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Thomas M. Howard, MD, FACSM Sports Medicine

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Presentation on theme: "Thomas M. Howard, MD, FACSM Sports Medicine"— Presentation transcript:

1 Thomas M. Howard, MD, FACSM Sports Medicine
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 Posterior Tibial Periostitis
Medial Gastroc tightness Posterior Tibial Periostitis 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 Tibialis and 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 Usually takes at least 2-3 weeks to develop
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”
Pes Cavus, Leg length issues Thin build Vitamin D Def and hormonal Disordered Eating Poor Bone Quality Weak core…

14 Exam Swelling and/or percussion tenderness Fulcrum Test Single leg hop
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 Flexibility Core Strengthening Calcium ? BMD
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 Fascial defects Anterior Lateral
Superficial posterior Deep posterior Fascial defects

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

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

22 Deep Posterior Muscles Major Nerve Major vessels Flex. Digit. longus
Flex. Hallucis longus 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 Popliteal Artery entrapment Strain MTSS
Buergers dz 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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