Lower leg injuries

Anatomy review the lower leg is divided into four compartments; each contains different muscles and the nerve and blood supply to each. The compartments are delineated by tough fascial sheathes which don't allow for much expansion of tissue.

contents: anterior tibialis, ext. hallucis longus, extensor digitorum longus, peroneus tertius, deep peroneal nerve and anterior tibial blood vessels. Muscles originate on the proximal 2/3 tibia and fibula, and insert on the bones of the foot.

2. Lateral compartment

contents: peroneus brevis, peroneus longus, peroneal artery, superficial peroneal nerve. Muscles originate on the fibula for the most part and insert on the plantar surface of the foot.

3. Deep posterior compartment

contents: flexor hallucis longus, flexor digitorum longus, tibialis posterior, tibial nerve, peroneal artery, post. tibial artery. These structures originate on the posterior proximal 2/3 of tibia, interosseous membrane and fibula.

4. Superficial posterior compartment

contents: gastroc, soleus, plantaris, popliteal artery, tibial nerve. Muscles originate on the femur and high on the tibia and insert into the calcaneus.

5. Interosseous membrane (syndesmosis) isn't a compartment but ligamentous sheathe that holds the tibia and the fibula together.

Compartment syndromes

1. Acute compartment syndromes

Etiology is usually a trauma incident to any compartment of the lower leg, usually the anterior compartment. This leads to uncontrolled swelling and hematoma in a closed area. Increases in pressure collapse the vascular structures which leads to hypoxia and throbbing pain.

Symptoms include a history of trauma, throbbing/aching pain, red and distended skin, tissue temp. elevation, "foot drop" due to compression of neurological structures, tension filled and hard, and a passive stretch will induce pain. One of the most significant symptom will be pain with passive motion.

Treatment consists of ice, elevation, rest, and immediate referral to physician. In severe cases the tendon sheathe is opened and pressure released to avoid permanent damage.

2. Exertional compartment syndrome

Etiology is exercise induced and much more common in athletics. The as circulation increases and muscle volume expands which may limit venous return leading to increased intra muscular pressure and pain.

Symptoms bilateral involvement, muscle weakness, "foot drop", paresthesias, onset at a consistent time during the exercise regime, usually in ant. or lat. compartments. Patients usually have pain relief after exercise is stopped.

Treatment can be done with a fasciotomy. More conservative means include rest, alter activities, ice.

Stress fractures

Stress fractures are fractures which develop as the result of abnormal or unusual repetitive stress which is applied to the bone. The chain of events is normally related to a change in shoes, running surfaces, distance, or exercise regimen. Surgery on another limb may also cause the patient to place more stress on the non affected limb and thus apply more pressure than normal. Bone which is subjected to repetitive stress remodels according to Wolff's law. ( bone responds to physical stresses or to the lack of them. Bone is deposited on areas subjected to stress and reabsorbed from areas of little stress. ) Trabeculae are resorbed by osteoclastic activity and new cells are laid down by the osteoclasts along the lines of stress. Approximately 10 days after the process is initiated, the bone becomes vulnerable to micro fracture because the resorptive phase has weakened the bone and the repair phase has not yet deposited sufficient new bone.

Etiology fx. may be more common in people with high arches (tibial) or people who pronate (fibular) when they run. Usually there is a change in workout, surfaces or foot gear which precipitates the increased stress.

Symptoms pain and point tenderness, some swelling, gradual onset, percussion, tuning fork or squeeze tests are positive, thickening or callus may be palpable. Not associated with muscle tests, resistance, or stretch.

Diagnosis early is very important, however, it may be difficult to differentiate between "shin splints" and stress fractures of the lower leg, and many foot related stress frx's do no present until the athlete or patient has become tired of the pain which may have been present for 2-3 weeks. The physician may make use of regular x-rays, or bone scans to aid in the diagnosis. ( bone scans use a radionuclide using 99m technetium phosphates. These are 100% sensitive to bony abnormality. ) MRI scans utilizing the T1 or T2 images may also be sensitive to bone stress problems.

The dark places in the x-ray represent the increased uptake of the radiological dye that are indicative of the tibial stress fracture. (female track athlete)

Tibial Stress Fractures are unusual in the male athlete, however, they do occur. This is an 18 y.o. baseball player.

The health care provider must try to get an accurate history of the patients injury and pain as well as examining any prior x-rays.

Treatment early dx is important with bone scan, x-ray takes 5-8 weeks to show calcium deposits. Eliminate the cyclic load causing the problem. Support arches with tape or padding, alter training, gait analysis, foot gear check ice after activity and rest are all appropriate. Ultra conservative rx is in a cast.

"Shin splints"

Anterior shin splints-careful with terminology etiology inflammation of ant. tib. muscle due to muscle imbalance, overuse, altered activity, hill work, or a varus foot. Sx pain along lateral border of the tibia associated with muscle stretch or contraction. Rx ice, stretch gastroc, strengthen ant. tib., rest, alter training.

This patient complained of "high shin splints, however, as seen in this bone scan, the unilateral pain was a high tibial stress fracture.

Posterior shin splints

Etiology pain and swelling in the post. tib.,flex. digitorum longus and flexor hallucis longus due to overuse, pronation, poor shock absorption. Sx pain at post. tib. insertion (deep) and pain when structures are stretched in inversion. Rx rest, ice, arch supports/orthotics, strengthening these mm and modify training.

Medial tibial stress syndrome

Etiology - pain and swelling at the origination of the post. tib., flex. digitorum longus and flex. hallucis longus. Mm are not painful or sore, but the musculotendinous attachment to the bone and periosteum are. Excessive mileage seems to be the main culprit.

Symptoms - pain on distal 1/3 of tibia relived with non weight bearing (NWB) and not related to muscle stresses. There is increased bone uptake and involvement of post. tibial cortex. Palpation is tender but not localized.

Treatment - rest, ice, alter activity, gradual return. Newest research shows tape and external supports are unhelpful. If the patient pronates the feet (turns in), orthotics with medial wedges to straighten up the feet may be helpful. However, care should be taken not to over correct with the orthotics or to try to correct large deviations all at one time. Be gradual, 1/16" to 1/8" at a time.

The USA. soccer team in 1990 competed in the World Cup Championships. Dr. William Garrett from Duke UN. traveled with them. He noted the following:

1/3 of the participants had stress fractures of the 100 members of the US men's senior national and USOC. teams, 97 % had abnormal bone growth, bone spurs, and stress fractures in their feet and legs. The significant correlation is that these athletes are not rookies, but seasoned veterans.

Shoe design may add to the incidence of lower leg and metatarsal stress fractures. The cleat pattern on a soccer shoe does not provide much lateral or medial stability due to the inboard pattern of the cleats.

The size of the ball may also hinder some youth players, young athletes under the age of 12 should consider using a size 4 ball or smaller before playing with the heavier, larger, adult size 5 ball.