Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies.

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.

Compartment syndrome in patients with Buerger disease and anticardiolipin antibodies.

We report two cases of acute compartment syndrome in the anterior compartment of the lower limbs of patients with the diagnosis of Buerger disease associated with positive anticardiolipin antibodies. We comment on the rarity of the case and on the possibility of interference of two associated thrombogenic conditions. The need for early fasciotomy is emphasized since the progression to necrosis is time dependent. Fasciotomy was the only reperfusion surgery utilized on these patients with resolution of the ischemia.

Rhabdomyolysis associated with compartment syndrome resulting in acute renal failure.

Compartment syndrome has rarely been reported associated with acute rhabdomyolysis. In the case described, the rhabdomyolysis was severe enough to cause compartment syndrome and acute renal failure after moderate exercise and alcohol intake and had the appearance of a myositis. The case emphasizes the importance of early recognition of compartment syndrome, as loss of pulses is a very late sign, and the examination of the urine to detect myoglobinuria in rhabdomyolysis. Measurement of creatine kinase is predictive of the extent of muscle damage and the development of renal failure.

The beneficial effects of dichloroacetate in acute limb ischemia.

OBJECTIVE: The purpose of this study was to determine the effects of dichloroacetate (DCA) in acute limb ischemia. METHODS: Anterior tibialis muscle samples of DCA-treated and control animals (Sprague Dawley rats) were collected and assayed for pyruvate dehydrogenase activity, lactate, adenosine triphosphate, and creatine phosphate using spectrophotometry. A physiograph was used to measure fatigability. In an ischemia/reperfusion model using New Zealand rabbits, serum lactate and end-tidal CO2 were compared. Skeletal muscle was evaluated microscopically for muscle necrosis. RESULTS: DCA administration resulted in a 50% increase in pyruvate dehydrogenase activity (p = 0.025), reversal of the increase in lactate levels seen during acute limb ischemia (p = 0.41), a significant increase in the time to skeletal muscle fatigue (p = 0.05), a trend toward increased adenosine triphosphate (p = 0.07), and a significant increase in creatine phosphate (p < 0.02). DCA treatment resulted in a decrease in serum lactate (p < 0.01) and end-tidal CO2 (p < 0.001). CONCLUSION: In acute limb ischemia and reperfusion, DCA administration provides metabolic protection to skeletal muscle.

[Mini-invasive distraction technique for treatment of severe ankle and foot deformities secondary to ischemic contracture of the leg].

OBJECTIVE: To explore the Ilizarov mini-invasive distraction technique for the treatment of severer ankle and foot deformities secondary to ischemic contracture of the leg. METHODS: Based on the tension-stress low of Ilizarov, a serial of adjustable three dimensions external distractive instrument was developed in our department. From April 2002 to March 2004, 8 patients with ankle and foot deformities secondary to ischemic contracture of the leg induced by trauma and fracture were treated with the distractive instrument. Of them, 4 patient were male and 4 female, aged from 13 to 31 years with an average of 23 years. Five affected legs were in the left and 3 in the right. Preoperative abnormal style included talipes equines in 6 feet and equinovarus in 2 feet, with extensive scar contracture in the legs. Five patients suffered from failure of soft tissue release before, two patients with severe bony deformity of the feet were underwent limited foot triple osteotomy in this department before the distractive correction. The distraction was begun from 7 d after operation and distractive time from 29 to 60 d with an average 46 d. RESULTS: All of the 8 patients were followed up from 10 months to 29 months, with an average of 13 months. All of deformities in the feet were corrected satisfactorily, full feet contacted with the ground in stand or walking and achieved with good function. No complication, such as pin tract infection, skin necrosis and neurovascular injury was occurred in this group. CONCLUSIONS: Mini-invasive distraction technique for treatment of severe ankle and foot deformity secondary to ischemic contracture of the leg is safe and mini-injury, it is also an effective approach for the treatment of various kinds of rigid foot anomaly.

Intramuscular compartment pressure measurement in chronic exertional compartment syndrome: new and improved diagnostic criteria.

BACKGROUND: Patients with chronic exertional compartment syndrome (CECS) have pain during exercise that subsides with rest. Diagnosis is usually confirmed by intramuscular compartment pressure (IMCP) measurement. Controversy exists regarding the accuracy of existing diagnostic criteria. PURPOSE: (1) To compare dynamic IMCP measurement and anthropometric factors between patients with CECS and asymptomatic controls and (2) to establish the diagnostic utility of dynamic IMCP measurement. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 40 men aged 21 to 40 years were included in the study: 20 with symptoms of CECS of the anterior compartment and 20 asymptomatic controls. Diagnoses other than CECS were excluded with rigorous inclusion criteria and magnetic resonance imaging. The IMCP was measured continuously before, during, and after participants exercised on a treadmill, wearing identical footwear and carrying a 15-kg load. RESULTS: Pain experienced by study subjects increased incrementally as the study progressed (P < .001). Pain levels experienced by the case group during each phase of the exercise were significantly different (P = .021). Subjects had higher IMCP immediately upon standing at rest compared with controls (23.8 mm Hg [controls] vs 35.5 mm Hg [subjects]; P = .006). This relationship persisted throughout the exercise protocol, with the greatest difference corresponding to the period of maximal tolerable pain (68.7 mm Hg [controls] vs 114 mm Hg [subjects]; P < .001). Sensitivity and specificity were consistently higher than the existing criteria with improved diagnostic value (sensitivity = 63%, specificity = 95%; likelihood ratio = 12.5 [95% CI, 3.2-49]). CONCLUSION: Anterior compartment IMCP is elevated immediately upon standing at rest in subjects with CECS. In patients with symptoms consistent with CECS, diagnostic utility of IMCP measurement is improved when measured continuously during exercise. A cutoff of 105 mm Hg in phase 2 provides better diagnostic accuracy than do the Pedowitz criteria of 30 mm Hg and 20 mm Hg at 1 and 5 minutes after exercise, respectively.

Vibrio vulnificus necrotizing fasciitis of the calf presenting with compartment syndrome.

We describe a 17-year-old boy with congenital spherocytosis and iron overload who presented with compartment syndrome of the calf as the initial manifestation of Vibrio vulnificus infection after minor trauma in a contaminated fish pond. The disease was complicated by necrotizing fasciitis requiring above the knee amputation. Childhood diseases associated with iron overload pose an increased risk for complicated V. vulnificus infections.

Delayed use of hyperbaric oxygen for treatment of a model anterior compartment syndrome.

This study examines the effect of delayed exposure to hyperbaric oxygen on muscle necrosis and edema development following compartment syndromes in the canine hindlimb. Compartment syndromes (100 mm Hg for 8 h) were generated in one anterolateral compartment of six anesthetized dogs. After a 2-h delay, three 1-h hyperbaric oxygen treatments (2 atm absolute pure oxygen) were given during the next 12 h. Two days later, technetium-99m stannous pyrophosphate (99mTc Sn-PYP) was injected intravenously; 3 h later, samples were obtained from the pressurized and contralateral control muscles, weighed for edema development, counted for 99mTC Sn-PYP uptake, and evaluated histologically. Hyperbaric oxygen treatments, even when delayed 2 h, reduced muscle necrosis and intramuscular edema to negligible levels (p less than 0.05) compared with untreated animals. In addition, muscle morphology remained essentially normal in all hyperbaric oxygen-treated animals. We conclude that even if hyperbaric oxygen treatments are delayed 2 h, edema and muscle necrosis are reduced significantly in a model compartment syndrome.

Chronic exertional compartment syndrome: muscle changes with isometric exercise.

UNLABELLED: Chronic exertional compartment syndrome (CECS) is a well-documented cause of lower leg pain in active individuals. The pathophysiology is unclear, although it is generally believed to be associated with increased intramuscular pressure, but there is very little information about muscle function in relation to the onset of pain. PURPOSE: To investigate strength, fatigue, and recovery of the anterior tibial muscles in CECS patients and healthy subjects during an isometric exercise protocol. METHODS: Twenty patients and 22 control subjects (mean age 27.6 yr and 33.0 yr, respectively) performed a 20-min isometric exercise protocol consisting of intermittent maximal voluntary contractions (MVC). Central fatigue was evaluated by comparing changes in electrically stimulated (2 s at 50 Hz) and voluntary contraction force before and during the exercise, and then throughout 10 min of recovery. Muscle size was measured by ultrasonography. Pain and cardiovascular parameters were also examined. RESULTS: The absolute MVC forces were similar, but MVC:body mass of the patients was lower (P < 0.05) as was the ratio of MVC to muscle cross-sectional area (P < 0.01). The extent of central and peripheral fatigue was similar in the two groups. The patients reported significantly higher levels of pain during exercise (P < 0.05 at 4 min) and after the first minute of recovery (P < 0.001). An 8% increase in muscle size after exercise was observed for both groups. There were no differences in the cardiovascular responses of the two groups. CONCLUSIONS: CECS patients were somewhat weaker than normal but fatigued at a similar rate during isometric exercise. Patients reported higher pain than controls despite comparable changes in muscle size, suggesting that abnormally tight fascia are not the main cause of CECS symptoms.

Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy.

Thirty legs in nineteen patients, eleven with bilateral and eight with unilateral chronic anterior-compartment syndrome, were treated by fasciotomy. In addition, five of these patients (six legs) had compression of the superficial peroneal nerve: two before and three after fasciotomy. One patient also had lateral compartment syndrome in one leg. The patients who had compression of the superficial peroneal nerve were relieved by partial fasciectomy and fasciotomy of the lateral compartment. In one of these patients, with bilateral nerve compression, both superficial peroneal nerves were anomalous. The patient who had lateral compartment syndrome was relieved by fasciotomy of this compartment. Two patients required a second fasciotomy due to recurrence of the chronic compartment syndrome. At an average length of follow-up of twenty-five months after fasciotomy for anterior compartment syndrome, functional capacity was unlimited or increased in eighteen patients (twenty-eight legs) and was unchanged in one patient (two legs) who had had compression of the superficial peroneal nerve. The intramuscular pressures in the anterior compartment were normal at rest as well as during and after exercise eight months after the original fasciotomy in twenty-eight legs and eight months after the second fasciotomy in two legs.

Chronic anterior tibial compartment syndrome. A light-microscopic, histochemical and electronmicroscopic analysis.

A case of chronic anterior tibial compartment syndrome is reported where the entity was accompanied with a primary neurogenic type of muscle atrophy. Histology, histochemistry and electronmicroscopy indicated the diagnosis. The authors concluded that in a moderate case of leg trauma with peroneal nerve involvement, when it is complicated by intermittent arterial spasm, the anterior tibial compartment syndrome may develop chronically.

The medial tibial stress syndrome. A cause of shin splints.

The medial tibial stress syndrome is a symptom complex seen in athletes who complain of exercise-induced pain along the distal posterior-medial aspect of the tibia. Intramuscular pressures within the posterior compartments of the leg were measured in 12 patients with this disorder. These pressures were not elevated and therefore this syndrome is a not a compartment syndrome. Available information suggests that the medial tibial stress syndrome most likely represents a periostitis at this location of the leg.

Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome.

Symptomatic liquefaction and calcification of muscle tissue as a late sequela of compartment syndrome of the lower leg is rare. The literature shows a high complication rate involved with simple debridement of these compartments. In our limited experience, complete compartmental debridement and immediate introduction of functional viable muscle may prevent the documented complications of chronic drainage and infection.

Compartment syndrome as a presentation of non-Hodgkin's lymphoma.

An 80-year-old woman sustained an injury to her left leg and presented having a compartment syndrome. Biopsy at the time of fasciotomy revealed lymphoma infiltrating the muscles of the left leg. We conclude that tumors may present as compartment syndrome and should be included with the differential diagnosis.

[Anterior compartment syndrome of the forearm caused by exercise: unusual cause of recurrent episodes of acute effort rhabdomyolysis]. / Le syndrome de loge antérieure de l'avant-bras provoqué par l'exercice: une cause rare d'épisodes récidivant de rhabdomyolyse aiguë d'effort.

INTRODUCTION: An effort-related compartmental syndrome is well known in the leg, but may be present infrequently, acutely or chronically in the anterior compartment of the forearm. EXEGESIS: We report a case of a 32-year-old man who presented four times after climbing exercises a bilateral compartment of the forearm, unusual because of the observation of rhabdomyolysis, but without irreversible damage. Clinical information and follow-up on two acute and 14 chronic cases were reexamined, showing a homogenous presentation. He refused fasciotomy because he stopped athletic activities. Measurement of intramuscular pressure after exertion was useful for diagnosis. CONCLUSION: A local effort-related pain must call to mind a chronic compartment syndrome of the forearm, which may risk incurring the acute form, with irreversible lesions of muscle and nerve, and possibly renal failure because of rhabdomyolysis.

Unusual causes of arterial insufficiency.

Most patients with vascular insufficiency in the legs suffer from atherosclerosis. Thus, it is easy to miss the diagnosis in occasional patients with disease due to other causes. Mechanical and functional disorders which affect major arteries or arterioles are described.

A case study using larval therapy in the community setting.

This article discusses the use of larval therapy by district nurses in wound bed preparation in the community. A case study is presented of a patient with a persistently necrotic and painful anterior tibial wound post-fasciotomy. The case study offers an insight into the practicalities involved in the use of larvae as effective and safe debriders of tissue for wound bed preparation. It is concluded that larval therapy is an underused and misunderstood resource when considering effective wound care and this treatment should be actively considered as an alternative therapy in wound care. There is a need for both qualitative and quantitative research in this field, enabling a more thorough discussion to be entered into by all practitioners with an interest in this subject.

[Morphological changes in tissues of extremities in military personnel with overload disease]. / Morfologicheskie osobennosti iamenenii v tkaniakh konechnostei pri peregruzochnoi bolezni u voennosluzhashchikh.

Extremely high physical activity results in anatomic-functional discordance in muscle compartments of segments of extremities. It leads to compartment syndrome consisting in compromised microcirculation, blood plasma infiltration of intercellular space, increased subfascial pressure at the same time we see intraosseous microcirculation disturbance and pathological alterations of bone tissue (hyperostosis, pathological reorganization, fractures), muscles, nerves and fasciae, that is confirmed by morphological alterations. Facsiotomy is of pathogenetic nature in patients with this pathology. Connective tissue replaces the site subjected to facsiotomy thus enabling to extend muscle compartment, normalizing in them intracompartment pressure under exercise stress, improving muscles, nerves, bones microcirculation, that enables elimination of anatomic-functional discordance of blood circulation and size of a muscle compartment under physical load and speeds up reparative processes in bones.