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Six common conditions that cause EILP

What should I do?

Clinicians should not use the term “shin splints” as a diagnosis and strive to define the problem by taking a detailed history and examination and confirm the diagnosis by investigations.

1)    Medial Tibial Stress Syndrome

The condition is defined by the site of pain, which is usually tenderness along the lower third medial tibia. In some cases it can co-exist with CECS of the deep posterior compartment and may need investigating if the treatment for MTSS is unsuccessful.

Clinical picture: The pathology of MTSS is unknown and it is thought to be a symptomatic expression of normal periosteal modelling at the site of maxmimum tibial strain under load.
The patient will complain of pain during exercise and can usually run through pain, with worse pain after cessation of the exercise and at rest. Pain can last for up to a few minutes and in some cases hours and days.

Investigations: MRI scan, plain x-ray to exclude other bone pathology, isotope bone scan and dynamic intra-compartment pressure, if CECS suspected.

Treatment: Rest in acute phases, physiotherapy, biochemical & functional & gait analysis, foot orthoses, injection (steroid and 15% glucose) under ultrasound guidance, shock wave therapy and, in recalcitrant cases, surgery.

2)    Chronic Exertional Compartment Syndrome

CECS is a condition in which increased pressure within a closed anatomical space compromises the circulation and the function of the tissues within that space.

Clinical picture: The patient typically presents with pain and tightness on exercise which is only relieved by variable period of rest, usually a few minutes. When pain occurs they have to stop. They can usually differentiate between symptom of tightness and cramp. In some cases they may experience reversible transient paraesthesia and numbness. It is usually bilateral and commonly affects the anterior department but can occur in the deep posterior compartment. Superficial posterior and peroneal compartments are rarely affected.

Investigation: Gold standard investigation is the dynamic intra-compartment pressure (DICP) test, which should generate information on maximum, mean, relaxation and resting pressure, together with a pressure tracing for on-the-spot interpretation and evaluation.

Treatment: Surgery – superficial fasciotomy or fasciectomy

3)    Tibial Stress Fracture

Tibial stress fracture is one type of incomplete fracture of the bone and occurs as a result of repetitive tibial strain imposed by loading during monotonous weight bearing activity.

Clinical Picture: The aetiology of tibial stress fracture is based on evidence that micro-stress fractures occur at the site of maximum shear strain as a result of repeated tibial bending. There is further evidence to suggest that micro-fractures are likely to occur as a consequence of reduced tissue resistance to strain following the development of remodelling related bone porosity.
The pain in the leg occurs during and after exercise and persists at rest and often the patient will limp with pain that may last for days and weeks after cessation of activity. The onset of pain is often acute, with recall of specific event that led to pain. In some cases they may experience “crescendo” pain, especially at night.

Investigations: X-rays which will indicate either a dreaded “black line” or, presence of callus. Isotope bone scan, CT scan and MRI scan.

Treatment: Rest for up to 6-9 weeks and immobilise in below-the-knee walker, preferably with pneumatic system to reduce swelling and loss of muscle power. In very rare cases, below-the-knee scotch cast. Rehabilitation with return back to sport can start once pain free.

4)    Superficial Peroneal (Fibula) Nerve Entrapment Syndrome

A condition in which pain is caused by pressure on a single nerve.

Clinical Picture: It is estimated that there is 17% incidence rate of SPNES. External or internal pressure causes reduction in blood flow to the nerve (local ischaemia), which leads to loss of axon ability to transmit action potential. If untreated this leads to a chronic condition with focal demylelination, axonal damage and scarring.
Pain paraesthesia, numbness, muscle-weakness and fatigue are some of the symptoms experienced by patients with activity, and the history and site of pain often mimics CECS.

Investigations: Nerve conduction studies may be useful in severely chronic conditions but they are largely unhelpful. Local anaesthetic as a diagnostic test is the investigation of choice.

Treatment: Steroid injection as initial treatment and, if that fails, surgery.
Other nerves that can also result in entrapment are sural, common peroneal (fibula) and posterior tibial nerves.

5)    Popliteal Artery Entrapment Syndrome

Occlusion of the popliteal artery occurs either as result of abnormal anatomy of the gastrocnemius muscle (usually the medial head) or thickened fibrous brand. There are six types of PAES.

Clinical picture:
Young, active individuals engaged in competitive and endurance sports. Patients will complain of pain in the leg during exercise, which is relieved instantly on stopping and can usually continue again. Often mimics CECS. Pain is specifically inferior to the popliteal fossa and often in the main belly of the gastrocnemius muscle.
Examination is usually unremarkable but PAES should be suspected if peripheral pulses disappear when the ankle is plantarflexed, even though this is not a reliable test but may be useful clinically. The condition can be bilateral but is usually unilateral.

Investigations: Duplex Doppler scan, arteriography, MRI scan and magnetic resonance angiogram (MRA) scan.

Treatment: Surgery except for type 6, which is most difficult to manage.

6)    McArdle Disease

McArdle is a painful muscle disease due to metabolic myopathy and is characterised by deficiency in myophosphorylase. It is an inherited condition, a rare autosomal recessive disease which is often referred to as glycogen storage disease type V (GSD-V). The incidence is reported as 1 in 100,000 and onset is first noticed in childhood but often diagnosed when aged 30-40 years.

Clinical picture: Patients will present with exercise intolerance with pain, early fatigue, painful cramps, and weakness of exercising muscles. There may be presence of myoglobinuria and creatine kinase due to muscle damage (rhabdomyolysis).

Investigations: Muscle biopsy and serial pre and post exercise serum creatine kinase.

Treatment: There is no specific treatment but vitamin B6 may reduce fatigue and sucrose intake prior to exercise may be helpful. Patient education along with advice on modification of their physical activity so as to exercise within their limit.


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