LOWER LEG - RUNNING

Abstract

HISTORY: A 41 yo male with a past medical history of depression, hypercholesterolemia, and shin splints who presents with acute left lower leg pain 3 days after running a 5 K course. Patient states that he had been biking for the previous 2 months, and had just restarted running 3 days prior to presentation. The day after he ran, he reports that his shin splint pain was rather severe bilaterally. Over the next 24 hours the right leg pain resolved, while the pain in his left leg worsened. On the morning of presentation, the patient awoke with intense pain in the anterior, medial, and lateral tibial region, a sensation of swelling and warmth, and weakness in dorsiflexion. PHYSICAL EXAMINATION: Vital signs stable. Temp 99.2 F. Examination of the left leg reveals erythema and 2 + pitting edema from the pretibial region into the dorsum of the foot. Palpation reveals firmness of the leg below the knee with pain throughout. There is a negative Homan's sign. Dorsalis pedis and posterior tibialis pulses 2+. Active ROM demonstrates a loss of 10 degrees of dorsiflexion; Plantar flexion, inversion, and eversion are within normal limits. Passive ROM is full in all directions. Strength is 4/5 anterior tibialis; 5/5 everters, inverters, and gastroc/soleus complex. DTR 2+. Sensation normal. Tuning fork negative. DIFFRENTIAL DIAGNOSIS: Deep Venous Thrombosis Stress Fracture/Acute Fracture Cellulitis Exertional Compartment Syndrome TESTS AND RESULTS: X-ray left tibia/fibula - Negative for fracture or stress reaction. Bone scan - negative for stress fracture Doppler US left leg - negative for thrombosis WBC 6.8 - normal differential; ESR 15. PT/INR/PTT - normal; CK 242 6. Compartment pressures - Anterior −38 mm Hg; Lateral −40 mm Hg; Deep Posterior −35 mm Hg; Superficial Posterior −18 mm Hg. FINAL/WORKING DIAGNOSIS: Exercise-induced exertional compartment syndrome of the anterior, lateral, and deep posterior compartments of the left leg. TREATMENT AND OUTCOMES: Non-weightbearing, elevation, and ice to the leg Consultation with Orthopaedic Surgery - if any progression of symptoms patient will be sent for emergent fasciotomy Physical Therapy with massage and modalities Will follow up after symptoms resolve to retest exertional compartment pressures bilaterally to determine the need for fasciotomy.