LOWER EXTREMITY
OVERUSE INJURIES
Andrew S. T. Porter, DO, FAAFP
University of Kansas School of Medicine - Wichita
Sports Medicine Fellowship & Family Medicine Residency at
Ascension Via Christi
KAOM CME Conference
11-08-2019
Lower Extremity Overuse Injuries in the Athlete
• Medial Tibial Stress Syndrome
• Chronic Exertional Compartment Syndrome
• Anterior Tibial Stress Fracture
• Posterior Tibial Stress Fracture
• Fibular Stress Fracture
• Navicular Stress Fracture
• Achilles Tendinosis
Medial Tibial Stress Syndrome (MTSS)
• Shin Splints
• Common cause of exercise-induced lower leg pain
• Most often seen in sports where repetitive running &
jumping are required
• Periostitis caused by traction of posterior leg muscles
MTSS
• Pain along the posterior medial border of the mid tibia
which worsens with activity
• Usually diffuse area that is involved
• Pain improves with rest but often does not completely
resolve
MTSS
• Imaging
• Plain X-rays
• AP & Lateral Tibia/Fibula with unaffected leg for comparison
• MRI with T2 Fat Sat Views in all plans
• Linear longitudinal edema of the periosteum
• MRI with STIR
• Bone Scan
• Linear diffuse uptake along posterior medial tibia
Anterior Tibia
Posterior Medial
Tibia
MTSS
• Treatment• Rest
• Activity modification would be best• Remember time off is lost training & quickly de-train
• Evaluation of training methods
• Formal Physical Therapy• Core strengthening, pelvic stabilization, mid foot strike, posterior tibial
strengthening
• ASTYM• Deep soft tissue friction massage
• Taping to off-load posterior medial tibia
• NSAIDs
• Evaluate shoe wear• Pes planus
• Surgery• Fasciotomy of deep posterior compartment
• Release of soleal bridge
• Reserved for refractory cases
Chronic Exertional Compartment Syndrome (CECS)
• Deep, aching exertional lower leg pain that results in
ischemic like pain
• Improves/resolves with rest but may remain bothersome for quite
some time
• Diagnosed with history and intercompartmental pressure
device
• ≥15 mm Hg at rest
• ≥30 mm Hg within 1 minute after exercise
• ≥20 mm Hg within 5 minutes after exercise
• CECS can turn into Acute Compartment Syndrome
CECS
• 22 year old male Army mechanic
• Training for APFT
• Maximum time is 16:36 for 2 mile run
• If he doesn’t pass the APFT he will be put on profile
• While training for APFT he develops exertional lower leg pain
described as fullness/tightness and cramping
• He has troubles lifting his feet up (dorsiflexion) and will often feel
like he is slapping the ground with his feet after he hits the 1.5 mile
mark
• What LE compartment is most likely involved?
CECS
Any/all of the 4 lower leg compartments can be involved
• Most common compartment
• Anterior
• 2nd most common compartment
• Deep posterior
CECS
CECS
• Treatment
• Formal Physical Therapy
• Core strengthening, pelvic stabilization, mid foot strike, posterior tibial
strengthening, eccentric strengthening of LE compartments
• ASTYM to lower extremity compartments
• Deep soft tissue friction massage
• Taping to off-load posterior medial tibia
• Evaluate shoe wear
• Pes planus, pes cavus
Mid Foot Strike
Mid Foot Strike
CECS
• Treatment
• Percutaneous dry needling of involved compartments & fascia
• Botulinum toxin injections into involved compartments
• Surgery
• Fasciotomy of involved compartments vs all 4 compartments
• Mini-open vs endoscopic vs open
• Reserved for refractory cases
• Convert to cross trainer if able to
• Prepare for APFT run portion with elliptical, swim
• Marathon runner converted into Triathlete
Stress Fractures
• Stress Fractures in general
• Specific treatment recommendations
• Anterior Tibia
• Posterior Tibia
• Fibula
• Navicular
Stress Fractures
• Occur when osteoclastic activity overwhelms osteoblastic activity
• Bone injury unfolds over a continuum of time without intervention
Normal Bone → Stress Reaction → Stress Fracture →Fracture
• Result from excessive stress on normal bone from overactivity
• Result from normal stress on a bone that is deficient (osteoporotic, poor nutrition, or in female athlete triad)
• Common injuries in athletes & people who are active
• Running sports account for 69% of stress fractures
• Suspect in someone who is active:• + bone pain
• + performs repetitive activities with limited rest or recent increase in activity
Stress Fractures
• Physical exam
• Tests to perform in the area of interest are palpation, the tuning fork test, the fulcrum test, & the hop test
• Palpation
• Pain over affected bone with palpation
• Fulcrum Test
• Pain in fracture site while applying a bending force (e.g., over exam table) to distal extremity while proximal extremity is kept relatively immobilized
• Hop Test
• Hopping 10 times on affected leg reproduces pain at fracture site
• Tuning Fork Test
• Vibrating tuning fork over fracture site results in pain at site
Stress Fractures
• Imaging• If a stress fracture is suspected, x-rays should be obtained
• Takes 2 to 3 weeks for signs of stress fracture (i.e., periosteal reaction, callus formation, fracture line) to show up on x-ray
• Often stress fractures do not show up on x-rays
• If x-rays are negative & diagnosis is needed to help guide care & return to activity a bone scan or MRI should be obtained
• MRI with T2 Fat Sat Views in all planes• Marrow edema & possibly a transverse line of signal change
• CT Scan to further stress fracture line
• Bone scan can stay positive for up to 18 months • Clinical progress should not be monitored with a bone scan
Stress Fractures – Prevention
• Distribute loading forces on the bone with cross training & biomechanical adjustments
• Orthotics, proper shoes, stretches, strengthening, running mechanics)
• Consume sufficient calories to maintain adequate energy availability
• Ensure appropriate intake of calcium and vitamin D.
• A study by Lappe of female Navy recruits showed reductions in stress fractures in those consuming 2000 mg of Calcium & 800 IU vitamin D daily (supplement or diet)
• Lappe J et al. Calcium & Vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res 2008;23:741-749.
• Tobacco should be avoided
• Women of child bearing age should try to maintain regular menses by consuming adequate calories & avoiding a negative energy balance
Stress Fractures – Treatment
• Nutrition, medication, & biomechanical recommendations
• Nutrition• Optimizing energy availability in diet
• Ensuring adequate calcium & vitamin D intake• Stress Fracture Prevention: 2000 mg Calcium + 800 IU Vitamin D
• Avoidance of tobacco exposure
• Medication • Acetaminophen PRN
• Avoidance of NSAIDs as they can slow bone healing
• Biomechanical • Offload the affected bone
• Reduce activity to pain-free functioning & pain-free cross-training
• Crutches may be needed to offload the injured area even more than a walking boot/cast or steal shank
• May require NWB • Goal = pain-free ambulation during the initial tx
Stress Fractures – Treatment
• Begin a rehabilitation
program when
tolerated
• Stretch & strengthen
supporting structures
• Start a gradual
increase in activity
when pain free
Factors influencing healing • Age
• Tobacco use• Lowers estrogen resulting in higher osteoclastic activity
• NSAIDs can slow bone healing • Lead to higher rate of non-union
• Menstrual dysfunction• Oligomenorrheic & amenorrhoeic females have decreased estrogen levels = higher osteoclastic activity
• Hormonal abnormalities
•Low growth hormone
•Low Testosterone
• Bone Quality
• –Nutritional • Adequate energy balance & protein intake
• Epcorates, UpToDate (Caloric intake)• Weight, exercise level
• Vitamin D and calcium
Return to Play
• Work on what the athlete can do
• Athlete is losing training time so readiness to RTP is not
just based on stress fracture healing
• Allow athlete to return to activities that are non-painful
ASAP
• Lose Cardio respiratory fitness, muscle strength, balance,
& proprioception fast
Stress Fractures
High Risk vs Low Risk • Because of their propensity for delayed healing &
nonunion, certain stress fractures are considered high
risk, necessitate prompt treatment, & may ultimately
require surgical fixation
• Navicular
• Anterior Tibia
• Low-risk stress fractures have a lower incidence of
delayed healing & nonunion
• Posterior Tibia
• Fibula
Stress Fractures
Low Risk vs High Risk • Biomechanical forces along the bone with activity are
used to classify tibia stress fractures as either
compression-sided or tension-sided
• When running, the tibia compresses posteriorly so the posterior
aspect of the tibia is considered compression sided
• These variable forces on different parts of the bone affect
the potential for delayed healing & nonunion
Stress Fractures – Specific Tx
• LOW-RISK STRESS FRACTURE INITIAL TREATMENT
• Posterior Tibia
• WBAT Boot for 2-12 weeks (longer with cortical break) then transition to
pneumatic tibial brace
• Fibula
• WBAT 1-4 weeks
• +/- Cam Walker Boot
Stress Fractures – Specific Tx
• HIGH-RISK STRESS FRACTURE INITIAL TREATMENT• Anterior Tibia (Tension Sided)
• NWB for 6-8 weeks → PWB → FWB over next 6-12 weeks
• Can consider Orthopaedic Surgical Referral at diagnosis or if clinical & radiographic
healing are not achieved
Anterior Tibial Stress Fracture
• 21 year old female presented with 9 months of pain in
anterior tibia
• As she recalled, the pain started after she was kicked in
the shin
• Played full college basketball season with the pain
• Presented to me after the season at Fall PPE’s
• X-rays were performed
Anterior Tibia Stress Fracture8/2/19958/2/1995
21 YEAR21 YEAR
FF
Page: 2 of 2Page: 2 of 2
XR Tibia/Fibula RightXR Tibia/Fibula Right
TIB-FIB LATTIB-FIB LAT
8/23/2016 4:57:05 PM 8/23/2016 4:57:05 PM
000XR16170496000XR16170496
------
------
------
IM: 1002IM: 1002Compressed 69:1Compressed 69:1
W: 1638W: 1638C: 2048C: 2048Z: 0.50Z: 0.50S: 136S: 136
8/2/19958/2/1995
21 YEAR21 YEAR
FF
Page: 2 of 2Page: 2 of 2
XR Tibia/Fibula RightXR Tibia/Fibula Right
TIB-FIB LATTIB-FIB LAT
8/23/2016 4:57:05 PM 8/23/2016 4:57:05 PM
000XR16170496000XR16170496
------
------
------
IM: 1002IM: 1002Compressed 69:1Compressed 69:1
W: 1638W: 1638C: 2048C: 2048Z: 0.50Z: 0.50S: 136S: 136
Further Work-Up & Treatment
• CT Scan had small fracture line that involved only the anterior cortex of the tibia (<15% width)
• MRI had edema in the area of stress fracture
• Vitamin D 25 OH was low at 15
• Conservative treatment initiated• WBAT during the day
• Activity modification
• Limited practice reps & time
• Adequate calorie intake
• 2000 mg calcium daily
• 50,000 IU Vitamin D weekly for 12 weeks
• Goal Vitamin D 25 OH > 40
• Bone stimulator 20 minutes daily to stress fracture site
2 months tx8/2/19958/2/1995
21 YEAR21 YEAR
FF
Page: 2 of 2Page: 2 of 2
XR Tibia/Fibula RightXR Tibia/Fibula Right
TIB-FIB LATTIB-FIB LAT
10/31/2016 9:09:48 AM000XR16218794000XR16218794
------
------
------
IM: 1002IM: 1002Compressed 67:1Compressed 67:1
W: 1638W: 1638C: 2048C: 2048Z: 0.41Z: 0.41S: 129S: 129
8/2/19958/2/1995
21 YEAR21 YEAR
FF
Page: 2 of 2Page: 2 of 2
XR Tibia/Fibula RightXR Tibia/Fibula Right
TIB-FIB LATTIB-FIB LAT
10/31/2016 9:09:48 AM000XR16218794000XR16218794
------
------
------
IM: 1002IM: 1002Compressed 67:1Compressed 67:1
W: 1638W: 1638C: 2048C: 2048Z: 0.41Z: 0.41S: 129S: 129
2 months NWB s/p ACL tear8/2/19958/2/1995
21 YEAR21 YEAR
FF
Page: 2 of 2Page: 2 of 2
XR Tibia/Fibula RightXR Tibia/Fibula Right
TIB-FIB LATTIB-FIB LAT
1/3/2017 2:09:22 PM000XR17001450000XR17001450
------
------
------
IM: 1002IM: 1002Compressed 68:1Compressed 68:1
W: 1609W: 1609C: 2114C: 2114Z: 0.41Z: 0.41S: 126S: 126
8/2/19958/2/1995
21 YEAR21 YEAR
FF
Page: 2 of 2Page: 2 of 2
XR Tibia/Fibula RightXR Tibia/Fibula Right
TIB-FIB LATTIB-FIB LAT
1/3/2017 2:09:22 PM000XR17001450000XR17001450
------
------
------
IM: 1002IM: 1002Compressed 68:1Compressed 68:1
W: 1609W: 1609C: 2114C: 2114Z: 0.41Z: 0.41S: 126S: 126
Case Continued
• ACL reconstruction progression continued
• Resumed WBAT to FWB then RTP basketball progression
• Sat out remainder of year to rehab and work out with
team
• Played full Senior College Basketball season
• No sequelae
NAVICULAR STRESS FRACTURE
• Most common tarsal bone stress fracture
• Central part is under the most stress as the “keystone” of the arch
• Linear fracture line usually occurs in the central avascular 1/3 of the bone & extends from the proximal dorsal pole to the distal plantar pole
• Mostly seen in athletic population
NAVICULAR STRESS FRACTURE
• HISTORY
• Aching pain in the dorsal midfoot that may radiate to the medial
arch & is VAGUE!!!
• “Doc – I must have tweaked my ankle but I do not remember
anything.”
NAVICULAR STRESS FRACTURE
• PHYSICAL EXAM
• Painful hop test on toes
• Pain at the “N” spot – nickel size area between extensor hallucis
longus & anterior tibial tendons on dorsum of foot (present 81% of
time in 1 study by Torg JBJS 1982)
NAVICULAR STRESS FRACTURE
• IMAGING
• XR
• Hard to see vertical fracture line & may need CT (only + 33% of
time in known fractures)
• CT - gold standard to evaluate the extent of the fracture
& evaluate for widening & sclerosis
• MRI – may show edema of stress fracture but should be
followed with CT
• BONE SCAN – may show stress fracture but should be
followed with CT
NAVICULAR STRESS FRACTURE
Bone Scan
NAVICULAR STRESS FRACTURE
9/6/19979/6/1997
20 YEA R20 YEA R
MM
Page: 17 of 20Page: 17 of 20
A Q M: 192\256A Q M: 192\256
TE: 76.78TE: 76.78
TR: 2300TR: 2300
FA : 90FA : 90
RMRM
EC : 1EC : 1
NEX:2NEX:2
Q UA DKNEEQ UA DKNEE
MRI LE Non Joint w/o C ontras t LeftMRI LE Non Joint w/o C ontras t Left
FT LO NG A XIS T2 FSFT LO NG A XIS T2 FS
9/22/2017 5:52:17 PM 9/22/2017 5:52:17 PM
018MR17020174018MR17020174
------
LO C : -16.62 LO C : -16.62
THK: 3 SP : 4THK: 3 SP : 4
FFSFFS
IM: 17 SE: 12IM: 17 SE: 12
C ompressed 15:1C ompressed 15:1
DFO V :22x22cmDFO V :22x22cm
W: 934W: 934
C : 467C : 467
Z: 2Z: 2
RR LL
AA
PP
9/6/19979/6/1997
20 YEA R20 YEA R
MM
Page: 34 of 44Page: 34 of 44
A Q M: 192\192A Q M: 192\192
TE: 64.85TE: 64.85
TR: 3416.66TR: 3416.66
FA : 90FA : 90
IRIR
EC : 1EC : 1
NEX:1NEX:1
Q UA DKNEEQ UA DKNEE
MRI LE Non Joint w/o C ontras t LeftMRI LE Non Joint w/o C ontras t Left
FT SHO RT A XIS IRFT SHO RT A XIS IR
9/22/2017 5:11:34 PM 9/22/2017 5:11:34 PM
018MR17020174018MR17020174
------
LO C : 48.58 LO C : 48.58
THK: 4 SP : 5 .50THK: 4 SP : 5 .50
FFSFFS
IM: 34 SE: 5IM: 34 SE: 5
C ompressed 15:1C ompressed 15:1
DFO V :14x14cmDFO V :14x14cm
W: 1008W: 1008
C : 358C : 358
Z: 2Z: 2
RR LL
HH
FF
9/6/19979/6/1997
20 YEA R20 YEA R
MM
Page: 15 of 26Page: 15 of 26
A Q M: 192\192A Q M: 192\192
TE: 27.34TE: 27.34
TR: 3566.66TR: 3566.66
FA : 90FA : 90
IRIR
EC : 1EC : 1
NEX:1NEX:1
Q UA DKNEEQ UA DKNEE
MRI LE Non Joint w/o C ontras t LeftMRI LE Non Joint w/o C ontras t Left
FT SA G IRFT SA G IR
9/22/2017 5:34:44 PM 9/22/2017 5:34:44 PM
018MR17020174018MR17020174
------
LO C : -44.89 LO C : -44.89
THK: 3 SP : 4THK: 3 SP : 4
FFSFFS
IM: 15 SE: 9IM: 15 SE: 9
C ompressed 14:1C ompressed 14:1
DFO V :22x22cmDFO V :22x22cm
W: 969W: 969
C : 445C : 445
Z: 2Z: 2
AA PP
HH
FF
NON-OEPRATIVE9/6/19979/6/1997
20 YEA R20 YEA R
MM
Page: 58 of 93Page: 58 of 93
A cq no: 1A cq no: 1
KV p: 120KV p: 120
mA : 100mA : 100
------
------
C T Lower Extremity w/o C ontras t LeftC T Lower Extremity w/o C ontras t Left
ReformattedReformatted
9/26/2017 12:06:22 PM
002C T17052740002C T17052740
------
------
THK: 3THK: 3
FFSFFS
IM: 59 SE: 104IM: 59 SE: 104
C ompressed 8:1C ompressed 8:1
DFO V :23.4x23.4cmDFO V :23.4x23.4cm
W: 1847W: 1847
C : 936C : 936
Z: 1Z: 1
RR LL
HAHA
FPFP
9/6/19979/6/1997
20 YEA R20 YEA R
MM
Page: 47 of 70Page: 47 of 70
A cq no: 1A cq no: 1
KV p: 120KV p: 120
mA : 100mA : 100
------
------
C T Lower Extremity w/o C ontras t LeftC T Lower Extremity w/o C ontras t Left
ReformattedReformatted
9/26/2017 12:06:22 PM
002C T17052740002C T17052740
------
------
THK: 3THK: 3
FFSFFS
IM: 48 SE: 105IM: 48 SE: 105
C ompressed 8:1C ompressed 8:1
DFO V :23.4x23.4cmDFO V :23.4x23.4cm
W: 2000W: 2000
C : 350C : 350
Z: 1Z: 1
RR LL
AA
PP
NAVICULAR STRESS FRACTURE
OPERATIVE
NAVICULAR STRESS FRACTURE
NAVICULAR STRESS FRACTURE
NAVICULAR STRESS FRACTURE
• TREATMENT
• If non-sclerotic margins & no widening >1mm on CT – NWB cast X
6 weeks
• If widening > 1mm on CT or marked sclerotic & irregular borders to
fracture – Screw +/- bone graft
• If athlete & quick return to play is an issue – consider screw for all
complete fractures
NAVICULAR STRESS FRACTURE
NAVICULAR STRESS FRACTURE
Achilles Tendinosis
• Tendinopathies• Tendonitis
• Tendinosis
• Tendinitis • Painful overuse tendon conditions
• Inflammation is present
• Tendinosis • Most common pathology in chronic painful tendons
• Occurs after repetitive injuries to a tendon that results in intertendinous scarring, disorganization of tendon fibers & degeneration.
• NO inflammatory component
• Bottom Line• Early on in a tendon injury, there is inflammation resulting in tendinitis, but after
about 6 weeks this generally evolves into tendinosis
• Almekinders LC: Anti-Inflammatory Treatment of Muscular Injuries in Sports. Sports Med. 1993;15(3):139-145.
Normal Tendon
• Type-I collagen bundles
packed tightly along the
tendon axis with sparse
fibroblasts between the
collagen rows
Tendinosis
• Collagen fiber disorientation
occurs with dense
populations of fibroblasts &
scattered vascular
hyperplasia (angiofibroblastic
hyperplasia)
Tendinopathy – Treatment
• Tendonitis
• STOP the inflammation
• NSAIDs (oral or topical)
• Rest
• Early activity modification
• PT
• Treatment may prevent the development of tendinosis
• Usually the first ~6 weeks
Tendinopathy – Treatment
Tendinosis• Healing is facilitated by creating an inflammatory
response
• To create inflammation
• Eccentric strengthening
• Deep soft tissue massage with tools (e.g., gua sha, Graston®, or
ASTYM®)
• Nitroglycerin patches (Nitro-Dur)1
• MSK US percutaneous needle tenotomy(with or without injection of
autologous blood, prolotherapy, or platelet-rich plasma)
1 = Not FDA Approved
ASTYM Tools
Tendinosis Treatment
• +/- NSAIDs
• NSAIDs will prevent an inflammatory response
• Concept of tendinosis diagnosis & treatment can be
utilized for tendons throughout hip & pelvis
• Most commonly applied to the Iliotibial (IT) band, Piriformis,
Gluteus Medius, Iliopsoas & Hamstrings
• Refractory Cases
• Tendon debridement for refractory cases
Achilles Tendinosis Diagnosis
• Best seen on Musculoskeletal Ultrasound (MSK US)
• Can also be seen on MRI
Case
• 32 year old Triathlete with 6 months refractory Left Achilles tendon pain
• No improvement with conservative care• NSAIDs
• Rest
• Activity modification
• Deep soft tissue friction massage
• HEP
• Night sock
• Performed percutaneous needle tenotomy (PNT) with autologous blood injection (ABI) under MSK US with 6 week RTP progression
PRE POST
72
Left Achilles Tendon Right Achilles Tendon
73
Achilles Tendinosis Case
• Patient got back to full activities (Ironman Triathlons) with
no restrictions & no pain
• Limited
• Some small controlled & observational studies of patients with refractory medial & lateral epicondylosis who received MSK ultrasound-guided PNT with ABI reported improvement in symptoms & in MSK U/S appearance of tendons
• Suresh SP, et al. British Journal of Sports Medicine. 2006;40(11):935.
• Connell DA, et al. Skeletal Radiology. 2006;35(6):371.
• Patella & Other Tendons Studies• Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for
the treatment of chronic tendinosis. J Ultrasound Med. 2009;28(9):1187-1192. Reference 13.
• James SL, Ali K, Pocock C, et al. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med. 2007;41(8)518-521.
• Ryan M, Wong A, Rabago D, Lee K, Taunton J. Ultrasound-guided injections of hyperosmolar dextrose for overuse patellar tendinopathy: a pilot study. Br J Sports Med. 2011;45(12):972-977.
• Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper’s knee. Injury. 2009;40(6):598-603.
Studies?
QUESTIONS
THANK YOU
Top Related