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chronic exercise induced leg pain/?anterior compartment syndrome
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chronic exercise induced leg pain/?anterior compartment... - June 3, 2005 6:38:00 AM
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Timothy
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Joined: April 20, 2005
From: Australia
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Hi, some words of wisdom would be appreciated in helping me figure out what to do about my poor aching legs!
Does anyone know of the success rate of fasciotomies for chronic anterior compartment syndrome? I have heard they often fail, but some case series I have read on Pubmed seem to indicate otherwise.
There is a diagnostic diffuculty in that my problem doesn't seem to behave like true compartment/pressure/ischaemia pathology-I don't get sore during or immediately after activity, but the next day! A physio I saw felt the pain was delayed onset muscle soreness secondary to excessive activity of anterior tibial muscles in maintaining the arch of the foot-I did a rehab. program aimed at foot and lower limb muscle balance plus general lower limb conditioning which did seem to help moderately, but I just don't have the time or motivation to do rehab. for the rest of my life. I have orthotics with an 'aggresive correction' to purportedly reduce excessive pronation, but these haven't helped much...
Anyway, has anyone heard of success rates for procedures of this type?
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Re: chronic exercise induced leg pain/?anterior compart... - June 3, 2005 9:32:00 AM
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srcase
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From: Michigan
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I have a patient right now that just started therapy for "bilateral periostitis" of both anterior lower legs. She has had this problem for over 15 years, beginning when she was in the army running with boots on. My concern at this point is the possibility of stress fractures (no bone scans have been done to my knowledge, the patient is not the best historian). Of course, I will try the typical treatments: rest, ice, ROM, reduce pronation, stretch calves, and eventually stregthen....but I am not too hopeful given the chronicity of this problem.
Any military therapists want to chime in with thoughts on this condition? I don't know of any research on the surgical procedures either.
Sarah
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Re: chronic exercise induced leg pain/?anterior compart... - June 3, 2005 11:30:00 PM
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Timothy
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From: Australia
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orthotics are like chili recipes, everyone has their own way. Some ways are better than others, how were they made, what did they actually do to correct, etc, can be that you need better orthotics..
Ben
I'm not exactly sure...Do they correct many things? And down in 'Ossie land' we call it 'Chilli con carne' ('cobber' ie 'mate'). I can't envisage how tweaking the orthotic slightly could make a massive difference...
Another thing I would like to know concerns the usefulness of intra-compartmental pressure testing? Is it valid? Does abnormal intra-compartmental pressure during exercise always correspond with pain?
Any ideas?
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Re: chronic exercise induced leg pain/?anterior compart... - June 4, 2005 9:23:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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I found this article interesting, and it fit a person I was treating who already had 3, yes 3 releases with no positive results:
CHRONIC EXERTIONAL COMPARTMENT SYNDROME: THE CONTROVERSIAL “FIFTH” COMPARTMENT OF THE LEG. The American Journal of Sports Medicine, Vol. 31, No. 5, September/October 2003.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: chronic exercise induced leg pain/?anterior compart... - June 4, 2005 5:48:00 PM
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dosrinc
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From: Bonita Springs
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Timothy,
if you are not sure what it is, don't have surgery on it.
Rick
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Re: chronic exercise induced leg pain/?anterior compart... - June 5, 2005 12:36:00 AM
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Alex Brenner PT MPT OCS
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Joined: February 29, 2004
From: Kentucky
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Timothy,
I had a patient a few months ago who underwent compartment fasciotomies of bilateral legs but not at the same time. He was referred to my clinic with shin splints. He described the pain as a increase in pressure and tightness in the LE at about the 10 minute mark of running, pretty much consistent with exercise induced compartment syndromes. I put him on the treadmill in my clinic and was able to reproduce these same complaints. On physical examination after running he had some muscle herniations coming through small tears in the fascia, these would go away after about 10 minutes rest. I tried to treat him conservatively for a couple of months but each time I tried to get him back to running the pain returned. He eventually underwent surgery on the right leg (worst symptoms) and made a great recovery. When we tried ramping him back up to running his left leg started hurting again but his right one was asymptomatic. He underwent the left fasciotomy a few months later. To make a long story short, his left leg did not respond like the right one and to this day were not able to get him back to pain free running. Now he has two huge scars down his legs and still can not run longer than 2 miles without pain.
Sarah,
It is possible that you patient originally had some stress fractures but I would doubt that is the case now unless she is doing a lot of running right now such as training for a marathon. Stress fractures are fairly rare on the civilian side but quite common in the military community mostly because of the running and marching mileage that we do. They are most common in basic training units where soldiers go from a period of relative inactivity (such as a high school student) to all of a sudden to a huge increase in physical activity (basic training where they run and march every single day). The stress fractures occur when the breakdown and restructuring of the bone exceeds the healing time. Unless your patient has recently gone from a period of less physical activity to a significant increase I would not suspect them. I have also noticed that the older and less traditional basic trainess (those privates over the age of 30) develop stress fracture more easily than the younger guys.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: chronic exercise induced leg pain/?anterior compart... - June 7, 2005 10:22:00 AM
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JLS_PT_OCS
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Alex covered the military angle pretty well.
I have found anecdotally a lot of people who are dorsiflexing their foot with their extensor digitorum, and their tib anterior actually tested weak.
You can spot these people a mile away, they have prominent extensor tendons and claw toes in sitting.
I have found encouraging a forward lean and hip extension through the running cycle decreased the load on the dorsiflexors and eliminated pain. I also did some retraining in gait to dorsiflex from the tib anterior and not extensor digitorum, that has helped several people.
Worth a try, and I agree with Alex that the compartment release does not have spectacular results. I'm not sure what the literature has to say about it...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: chronic exercise induced leg pain/?anterior compart... - June 7, 2005 2:32:00 PM
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srcase
Posts: 551
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From: Michigan
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Thanks Alex and Jason,
Today, I had the patient ride the stationary bike and her lower leg started to burn after about 4 minutes. She did get fitted for proper tennis shoes for walking, to help control pronation, and was instructed in ice massage. Basically, she is just very inflexible, especially her calves, quads and hip flexors. So we are doing a lot of stretching, active-assisted dorsiflexion, and hip strengthening (weak abductors and extensors). Any other ideas?
Sarah
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Re: chronic exercise induced leg pain/?anterior compart... - June 8, 2005 7:28:00 AM
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JLS_PT_OCS
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I would consider some soft tissue work to the painful area, I have seen this work temporarily in some patients, just massage along the medial tibia to pain tolerance, assuming that is her location of pain.
Given the history of this problem, I'm not sure how effective that will be, it's just an anecdotal solution....
Has she had compartment pressures tested??
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: chronic exercise induced leg pain/?anterior compart... - June 8, 2005 8:46:00 AM
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srcase
Posts: 551
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From: Michigan
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Jason,
I was going to try the soft tissue work next time....it may be more effective than ice massage. I think what has me confused is that she really doens't complain of pain when she comes to therapy, and is not good at pinpointing when it occurs (during "exercise"), that's why I tried the bike test. I think I'll get her on the treadmill next time too and see how many minutes it takes to bring on symptoms.
I am also not clear on what kind of tests she has had done. She has had many different physicians. I thought about calling the referring physician, but according to the patient, he told her she needed to lose weight by exercising more and wear high heels more often! I don't even want to go there.....
Sarah
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Re: chronic exercise induced leg pain/?anterior compart... - June 8, 2005 9:03:00 AM
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karmzack
Posts: 181
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From: Hawaii
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I agree with Jason, a Stryker test would be useful given long history and ease of reproduction of symptoms with low impact exercise. Of course a Stryker test is only indicated if a fasciotomy is being considered as a treatment option. I've read favorable outcomes from anterior fasciotomies with return to sports in 8-12 weeks, but it's still a last option.
I have tried the Cho-pat shin splint compression sleeve for some of my tough patients, most benefit from it, but I think it's like sticking a band aid over the real problem, whatever that may be.
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Zack Solomon MPT, OCS, CSCS
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Re: chronic exercise induced leg pain/?anterior compart... - June 14, 2005 1:43:00 PM
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Christine013
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Joined: June 13, 2005
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Hello-
About a month ago, I received fasciotomies on both calves. Just some background info about me; i am a high school sophomore and play field hockey and lacrosse year round. In september during my field hockey season, my team would go on longggg runs and almost immediately, my calves would start swelling and hurt like hell. I didn't know what was wrong until i saw our trainor. She thought it was compartment syndrome, and later turned out to be right. When i told my parents about my condition, they didn't believe me at first. But after about 8 months of continuous pain and complaining, I finally saw the right doctor who in fact, conducted a very painful test and concluded that i had compartment syndrome. We decided to have the surgery performed asap so that i could have a chance to get back for my upcoming field hockey season. On thursday, it will be a month since my surgery, and i am doing exceptionally well. At first it was tough, for three weeks i was double casted up to my knees and was not able to walk very well... but now i'm in walking boots and am doing fine without crutches. i've seen my doctors numerous times since my surgery, and he expects me to make a full recovery by august. I hope this helps Timothy in the first post!
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Re: chronic exercise induced leg pain/?anterior compart... - June 15, 2005 5:54:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Christine,
It will be interesting to see how your legs respond when you start running on them. I would suggest progression of a slow walk to jog program. Please let us know how you do when you start running.
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Alex Brenner, PT, MPT, OCS
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Re: chronic exercise induced leg pain/?anterior compart... - July 2, 2005 1:34:00 PM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Hi all,
Just remembered this thread and wanted to give you an update on this particular patient I spoke of above. At one point, she had a lot more leg pain after attempting situps (military style) and sitting on a set of bleachers for a couple hours. I took a look at her lumbar (I know, should've done this the first day), and she defnitely has some impairments in AROM, joint mobility, and neurodynamics (slump and straight-leg raise, traction actually provoked her symptoms). She always complained of unilateral anterior thigh pain (which she blamed on a quad strain from playing softball) as well as bilateral lower leg pain, and L4 myotomal testing is significant, reflexes diminished....so, I called the doctor, but it's not his area of expertise, so she has to find another doctor to refer her back to me for her spine. Goes back to my theory that if it's bilateral, check the spine. I'll trust my instincts next time.
Sarah
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Re: chronic exercise induced leg pain/?anterior compart... - July 6, 2005 6:51:00 AM
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JLS_PT_OCS
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From: USA
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I would go one better and say even if it's unilateral, check the spine.
And you need another referral to treat another problem??
Ugh. Here we go with the direct access thing again. I guess while she's waiting she can go to the massage therapist...
:)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: chronic exercise induced leg pain/?anterior compart... - July 6, 2005 12:09:00 PM
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nari
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From: Australia
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Sarah
Even if it's unilateral check the spine and most importantly, the neurodynamics!
Nari
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Re: chronic exercise induced leg pain/?anterior compart... - July 6, 2005 2:14:00 PM
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karmzack
Posts: 181
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From: Hawaii
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You kill me with this neurodynamics stuff! What does exercise induced leg pain have to do with [URL=http://www.neurodynamics.com/]recognition systems[/URL]?
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Zack Solomon MPT, OCS, CSCS
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Re: chronic exercise induced leg pain/?anterior compart... - July 6, 2005 2:16:00 PM
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karmzack
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From: Hawaii
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I'm kidding. (At least I'm out there looking for more info)
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Zack Solomon MPT, OCS, CSCS
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Re: chronic exercise induced leg pain/?anterior compart... - July 7, 2005 2:58:00 PM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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*hangs head* yeah, I know I know. I am constantly thwarted by admonitions to lay off looking at spines when someone comes in with knee or foot, or any other extremity pain. It goes something like this, "well, technically, we don't have a prescription to treat the low back, so you can't do ....(fill in the blank: muscle energy, nerve gliding, lumbar mobs, pelvic floor, stabilization training etc.)
My response is usually a smile and nod. Ug. Basically, even if I do find something else going on, I can't treat it without a prescription to cover my a**
Sarah
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