Yudu - sportEX medicine - 1999-2010

LOWER LIMB INJURIES

Investigations may include ● MRI to describe tendon thickening, tears, ruptures, tenosynovitis ● X-ray to exclude os trigonum ● Bloods if there is no history of trauma or systemic disease is suspected

Management: Management is a modified version of the TA rehabilitation included later in this paper. Orthoses, manual ther- apy, addressing inflammation and inten- sive rehabilitation are particularly useful strategies.

Conclusion Management of chronic exercise induced leg pain is a complex process that requires accurate diagnostic skills and a sophisti- cated clinical decision making paradigm

Medial malleolus

Achilles tendon

Flexor hallucis longus

Flexor retinacu- lum

Flexor

digitorum longus

Tibialis posterior

Figure 8a: Anatomy of the posterior medial aspect of the ankle and leg

backed up by state of the art diagnostic facilities. A team approach to diagnosis optimises results while the lack of that

Figure 8b: MRI of tibialis posterior tendinitis (coronal view)

approach in management prevents even adequate results - especially in resistant cases.

Exercise induced leg pain YES Y Y

Relief within minutes of rest

Paraesthesia/ numbness

NES/ CCS/ spinal

● History ● Back exam ● EMG ● ICP

CCS/ spinal

● History ● Back exam ● ICP ● EMG

diagnosis Y

MTSS/ CCS/ spinal

● History ● Back exam ● X-ray ● Isotope ● ICP

Consider other

Relief within minutes to hours of rest

N diagnosis

Consider other

Pain during activity

Pain during and after activity

Pain during, after, & at rest

Y fracture

● History ● X-ray ● Isotope ● ICP

Stress N diagnosis

Consider other

Surgical emergency

Chronic NO

- not within the scope of this paper but consider:

Acute Acute CS

● History ● ICP

Fracture Tumour

Diagram 1: Exercise induced leg pain differen- tial diagnosis algorithm

Conclusion When a subject presents with EILP - think: 1. Medial tibial stress syndrome (MTSS) 2. Chronic compartment syndrome (CCS) 3. Stress fracture 4. Nerve entrapment syndrome (NES)

32 SportEX

Other possible differential diagnosis are very important to consider if or when a subject remains symptomatic when medial tibial stress syndrome, chronic compart- ment syndrome, stress fracture and nerve entrapment have been eliminated or have not responded to treatment include:

● Arteriovenous fistula ● Fascial muscular hernia ● Diabetes mellitus ● Spinal claudication ● Popliteal artery entrapment syndrome ● Tumuors ● McArdle syndrome