SPORTS MEDICINE

CASE STUDY 2 – 18 YEAR OLD MALE YOUTH TEAM PROFES- SIONAL FOOTBALLER Background Complains of a 2 year history of insidious onset bi-lateral calf tiredness/ache and increasing foot tingling/numbness affect- ing him during games and to a lesser extent training. ■ His general health is reported as good. ■ He has no pain at rest. ■ He has no pain when running slowly ■ The condition is gradually worsening. ■ He has been told that he has compart- ment syndrome by various manual ther-

apists and sports practitioners who have seen him during the 2 year period.

■ MRI Spine, reported as normal ■ His team doctor and previous physio- therapist have suggested his problem may be linked to the ‘biomechanics’ of his running style i.e. pronation.

■ He has received insoles for his shoes for apparent over-pronation, to no effect.

■ He has received manipulative therapy to his spine to correct various apparent ‘abnormalities’ relating to his sacro-iliac joints and ‘leg length inequalities’, to no effect.

■ He has received treatment for ‘muscle Action point YOU decide to explore the case further through deeper questioning, revealing the following

■ The pain only occurs when running hard and especially when the patient is ‘on his toes’ ■ He plays as a midfielder which involves lots of changes of direction, straight line running is less likely to reproduce his symptoms

■ Symptoms are worse during games and less so during training ■ When the pain comes on his calf feels ‘full’ and tight and he struggles to keep pace with the game

■ If he eases off and ‘strolls’ his pain disappears – he does NOT have to stop ■ He also reports that his boots feel tight when the symptoms come on ■ The pain seems to be starting earlier in the games and the coach is concerned about his ‘fitness’

Considerations ■ The pain pattern is clearly exercise induced

■ There is a relationship to effort/HR ■ There is a relationship to being ‘on his toes’

■ Shin pads and ties are worn during games and not during training sessions

■ Previous NMS treatment has been inef- fective

■ Previous surgery for compartment syn- drome has been ineffective ■ The condition is worsening

Question1 - Could this be a vascular flow problem? Y/N

Supporting evidence ■ There is little, if anything to support a compartment syndrome or NMS hypothesis. ■ Indeed, remedial surgery for compartment syndrome (fasciotomy) has already failed. ■ The pain pattern is non-dermatomal. ■ The condition is not responding to conventional NMS methods ■ The condition is clearly effort/heart rate related. ■ The symptoms are reproduced during exercise conditions. ■ His use of shin pads and ties during games may be a factor in restricting the neurovascular system during exercise conditions

■ There may be a biomechanical vascular link to the description of ‘being on his toes’. ■ The subjective descriptions of ‘tired’, ‘fullness’ and shoe tightness are commonly reported ischaemic symptoms.

■ The vascular system has not so far been proposed, or ruled out as a hypothesis.

Negating evidence ■ The patient is ‘too young’ to suffer ischaemic pain – faulty clinical rea- soning – many young athletes have been shown to suffer biomechanical flow limitation problems.

■ The patient reports being able to ‘stroll around’ at lower levels of effort - faulty clinical reasoning – symp- toms of mild to moderate flow limi- tation are often only revealed at high end effort/HR or under specific bio- mechanical conditions – in this case being ‘on his toes’.

imbalance’ to no effect.

■ He has had previous surgical calf com- partment fasciotomy to no effect.

■ He reports no relevant past medical his- tory or family history

■ He takes no medication.

Questions ■ What are your thoughts at this stage ■ Do you see a similar pattern to case 1? ■ Can you/should you offer a treatment that the other therapists have perhaps not done?

■ Should you take a different approach? If so, what?

Action point

You decide to explore the vascular option via objective testing in your clinic which has some gym equipment including a treadmill. www.sportex.net

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