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Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Hess Orthopedics &
Sports Medicine
Harrisonburg, Virginia
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Its just Shin Splints,
Isn’t it?
Introduction
There is an old saying in medicine that states, “when you hear hoof-beats, think horses, not zebras”, the implication being that when treating a patient, common symptoms should lead you to rule out common pathologies before considering more exotic (and far less likely) etiologies to explain the patient’s symptoms. Certainly there are numerous cases that have proved this idiom correct. However, as physicians, we must be mindful that occasionally there is an exception to the rule, and occasionally “hoof-beats” are zebras.
Let me share with you a recent experience that demonstrated this very fact. I received a referral to see a patient who complained of left lower leg pain following the start of football practice approximately nine weeks prior to presentation in my office. He had been initially diagnosed with “shin splints” and treated with R.I.C.E methods by members of the athletic training department at his high school. When his symptoms persisted, the patient was seen by his primary care doctor --whose assessment was that the patient was suffering from severe shin splints-- and prescribed an oral anti-inflammatory and some additional physical therapy. However after several additional weeks without relief, the patient’s primary care provider referred him to me.
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On clinical exam, the patient demonstrated mild palpable tenderness along the distal medial and anterior lateral aspects of the left leg that was significantly worse with exercise (I had the patient jog the stairs in my office). He described pain that was both an ache as well as a burning sensation at times. Pedal pulses were palpable, and he demonstrated no neurological deficits. Plain radiographs of the extremity were negative for fracture or periosteal reaction. Considering the failure of more conservative care, and the clinical presentation, I was concerned with the possibility of exertional compartment syndrome. Consequently, I performed an evaluation of compartmental pressures, both at rest and following activity. His resting pressure was approximately 13 mmHg, and his post-exercise pressures were approximately 39 mmHg in the anterior compartment where he related his most significant pain.
Considering the significance of his symptoms and a generalized failure of conservative care, the patient elected to undergo anterior compartment release. He has been pain free following his surgery, and is looking forward to returning to football.
Medial Tibial Stress syndrome:
This complex syndrome has been used to characterize activity-induced pain in the lower extremity. This syndrome can encompass a number of disorders, including periositis near the origins of the soleus and flexor digitorum longus muscles along the tibia as well as tibial stress fracture. Commonly, the patient demonstrates contributing factors such as rearfoot varus, excessive forefoot pronation, excessive femoral anteversion or increased tibial torsion and genu valgum. Such structural pathology predisposes patients to excessive and unbalanced pronation during the gait cycle, with subsequent overloading of the distal extremity.
The differential diagnosis for this condition includes: stress fracture, chronic or exertional compartment syndrome, sciatica, deep venous thrombosis, popliteal artery entrapment, muscle strain, tumor, and infection. Commonly, patients demonstrate tenderness localized to the posteromedial border of tibia in it's mid to distal third regions. Tenderness is usually more localized with stress fractures—and is worse with activity and resolves with rest. Often these symptoms resolve with conservative care, including rest and protected immobilization. In some cases more aggressive immobilization, including casting, may be necessary.
Exertional Compartment Syndrome
Exertional compartment syndrome is a condition in athletes that can occur from repetitive loading or exertional activities. The anterior compartment of the leg is the most commonly effected, and patients often describe pain that is burning in nature, which worsens with activity and completely subsides after 15 minutes of activity cessation. Resting pressure as well as dynamic pressure studies should be performed to give the surgeon a "pressure profile" of the patient, and these are the gold standard for the diagnosis of chronic exertional compartment syndrome. Normal compartment pressures at rest are between 0 and 4 mm Hg. A dynamic, post-exercise reading of greater than of 35 mm Hg is highly indicative of compartment syndrome. A dynamic pressure greater than 40 mm Hg is considered diagnostic.
Conservative therapy has been attempted for exertional compartment syndrome, but it is generally unsuccessful once the patient returns to normal activity. When indicated, surgical decompression via fasciotomy of the involved compartment commonly addresses the patient’s symptoms, and recurrence after fasciotomy is unusual.
Discussion
Keep your eyes open –sometimes that simple case of “X” that presents in your clinic may not be so simple. Not every patient with heel pain has plantar fasciitis, and not every thick, discolored nail is of fungal origin. You have been trained to look for both “horses” AND “zebras.” You are the lower extremity specialists –your training and background have uniquely prepared you to serve your patients. In the case I described above, I called the referring provider to update him on my findings and the course of care for the patient in question. As it turns out, the referring physician demonstrated an adequate working knowledge of exertional compartment syndrome –he had just never suspected it on our mutual patient.
We at PRESENT love hearing from you. I would strongly encourage you to share your interesting cases, insights, and pearls of wisdom with our online community in the eTalk function on PRESENT Podiatry. I look forward to hearing from YOU.
We at PRESENT love hearing from you, and look forward to learning from you. I encourage you to post your interesting cases in the eTalk section of PRESENT podiatry to promote our collective knowledge. We look forward to hearing from you!
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