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
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
Y
NES/ CCS/ spinal
● History ● Back exam ● EMG ● ICP
N
CCS/ spinal
● History ● Back exam ● ICP ● EMG
diagnosis Y
MTSS/ CCS/ spinal
● History ● Back exam ● X-ray ● Isotope ● ICP
Consider other
Y
Relief within minutes to hours of rest
N diagnosis
Consider other
Pain during activity
N
Pain during and after activity
N
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: