Medial Lower Leg Pain in a Middle-Aged Triathlete

Abstract

HISTORY: A 43-year-old triathlete presented with left distal medial lower leg pain that started gradually about 2-3 weeks prior to presentation. He denied inciting trauma and described the pain as a 5/10 sharp pain provoked by walking, running, and ankle dorsiflexion and plantarflexion movements. He endorsed mild left distal medial leg swelling but denied leg weakness or numbness and previous injury to this area. He was taking ibuprofen and had seen a chiropractor who performed several treatments including grastin, massage, taping, and a compression sleeve with minimal relief. He was training for his first full Ironman triathlon, scheduled for 12 days from presentation. PHYSICAL EXAMINATION: Gait was non-antalgic. No visible swelling or ecchymoses of the left lower leg. Only tender to palpation in the left distal medial leg near the myotendinous junction of the medial gastrocnemius. Full ROM at the knee and ankle, but left end-range ankle dorsiflexion was painful. Strength was 5/5 about the knee and ankle, but he had pain with toe raises and toe walking on the left. DIFFERENTIAL DIAGNOSIS: 1. Gastrocnemius strain or tear 2. Soleus strain or tear 3. Plantaris strain or tear 4. Achilles tendon injury 5. Posterior tibialis strain or tear 6. Fascial defect/muscle herniation 7. Deep posterior compartment syndrome 8. DVT TEST AND RESULTS: Limited diagnostic ultrasound of the left distal medial leg revealed a near tear of the plantaris tendon near the myotendinous junction with evidence of disruption of tendon fibers and surrounding anechoic fluid. There was neovascularization on color doppler and tenderness to sonopalpation. FINAL/WORKING DIAGNOSIS: Plantaris Tendinopathy TREATMENT AND OUTCOMES: He was encouraged to continue symptomatic treatments with his chiropractor and could also consider kinesiotaping. His goal was to complete the full Ironman, even if he was slower than anticipated and called about one week later to ask if there were additional treatment options. He wished to proceed with experimental sonographically-guided injection of dextrose hyperosmolar solution to the site of pathology of his plantaris tendon, which was performed 4 days prior to the Ironman triathlon. By race day, his pain had improved, and he was able to complete the full Ironman within his original goal time.