wk 10- leg and calf pain Flashcards
bone pathology of the leg
stress fracture (anterior tib or medial tib, fibula)
medial tibial stress syndrome
soft tissue pathology of leg
muscle strains (gastroc, soleus)
muscle contusions
DOMS
compartment syndrome
bakers cyst
pes anserine bursitis
joint pathology of leg
proximal tibiofibular sublax
OA/ inflammatory arthritis
neural pathology of leg
referred pain
nerve entrapment (tibial/sural)
vascular pathology of leg
vascular entrapment (popliteal)
DVT, thrombis, emoblism
leg pain can involve ?
one or more of five pathological processes often with multiple occuring at the same time
- bone stress
- vascular insufficiency
- inflammation
- nerve entrapments
5.elevated intracompartmental pressures
pain absent at rest that presents with exertion
compartment syndrome
posterior pain absent at rest but presents on exertion
popliteal artery entrapement syndrome
improves with pre participation stretching
medial tibial stress syndrome and muscle strains
doest improve with pre participation stretching
stress fractures and compartment syndrome
pain when resistance to muscle tendon units including insertion/origin
MTSS
muscle strains
tendinopathy
focal pain over bone
stress fracture
muscle herniation
diffuse swelling in calf
DVT
palpable swelling on muscle insertion on medial border of tibia
MTSS
shooting pain, sensation loss, loss of motor power
nerve injury, entrapment or radiculopathy
improves with cold therapy and anti inflammatories
inflammation pathology
osteoid osteoma
night pain or wakes up a patient
tumour
difference between stress fracture and MTSS
pain:
SF: focal sharp tenderness
MTSS: diffuse on posteriormedial border of tibia
effect:
SF: constant or worse with impact
MTSS: decreases as warm up or stretches. worse in morning or after exercise
imaging:
SF: MRI
MTSS: MRI
what is MTSS
micro tears and inflammation of the periosteum
originally thought to be caused by post tib overuse therefore more common in pronated foot types
risk factors of MTSS
excessive pronation
training errors
footwear fatigue or improper footwear
surface
muscle dysfunction
decreased flexibility
female
high BMI
grading MTSS
frederickson classification system
grade 1: periosteal oedema
2/3- progressive marrow involvement
4- cortical stress fracture
other DDx for MTSS
stress fracture
compartment sydrome
popliteal artery entrapment
muscle tear
nerve entrapment
management for MTSS
- PEACE AND LOVE
- rest/deload
- shock abosorbing innersoles
if not getting better
1. immobilise/CAM walker, below knee
2. taping to control pronation
3. FW change
4. semi rigid orthotic
5. soft tissue therapy of tightness of focal thickening (friction massage)
typically how long does it take to resolve MTSS
resolution in 1 month, 50% reduction in pain in 1 week
if untreated can develop to stress fracture
return to impact activity dependent on grade of MTSS/SF
1- 2-3weeks (periosteal oedema)
2-4a: 6-7 weeks
4b: 9-10 weeks (cortical break)
pathophysiology of bone stress injury
repetitive loading of bone causing microdamage without adequate bone remodelling through recovery
clinical features of BSI
-increase in load
-focal pain around medial posterior tibia
-pain aggravated by activity
-may cause rest or night pain
-more common in rigid cavus foot types, pronated foot types, leg length differences
-eating disorder/BMD problems
management of BSI
- immobilise (pneumatic CAM walker) 2 weeks, add another 2 weeks if pain present
- reintroduce load
- change surface, footwear, technique (shorter stride, slower speed, reduce distance)
- custom semi rigid orthotics
anterior cortex stress fracture
prone to delayed union/ non union and complete fractures due to poor blood supply and under tension due to bowing of tibia
management of anterior cortex stress fracture
- immobilise (penumatic brace)
- assess nutrition
- ultrasonic bone stimulation early on for healing
if no progress after 4-6months - intramedullary rodding
- bone grafting
- drilling
prognosis is 12 months return to sport using brace
what is chronic exertional compartment syndrome
increased pressure within closed fibro osseous space due to thickened and non compliant fascia which doesnt allow the muscle to expand
this causes
1. reduced blood flow
2. reduced tissue perfusion
common in endurance athletes
most common type of compartment syndrome
anterior
then
lateral
deep posterior
clinical features of CECS
no pain at rest
ache, tightness building with exercise, usually around 10-15 mins in
decreases with rest
how to test CECS
pressure testing, imaging is tyically negative because need to stimulate exercise
basal ICP of >10mmHg,
1 MINUTE post exertion >30mmHg
5 MIN POST >25mmHg
muscles and nerve in anterior compartment
tib ant
ext dig longus
ext hallucis longus
peroneal tert
deep peroneal nerve
muscles and nerve in lateral compartment
peroneus longus and brevis
superficial peroneal nerve
lateral compartment syndrome can cause parathesis where
dorsum of foot
management of CECS
- rest
- deep massage therapy
- soft tissue therapy (friction, needing, active release)
- running technique
shorter stride - botox injection to decrease pain
- surgery- fasiotomy (incision)/fasciectomy (removal of portion)
muscles and nerve in posterior compartment of thigh
tib post
flexor hallucis longus
glexor digitorum longus
tibial nerve
surgery outocmes of CECS
80-90% of patients satisfied
some had reccurance
which was most common with deep posterior compartment (52% satisfied with fasciotomy)
gastroc/soleus muscle strain acute injury caused by
extending the knee with ankle dorsiflexion
lunge forward
sudden eccentric overstretch
most common on medial head as its longer
grades for gastroc/soleus muscle strains
1- pain on SL calf raise or hop (10-12days)
2- pain and weakness with active plantarflexion, loss of dorsiflexion (16-21days return), mild to mod swelling/bruising
3- thomas test positive, cant contract calf (6months after surgery), presents with considerate swelling and bruising within hours
management of muscle strain
- PEACE and LOVE
- heel raise in shoes to decrease stretch
- passive stretching and isometrics (resistance band)
- gradual loading of isotonics around 10 days when muscle as tensile strength (concentric calf raise, to then eccentric, bilateral to SL)
5.soft tissue therapy - agility/plyo/sport specific activity
difference between PAES and CECS
PAES disappears immediately
CECS may take until the muscle cools down so longer
PAES cause
anatomical variation of artery with medial gastroc attachment
causes a claudication type calf pain
diagnosis of PEAS
doppler pulse during active plantarflexion or dorsflexion
post exercise pulse may be weak or absent
what can PAES cause
enodthelial damage (atheroscleoris accelerating)
management of PAES
- surgical correction of medial gastroc head insertion
- popliteal artery release
disgnosis test of DVT
hollmans test
