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Exertional Leg Pain5 Diagnosis to Consider in Unusual Case ManagementDelmas Bolin, MD, PhD, FACSM, FAAFPDirector, PCA Center for Sports MedicineMedical Director, Roanoke College Athletic Training ProgramHead Team Physician, Radford UniversityAssociate Professor, Family & Sports MedicineVia College of Osteopathic Medicine – Virginia CampusBlacksburg, VirginiaObjectivesMostly…there are zebras.• Recognize key historical features of exertionallower extremity complains• Recognize “compartment syndrome” as both adiagnosis and symptom• List at least 3 “uncommon” causes of exertionalleg pain and claudication• Describe diagnostic approaches usingprovocative measures21 year old with “shinsplints” for 3 years.Pain achy/crampy onthe anterior shins R>LOnset with running ~ 1-1.5 miles.No change withcessation, orthoticsSymptoms resolve withrest ~ 5 min.Case 1Causes of Exertional Leg PainPain• Medial Tibial StressSyndrome• Stress FracturesClaudication• CECS• PAES• Nerve entrapmentsPathophysiologyUnderlying symptoms of CECS• Exercising Muscle• Increasing blood flow• Muscle fibers can swell20 X• Weight & volume up 20%• Mismatched supply vsdemand eventually stopsperfusion• Ischemia painful & leadsto muscle damageProgressive Damage• pressure in confined space blood flow & leads to ischemia• 50 mm Hg pressure flow to 70%.• 80 mm Hg pressure flow to 5%.• Prolonged ischemia damagesnerves & muscles (acute)• 50 mm Hg pressure for 4-8 hrs leadsto muscle necrosis• 40 mm Hg left for 6 hours lead tosensorimotor & neuromuscular deficitsImage for educational purposes only, downloaded from: http://www.darrenlol.com/wp-content/uploads/2010/10/227_x600_get_problem_shinsplints.jpgPage 1

Anatomy of the Lower LegLeg Compartment Pressures as aFunction of Exercise120100806040200Rest Exercise 0 1 2 3 4 5 6 7 8 9 10Adapted from Touliopolous S and Hershman EB Lower Leg Pain SPORTS MED 1999:27195DiagnosticsFollowed based on the most common diagnosis• Radiography• EMG• Bone Scan• Near-IR Spectroscopy *• Sensitivity 78 (68-86)%• Specificity 67 (22-96)%• Direct Pressure Testing *• Sensitivity 77 (67-86)%• Specificity 83 (36-100)%• MRI* van den Brand et al (2005) AJSM 33:699• Direct measurement ofcompartment pressures• Slit catheter incompartment• Resting P > 15 mmHg• Exertional P (1 min afterexercise) > 30 mmHg• 5 min after exercise > 20mmHg• BP dependentDiagnosisCompartment Rest 1 min afterexercise5 min afterexerciseR ant 29 70--R lat 24 27 --L ant 9 17 --L lat 7 16 --TreatmentConservative Measures Usually Fail – Why?• Non Operative• OperativeOperative Treatment• A: Single or twoincision technique• B: IM septum & releaseof lateral compartment• C: Fasciotomy anteriorto intermuscularseptum• D & E: Superficialposterior compartmentrelease if neededAdapted from Rorabeck CH: A practical approach to compartment syndromes: III. Management. Instr Course Lect 1983;32:102-113.Page 2

Case 1: Resolution• Compartmentrelease• 4 week post-op &progressive rehab• Custom orthotics• Full RTP withoutcomplicationsCase 2: Claudication• 20 yo LAX w/ bilateralexertional shin pain for 9months• Pain @ medial tibialborders, throbbing• Onset 10-30 min intoworkouts.• Pain resolved 30-60 minpost exercisePertinent Physical Exam• 64”, 131# (BMI 22.4)• Gait: ↑ pronation right foot• Pain distal medial aspects oftibias bilaterally; mildly tightanterior compartment• (+) Tinel’s over bilateralcommon peroneal & suralnerves• Pain along medial tibial bordersw/resisted ankle motions• Normal pulses – Popliteal harderto palpate on leftCase 2: Diagnostic Testing(4 month work-up reveals no diagnosis)• Radiographs:• Bilateral tib/fib,knees/ankles• Bone Scan:• Bilateral ↑ uptake midtibias, c/w shin splints• MRI• Bilateral tib/fib (-)• ECS testing (-)• Coagulopathy work-up (-)Case 2: Further Diagnostic TestingBe persistent; insist on provocative maneuvers• ABI/ Plethysmography• Negative• CT angiogram• Negative• Repeat CT angiogram• After exercise and with activedorsiflexion bilateral ankles• Bilateral popliteal arteryentrapment, left greater thanrightAtypical ClaudicationSimilar symptoms between CECS & Popliteal Entrapment• 854 patients withclaudication• 557 women; 297 men• Symptoms• Cramping swellingparasthesia• Persistent symptoms18 months (6-24)• Radiographic work up• ABI, Plesthysography& CS testing (if indicated)Turnipseed J Vasc Surg 2009 49:1189-95.Page 3

Results240/854 patients for surgical treatment• 233 Patients• 30 FPAES• 203 CRECS» 72% ant/ lateral» 16% deep post» 12% sup post• 7 Patients• Abnormal non-invasivevascular testing» 2 venous» 5 arterial =anatomic PESAnatomic Entrapment is relatively rare;Functional entrapment may exist in up to 15%of CECS patients – Surgical implications• Anomalous relationshipof muscle & artery inpopliteal fossa• Type I: Aberrant course• Type II: Atypical muscularinsertion» Soleus, lat head gastroc,plantaris, popliteus• Type III: Both present• Type IV: Artery deep topopliteus muscleAnatomic PAESTurnipseed J Vasc Surg 2009 49:1189-95.Image from: Kukreja et al Diagn Interv Radiol 2009;15:57-60.Anatomic vs FunctionalAnatomic EntrapmentCharacteristics and clues to diagnosisAnatomic entrapmentpatients usually havefocal extrinsiccompressive bands oftendon or fascia thatare associated with thedevelopment of intrinsicarterial disease andsubsequent ischemicsymptomsFunctional entrapmenthave more diffuselateral compression ofdisease-free vesselsand/or symptoms thatresult from peripheralnerve compression• Male (72%)• Older (mean age, 43years)• Sedentary (14%athletically active)• Restrictive claudicationsymptoms (exercisedistance < 2 blocks 70%)• Noninvasive test + ofperipheral occlusivedisease (30%)Functional EntrapmentThis is an “overuse” injury• Younger (mean age,24 years)• Female (66%)• Well-conditioned,highly trained athletesor have active lifestyles(90%)• Normal resting & postexercisenoninvasivetestsDiagnostic Work-upAnkle Brachial Index Vascular MRI/MRA w/StressTurnipseed, WD. Popliteal entrapment syndrome. J Vasc Surg. 2002;35:910-5.Page 4

• Surgical decompression &exploration of left poplitealartery• Full return to activity 12 weekspost surgery with slowprogression of activity• Left leg remainedasymptomaticCase 2: Resolution• With increased activity levels,pain in right leg returned• Decompression of rightpopliteal artery performed• Returned 12 weeks aftersecond surgery• Currently asymptomatic x 5 years;coaching HS LaxUnusual Causes – Case 3• 21 year old pitcher• 4 week onset ofexertional calf pain• 3 months after hitin thigh with linedrive• Radiology negative• (+) deep posteriorcompartment testUnusual Causes – Case 4Circuitous diagnostic testing• 48 year old tri-athletepresents with exertionalL calf pain• Previous lateralmeniscus• MRI of calf, knee• Angiogram, USCystic Adventitial Disease• Claudication• Men, 4 th -5 th decade• Origin• Synovium• Mucin-secreting cellsincorporated into arteries• Popliteal artery 85%• Symptoms wax/wane• Ishikawa’s sign• Pedal pulse lost with kneeflexion.N Ni Mhuircheartaigh, et al 2005 BJSMCystic Adventitial Disease-Diagnosis• Popliteal US• MR Angiogram• “Scimitar Sign”• External compressionCystic Adventitial Disease-Diagnosis• PTA relatively ineffectivefor treatment due toexternal high-pressurecystic structureFox et al. J Vasc Surg 1985,2:464• US guided aspirationeffective althoughrecurrence reportedSieunarine et al J Cardiovasc Surg 1991 32:702• Close US follow up indicatedPage 5

• Cyclists. 50’s• External IliacArtery fibrosis• Repetitive trauma• Claudication• Neurologic• Swelling• Iliac fossa bruitwith exertionhttp://www.wired.com/news/images/full/tourofcali1_f.jpgEndofibrosis• ABIEndofibrosis - Diagnosis• Sensitive, non-localizing• Compare rest/ exercise• Duplex US• Combine with exerciseABI, Plethysmographyand segmental pressures• Contrast angiography• Gold standard• 100% sensitive withthigh in flexionEndofibrosis Treatment• PTA with/withoutstent• Helpful• Risks• Surgery• Endarterectomy withvein patch or bipass• Success vs downside• Seat mechanics• 29 year oldmarathon runnerwith runninginduced pain• Onset at 1 mile• Distal 1/3 medialtibia to medial arch• Relieved afterrunning cessationUnusual Case 5Nerve Entrapments• Common peroneal• Sural• Tarsal tunnel• Foot & ankle• Overuse & Microtrauma• Work-up• Detailed NCV• US• High resolution MRIColeman Block TestCavus foot type may be overlooked mechanical contributor• Forefoot "off-weighted" byplacing a block under the heel• Rearfoot no longercompensates for forefootcavus• If rearfoot normalizes & becomesperpendicular to the ground, thedeformity lies in the forefoot• In rigid cavovarus foot, thedeformity does not reduceImage adapted from Default et al. RadioGraphics 2003; 23:613–623 ● Published online 10.1148/rg.233025053Coleman S, Chestnut W A simple test for hindfoot flexibility in the cavovarus foot. Clin Orthop 1977;122:60-62.Page 6

BiomechanicsFibular motion deficit may contribute to exertional symptomsPersistent SymptomsWhat if symptoms recur after compartment release?• Fibular motion with gait• Motion is anterolateral topostero-medial• Talus inversion• ATF pulled tight• Pulls distal fibula anterior• Proximal fibula moves posterior– becomes locked• Irritation common peronealnerve• Neuromuscular alterationImage from http://www.pilatespatio.com/legfoot.phpSummaryThank You• Exertional symptoms can be challenging todiagnose: Start with a systematic approachbased on most common diagnosis• When suspecting unusual causes, vascular arethe next most common causes• US can be helpful first line, but provocactivemaneuvers must be utilized• Don’t abandon your patientPage 7