I had a recent case that challenged my diagnostic skills. A young soccer athlete was referred to me who complained of right lower leg pain following the start of soccer practice approximately 6 weeks prior to presentation in my office. He had been initially diagnosed with “shin splints” and treated with R.I.C.E methods by his team trainer. His symptoms persisted and he was seen by his primary care doctor. The assessment was same. He was suffering from “severe” shin splints. Oral anti-inflammatory meds, R.I.C.E. and some home exercises were given. NO response then he was ordered outpatient physical therapy. A few treatments went by without relief; the patient’s primary care provider referred him to me.
My exam showed the patient demonstrated “classic” shin splint palpable tenderness along the distal medial and anterior lateral aspects of the right leg. The worsening of the pain with exercise was present, also a common finding in the shin splint injuries. With my athlete patients I will often make the patient exercise to the point of where they get similar onset of pains reported. We did so. He described pain that was both an ache and a burn in sensation at same locations above. He had strong pulses. All sensation was intact. This young man had very large, muscular calves which were very tight and turgid even in resting condition. His leg x-rays were negative for stress fracture. My next most likely diagnosis was Chronic Exertional Compartment Syndrome (CECS). I set up a time to analyze leg compartmental pressures: resting and post exercise reading are indicated. His were 10 mm and 38 mm respectively.
Shin splints have a variety of presentations.
This syndrome can encompass a number of overuse disorders, they all share a common finding of periostitis (bone inflammation) near the origins of the soleus and/or flexor digitorum longus muscles. Flexor origin shin splints tend to be distal medial in pain…. Soleus origin shin splints can be that but also deeper and lateral (seemingly – anterior pain in location) … This is the tricky presentation…. . Commonly, the patient demonstrates many contributing factors most notable being; structural pathology predisposes patients to excessive and unbalanced pronation during the run/gait cycle, with subsequent overuse of the muscles of the distal extremity.
The differential diagnosis for this condition includes: stress fracture, chronic or exertional compartment syndrome, sciatica, deep venous thrombosis, popliteal artery entrapment, muscle strain, tumor, and infection.
Digging deeper for some answers…
Exertional compartment syndrome is a condition in athletes that can occur from repetitive activities and progressive competitive training. The anterior compartment of the leg is the most commonly affected location. Patients describe pain also as is burning in nature, which worsens with activity and completely subsides after 15 minutes of activity cessation. It seems, initial activity places a demand for blood supply for the muscles. This results in vascular inflow, engorgement, and expansion of the muscles in a confined fascial structure or “compartment”. The result is relative compression and pain. Resting and immediate post exercise is the gold standard for the diagnosis of chronic exertional compartment syndrome. A dynamic, post-exercise reading of greater than of 35 mm Hg is highly indicative of compartment syndrome. A dynamic pressure greater than 40 mm Hg is considered diagnostic.
Conservative therapy may help in the near term, but the condition will often flare when athletics are resumed. When indicated, surgical decompression via fasciotomy of the involved compartment is definitive in correction of the problem.
What is to become of this young athlete?
Considering the failure of conservative care, and the indisputable pressures measured…. the patient elects undergo anterior leg compartment release. I expect this to fully solve his problem. For me, lessons are always learned.
On referral patients, which are a good bulk of our clinic’s sports medicine cases, I always seek a wide ranged differential diagnosis. It may walk like a duck, and talk like a duck, but some times geese can look and talk that way too. In this case, I applaud the referring provider who saw that this patient may benefit from a specialist’s point of view. I called her on my findings, diagnosis and course of care for the patient in question. I got the proverbial …. “Ah Hah..I knew it !” As it turns out here, the referring physician demonstrated more than adequate working knowledge of lower extremity. As doctors, we are not expected to know everything… but we need to be smart enough to know what we don’t know.