EXERCISE-RELATED LEG & FOOT PAIN - WATER SKIING

Abstract

242 HISTORY - A 24 elite male water-skier was suffering from left buttock, posterior thigh, calf and foot pain. This was a claudicant-type pain, only occurring after 10+ minutes of activity (skiing) and then worsening until exercise needed to be ceased. It occurred every time the patient attempted to ski and thus prevented him from competing. There was also associated numbness, particularly in the heel and sole of the foot. Six years previously, he had suffered a posterior dislocation of the left hip joint during a water-skiing accident. It was successfully reduced, but the leg and foot symptoms had commenced shortly thereafter and had worsened over time. The patient had previously had normal nerve conduction studies and had undergone a popliteal fossa exploration to release the neurovascular structures, which was unsuccessful. He had also tried physiotherapy, massage and rest from all exercise on a few occasions, with no improvement. PHYSICAL EXAMINATION - Examination at rest was essentially normal, including hip range of motion, neural stretches, peripheral pulses and reflexes. After exercise, particularly in a position that simulated his racing stance (left leg extended with hip flexed), his pain could be reproduced. Weakness of toe extension and ankle dorsiflexion was demonstrated, along with reduced sensation in the heel and sole of the foot. DIFFERENTIAL DIAGNOSIS- Left sciatic nerve entrapment at either of the following levels: Piriformis (posterior hip) L5 +/- S1 nerve roots in lumbosacral spine Hamstring syndrome (ischial tuberosity) Compartment syndrome of multiple left lower leg compartments TEST AND RESULTS - Pre-exercise nerve conduction studies were normal. Immediately post-exercise, left sciatic nerve conduction was very abnormal, with abolition of F wave responses. These returned to normal after 10 minutes of rest. Lumbosacral MRI scan was within normal limits. Left hip and buttock MRI scan demonstrated a normal left hip joint with some residual posterior scarring. Left deep posterior leg compartment pressures were borderline high-normal (resting 13mmHg rising to 27 at 1 minute post-exercise). FINAL/WORKING DIAGNOSIS - Left sciatic nerve entrapment at the level of piriformis muscle, secondary to scarring from previous hip trauma. TREATMENT - The patient had an exploration of the left buttock region, with piriformis release and debridement of scar. Six months post-operation his post-exercise nerve conduction studies had returned to normal. At nine months post-operation, he was able to compete and won a National Championship race.