LOWER LIMB INJURIES

the anterior compartment and 35mmHg in the deep posterior compartment. In the superficial posterior and lateral compart- ments, the pressure threshold varies between 15-25mmHg.

Clinical symptoms: The cardinal feature of CCS is pain that occurs on exertion or activity and is relieved with a variable period of rest (claudication-like). Patients often describe in addition to pain, their symptoms as ‘tightness’ rather than a cramp, which increases in severity. However this is not a consistent descrip- tion as other terms such as ‘piercing’, ‘contracting’, ‘cramp-like’, or ‘burning’ are also used by subjects.

Medial sided tibial pain seems usually to be described as soreness or dull ache, often as deep pain in the calf.

The lateral sided tibial pain may be more aching and cramping in quality but is extremely variable.

In the main patients will complain of pain in the lower leg during exercise which is relieved by variable periods of rest. Pain may be non-specific in its localisation. The pain experienced may vary from an irritation to disability. Symptoms are often related to running and thus are seen in many sports.

Examination: The findings on examina- tion of the lower limb are always normal.

Investigations ● Plain radiographs - to exclude any other bony pathology

● Urine test - to exclude diabetes melli- tus ● Isotope bone scan - to exclude stress fracture ● Dynamic intra-compartment pressure measurement (ICPM) (Fig.2) - most objec- tive diagnostic test available to CCS

Treatment: Once the diagnosis is estab- lished superficial fasciotomy is the proce- dure of choice.

Conservative measures

such as physiotherapy, orthoses and oth- ers are less beneficial.

There is evidence

to show that foot othoses increase com- partment pressures and are not indicated in management of CCS.

2. MEDIAL TIBIAL STRESS SYNDROME (MTSS) This condition is much more difficult to assess as the diagnosis is entirely depen- dent on history and the clinical finding of tenderness along the medial tibia border. A 1/3 leg isotope bone scan is commonly the investigation of choice with the clas- sical diffused uptake (Fig.3) along the medial tibia border confirming the diag- nosis. This in recent time has been viewed with caution as the same uptake is often seen in asymptomatic limbs. The condition is often confused with compartment syn- drome.

Pathogenisis: The pathology of MTSS is unknown and is thought to be a sympto- matic expression of normal (albeit hyper- stimulated) periosteal modelling at the site of maximal tibial strain under load. Periostitis or symptomatic periosteal mod- elling occurring along the lower 1/3rd medial border of the tibia is a consistent

Figure 3: Isotope bone scan showing dif- fuse uptake in MTSS

finding. Abnormal biomechanical factors and in particular abnormal pronation are thought to contribute in the development of this condition. There is some evidence to suggest a correlation between supinat- ed feet and MTSS. Supinated feet are usu- ally less shock absorbing.

Clinical symptoms: The patient will com- plain of lower limb pain either during or after exercise. The pain will last much longer after exercise usually between a few hours to days in some cases. Classically the pain is always located in the inner tib- ial border usually the lower 1/3 leg.

On

examination there is extreme tenderness in this region.

Often there is history of

excessive running on hard surfaces or playing on Astro-turf surfaces. Many patients are able to continue with their activity despite the pain.

Examination: The most striking feature is the inner tibial border tenderness. The limb is otherwise normal.

Investigations: ● Plain radiographs - to exclude other bone pathology ● Isotope bone scan - diffused uptake ● Dynamic ICPM - to exclude co-existing CCS

Figure 2: Dynamic intra-compartment pressure measurement

Treatment ● Rest and physiotherapy - strength and flexibility programme on lower limb mus- cles, particularly tibialis posterior, per- oneal and calf muscles. This could be com- plemented by modality treatments such as laser, interferential and ultrasound to reduce inflammation and scar tissue. Friction and massage have been found to be beneficial in reducing the symptoms ● Biomechanical and gait analysis - foot

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