0:1–3. • Diebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot running on chronic exertional compartment syndrome: a case series. Int J Sports Phys Ther. 2011;6:312-321. • Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012;40:1060-1067. • Helmhout et al. The Effectiveness of a 6-Week Intervention Program Aimed at Modifying Running Style in Patients With Chronic Exertional Compartment Syndrome. The Orthopaedic Journal of Sports Medicine. • Isner-Horobeti ME, Dufour SP, Blaes C, et al. Intramuscular pressure before and after botulinum toxin in chronic exertional compartment syndrome of the leg: a preliminary study. Am J Sports Med. 2013;41:2558–2566. • Pedowitz RA, Hargens A, Mubarak SJ. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18:35-40 • Roscoe D et al. Intramuscular Compartment Pressure Measurement in Chronic Exertional Compartment Syndrome:New and improved diagnostic criteria. Am J Sports Med 2015 43: 392

  28. Stress Fracture

  29. “A high school athlete with shin pain has a stress fracture until proven otherwise”

  30. Definition “A fracture caused not by a direct blow, twist, or fall, but by cyclical loading that exceeds the bones natural repair capacity”

  31. Stress fracture hypothesis “Bone remodeling is a balance between osteoclastic resorption and osteoblastic reconstruction” As loading increases, additional bone resorption occurs Time lag between the two is 2 to 3 weeks

  32. Stress fracture hypothesis When activity is increased, local weakness and microdamage may be caused by increased osteoclastic activity Stress fractures occur when muscle becomes fatigued and unable to absorb added force Impact forces are transferred to bone which causes overload and stress fracture

  33. Female Athlete Triad Risk of stress fractures in athletes with menstrual disturbance is 2 to 4 times that of eumenorrheic athletes Disordered eating, amenorrhea, and osteoporosis Functional Hypothalamic Amenorrhea from insufficient energy intake Decreased leptin levels, decreased gonadotropins, hypoestrogenic state lead to reduced calcium absorption, increased bone resorption, suppressed bone formation

  34. True or False A stress fracture is a small crack in a bone

  35. False

  36. False

  37. True or false Stress fractures are caused by weak bones

  38. False 1. Abnormal stress on normal bone Not weak bones but weak or fatigued muscles 2. Normal stress on abnormal bone 3. Abnormal stress on abnormal bone

  39. Clinical tests There are no clinical tests to diagnose a stress fracture The diagnosis is made by radiological imaging Schneiders AG et al. The Ability of Clinical Tests to Diagnose Stress Fractures: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther 2012;42(9):760-771.

  40. X-ray “While X-ray can rule in a stress fracture, X-ray can not rule out a stress fracture” X-ray sensitivity of 10 to 50%

  41. X-ray First Visit

  42. X-ray First Visit

  43. X-ray 1 month

  44. X-ray 3 month

  45. X-ray 3 month

  46. MRI “MRI can rule out a stress fracture and MRI can grade a stress fracture” Sensitivity 88%, Specificity 100% Gaeta M et al. Radiology. 2005 May; 235(2):553–561.

  47. Grading Adapted from Arendt et al. Clin Sports Med 1997. 16(2): 291-306

  48. Grade 1

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