Dr Mark Hutchinson, professor of Orthopaedics and Sports Medicine at the University of Illinois Medical Centre, and star of the three million times viewed BJSM physical examination videos, gives Karim Khan an update on examination and management of leg pain. He explains why he doesn’t use the term ’shin splints’.
In this podcast Dr Hutchinson covers: (i) clinical work-up of persistent leg pain (ii) investigating compartment pressure (iii) two or four compartments? (iv) tips for surgeons treating compartment syndrome (v) fasciotomy or fasciectomy?
These notes have kindly been donated by a student and are purely for informational purposes only. Physiowizard does its best to screen information however the information may not necessarily reflect the beliefs of Physiowizard and we cannot guarantee its accuracy.
- Move away from the term shin splints (athlete led- umbrellas a few diagnoses)
- Medical diagnosis
- Runner – increased running, increased leg pain
- Leg pain – broad differential diagnosis – dehydration, metabolic issues, muscle strain
- R/O four main common diagnosis:
- Stress fracture, medial tibial periostitis (where muscles are inserting onto the medial border of tibia, inflammation or stress fracture in this region).
- Popliteal artery entrapment
- Chronic exertional compartment syndrome
- Pain pattern
- Time of pain
- Location of pain
- Other symptoms
- Target rest of examination – Focuses initially on likely diagnosis and then expands as necessary.
- Routinely will have plain radiographs
- AP lateral and obliques – inexpensive, to confirm diagnosis.
- Good history
- History pattern clues to diagnosis.
- R/o lumbar spine referral
- Distal nerve/ vascular is intact
- Palpate medial border tibia – feel for swelling or focal area of pain.
- Is localised/focal pain on bone (less than 1 thumb) suspect stress fracture
- If broader pain on posterior medial border of tibia suspect medial tibial periostitis.
- If pain is located over anterior lateral soft tissue compartment suspect compartment syndrome.
- If pain is deep and posterior could be compartment syndrome but need to r/o popliteal artery entrapment syndrome.
- Will check pulses –dorsal, pedal and posterior.
- Actively plantar flex and dorsi flex. Palpate to see if pulses diminish with those movements.
- Can use Doppler ultrasound to monitor flow of arteries.
Investigating Compartment Syndrome
- No pain at rest
- 5-10min into run feel pressure build up in anterior lateral aspect of their lower limb.
- Can cause pain, can stop them running, can cause numbness in dorsal aspect of their foot. When stopping pain/pressure resolves.
- R/o stress fracture which may have associated swelling.
- This history alongside physical examination would suggest appropriate to test for compartment pressures.
- Handheld instrumented device (Stryker). All 4 compartments in both legs before and after exercise.
Pre exertion/post exertion results.
- Normal 0-10.
- Abnormal at rest 20-25.
- Positive over 25-30 or >10 compared to pre exertion measurements. (Confirms compartment syndrome. Can then become candidate for surgical release).
- 10-20 don’t treat just monitor.
- 90-95% successful
- In women 85-90%.
- If nil other associated diagnosis successful
- Mis diagnosis can explain some poor success with surgery
- Complication risk – fairly high risk –
- Cellulitis, wound issues, superficial peronial nerve ( varied presentation -can leave area of numbness)
- Post –op – Compression dressing, ice therapy