Leg and Calf Region Flashcards

Functional Anatomy of the Leg and Calf

  • Region between the knee and the ankle.

Muscles of the Leg and Calf

  • Deep Posterior Compartment:
    • Popliteus
    • Tibialis posterior
    • Flexor digitorum longus
    • Flexor hallucis longus
  • Superficial Posterior Compartment:
    • Soleus
    • Gastrocnemius
    • Plantaris
  • Anterior Compartment:
    • Tibialis anterior
    • Extensor digitorum longus
    • Extensor hallucis longus
    • Fibularis tertius
  • Lateral Compartment:
    • Peroneus longus
    • Peroneus brevis

Outcome Measures for Leg and Calf Pain

  • Very few patient-reported outcome measures exist.
  • Medial Tibial Stress Syndrome Score:
    • This PROM could also be used for stress fractures.
  • No PROMs for compartment syndrome.

Causes of Leg Pain

  • Stress fracture:
    • Medial tibia
    • Anterior tibia
    • Fibular
  • Tumours:
    • Osteosarcoma
    • Osteoid osteoma
  • Acute fracture
  • Referred pain from spine
  • Infection (osteomyelitis, cellulitis)
  • Medial tibial stress syndrome
  • Chronic compartment syndrome:
    • Superficial posterior
  • Chronic ankle injuries and Maisonneuve fracture
  • Periosteal contusion
  • Vascular insufficiency/claudication
  • Acute compartment syndrome
  • Chronic (exertional) compartment syndrome:
    • Anterior
    • Lateral (peroneal)
    • Deep posterior
  • DVT
  • Chronic transition to acute compartment syndrome
  • Popliteal artery entrapment
  • Syphilis
  • Femoral endarteritis
  • Sickle cell anaemia
  • Atherosclerotic disease
  • Sarcoidosis
  • Superficial peroneal nerve entrapment
  • Rickets
  • Muscle herniations
  • Paget’s disease
  • Baker’s cyst or ganglion cysts
  • Erythema nodosum

Tibial Stress Fracture

  • Prevalence (medial and anterior):
    • Posteromedial stress fracture is more common than anterior.
    • Commonly caused by high impact sports - running/jumping sports (e.g. runners, soldiers, dancers).
    • 4.9% - 19% prevalence in US military trainees
    • Up to 58% of all lower limb stress fractures in military recruits.
    • High recurrence rate in military recruits (up to 36%).
    • Can progress to full fracture.
    • Incidence increases with:
      • Increased training loads (e.g. double days)
      • More rigid and unforgiving surfaces
      • Amenorrhea (≥6 missed cycles in 12 consecutive months)
  • Signs and Symptoms
    • Gradual pain, typically aggravated by exercise/physical activity
    • Often with an associated increase in training or changed playing surface
    • Pain may occur with:
      • Walking
      • At rest
      • At night
    • Local tenderness over the tibia
  • Diagnosis
    • Palpation over medial border of tibia – posteromedial may present as calf pain
    • Applying tuning fork vibration over site of tenderness
    • Foot assessment
      • Potential rigid pes cavus (supinated) foot – reduced load absorption
      • Potential excessively pes planus (pronated) foot – muscle fatigue
      • Potential leg length discrepancy
    • Bone scan/MRI- MRI preferred as extend of oedema and cortical involvement correlated with RTS
    • Assess footwear and biomechanical analysis on treadmill (video record to help pt understand)
  • Treatment
    • Alter running technique to reduce tibial stress:
      • Shorter stride length
      • Slower running speeds
      • Reduced millage
    • Initial period of rest (sometimes NWB with crutches) until no TOP
    • If pain persists – continue rest (4-8 weeks)
    • Once pain-free and no TOP – gradual return to activity
      • Increase quality and quantity (i.e. load) over 4 – 8 weeks
    • Cross-training with low impact (e.g. swimming, cycling, water running)
    • Pain with soft tissue can be treated
    • Treat biomechanical deficits observed (e.g. foot pronation – orthotics)
    • Pneumatic brace – more rapid RTS in athletes
  • Anterior Tibial Stress Fracture: Treatment
    • Immediate use of a pneumatic brace
    • Discontinue anti-inflammatory medications and smoking
    • Thorough screening for associated nutritional and biomechanical risk factors
    • For elite-level athletes use of electrical or ultrasonic bone stimulation
    • If no progress by 4-6 months – surgery required
    • Intramedullary rodding (+/-) bone grafting, debridement and drilling is recommended
    • Anterior tibial stress fracture prone to delayed/non union due to poor vascular supply and increase bowing under tension.

Tibial Fracture

  • Fracture of the tibia (primary weigh bearing bone) or fibula
  • Excessive forces – typically a MVA or sporting injury/fall
  • Signs and Symptoms
    • Pain ++
    • Swelling ++
    • +/- Deformity
    • Inability to WB (Tibia)
    • Known MOI
    • +/- open wound
  • Diagnosis
    • POP ++
    • Pain with compression or WB
    • Imaging for confirmation – plain radiography (x-ray)
  • Acute Fracture: Treatment
    • Refer to for imaging/ED if in private practice (depending on injury)
    • Conservative (less severe fracture – non-displaced)
      • Immobilisation – brace/splint can allow for swelling (~12 weeks lower limb)
      • Pain relief
      • ? Period of NWB or WB to initiate bone growth (depending on severity)
      • Rehabilitation – Maintain other muscles, ROM, isometric, isotonic etc
    • Surgical intervention
      • ORIF – intermedullary nailing / plates and screws
      • OREF
      • Post surgical rehabilitation

Medial Tibial Stress Syndrome

  • Previously known as “shin splints” thought to be a traction injury of the soleus/flexor digitorum longus muscle on the posteromedial border of the tibia
  • Typically seen in individuals with excessive pronation whereby soleus supports the foot during gait – leading to traction injury of the tibia
  • 4 – 35% prevalence in runners, dancers, and military personnel
  • Risk factors:
    • Excessive pronation of the foot
    • Training errors
    • Shoe design
    • Surface type
    • Muscle dysfunction
    • Muscle fatigue
    • Decreased flexibility
    • Female sex
    • Higher BMI
    • History of MTSS or stress fracture
  • Signs and symptoms
    • Diffuse pain along medial border of tibia, typically decreases with warm up
    • Focal pain ?? Stress fracture
    • TOP – medial border of tibia
    • Often can complete training session/physical activity but pain recurs after exercise and worse the following morning
  • Diagnosis
    • Palpation over medial border of tibia
    • Foot assessment
      • Potential excessively pes planus (pronated) foot – muscle fatigue
      • Potential leg length discrepancy
    • X-ray typically negative
    • Isotopic bone/MRI scan may show some patchy areas along the medial border but in contrast to stress fracture which is focal uptake
    • Assess footwear and biomechanical analysis on treadmill (video record)
  • Treatment
    • Rest, ice, analgesics as required
    • Activity modification – switching to non-impact activities (e.g. swimming, cycling)
    • Resistant cases may require immobilisation and protected WB (e.g. bracing)
    • Taping techniques to control pronation (e.g. low dye taping)
    • Appropriate footwear and shock absorbing orthotics (medial arch support)
    • Pneumatic brace
    • Soft tissue techniques (e.g. digital ischaemic pressure) of soleus and/or other key muscles +/- passive/active dorsiflexion/plantarflexion
    • Muscle strengthening as a progression
    • Flexibility/stretching of relevant muscles
    • Electrotherapeutic agents – Iontophoresis, e-stim, ultrasound – poor evidence
    • PRP injections – little evidence
    • Surgical release

Periosteal Contusion

  • AKA - Bone bruise of the tibia – Swelling under the periosteum
  • caused by direct force to the bone
  • Sports – Soccer, rugby, AFL etc – Home accidents (tow ball)
  • Relatively common due to the superficial nature of the bone
  • Signs and Symptoms
    • Pain ++
    • Swelling ++
    • Bump forms on the shin bone
    • Known MOI - trauma
  • Diagnosis
    • POP ++
    • Pain with compression or WB
    • Potential weakness/pain during movement
    • Deformity (e.g. bump)
  • Treatment
    • Acute management – POLICE – avoid HARM
    • Following the inflammatory period
      • STT – anterior, lateral, and posterior compartments
      • Hydrotherapy – aqua walking/swimming
      • Physical activity – walking
      • Ensure ROM
      • Ensure strength (isometric  isotonic)
      • Gradual RTS

Chronic Exertional Compartment Syndrome

  • What is CECS?
    • “an increased pressure within a closed fibro- osseous space causing reduced blood flow and reduced tissue perfusion subsequently leading to ischaemic pain and possible permanent damage to the tissues of the compartment.”
  • Pathogenesis
    • Overuse  inflammation and fibrosis of the fascia surrounding the muscle compartments
    • Subsequent exercise = muscles unable to expand  increase pressure and ischemia of the compartment
    •  Ischaemic pain and possible tissue damage
    • Prevalence estimated at 7.6% of the general population
  • Compartment Syndrome: Signs and Symptoms
    • Anterior compartment (most common)
      • Anterolateral leg pain with exertion
    • Lateral compartment
      • Lateral leg pain with exertion
      • Paraesthesia along the superficial peroneal nerve (dorsum of the foot)
    • Deep posterior compartment
      • Posteromedial tibial pain with exertion
    • Superficial posterior compartment (rare)
      • Posterior calf pain with exertion
    • Compartment Syndrome: Diagnosis
      • Clinical Diagnosis = 5 P’s
        • Pain out of proportion with exertion
        • Paraesthesia
        • Pallor
        • Paresis
        • Pulse deficit
      • Gold Standard = Compartment pressure testing using the Stryker device
        • >25mmHg post exercise = CECS
      • MRI can be used but expensive and unclear
    • Differential diagnoses
      • Tibial stress fracture
      • Medial tibial stress syndrome
      • DVT
      • Vascular or neural entrapment
    • Compartment Syndrome: Treatment
      • Conservative management first
        • Address potential contributing factors – running biomechanics, footwear, training loads
        • STT – deep massage, sustained muscle tension +/- active and passive movements
        • Dry needling
        • Limited evidence for Botox injection
      • Surgical intervention
        • Fasciotomy
        • Not always successful
        • Post surgical rehab – POLICE, ROM, 3-5 days of limited WB  WBAT, following wound healing – non-impact strengthening (cycling, swimming), return to jogging (4-6 weeks post op), RTS participation 6-8 weeks post op, no pain and 90% strength prior to full RTS.

Causes of Calf Pain

  • Muscle strains
    • Gastrocnemius
    • Soleus
    • Plantaris
  • Referred pain
    • Lumbar spine
    • Myofascial structures
    • Superior tibiofibular joint
    • Knee (Baker’s cyst, PCL Posterior capsular sprain)
  • Deep venous thrombosis (DVT)
  • Muscle contusion
  • Superficial posterior compartment syndrome
  • Muscle cramp
  • Deep posterior compartment syndrome
  • Delayed onset muscle soreness
  • Vascular entrapment
    • Popliteal artery
    • Endofibrosis of the external iliac artery
  • Nerve entrapment
    • Tibial nerve
    • Sural nerve
  • Stress fracture of the fibular
  • Stress fracture of the posterior cortex of the tibia
  • Varicose veins (e.g. superficial thrombosis)

Deep Vein Thrombosis

  • A blood clot (thrombosis) that occurs in the venous system, typically due to a lack of movement either post injury or due to environmental circumstances (e.g. long- haul flight)
  • Signs and Symptoms
    • Pain (throbbing or cramping type)
    • Swelling of the calf or leg
    • Warm skin and red/darkened around the area
    • POP to the lower limb
  • Diagnosis
    • Wells’ Clinical prediction rule
      • One study shows a score <1 able to rule out DVT with 100% sensitivity
      • Score ≥2 able to confirm DVT with 90% specificity in trauma patients
    • Homan’s test – poor diagnostic utility
    • POP
  • Treatment
    • Anticoagulation medication
    • Thrombolysis – dissolve the clot (large DVT)
    • Inferior vena cava filter – when anticoagulation medication is contraindicated
    • Compression stockings

Muscle Strains: Gastrocnemius

  • Rapid acceleration from standing by extending the knee with a dorsiflexed ankle
  • Common in sports requiring acceleration (e.g. tennis, squash)
  • Medial head is more commonly injured
  • Grade I - stretch injury
  • Grade II - partial tear
  • Grade III - complete rupture
  • Signs and symptoms
    • TOP at site of strain
    • Palpable defect if large tear
    • Antalgic gait (i.e. limp)
    • Bruising, discolouration, swelling
    • Limited and painful ROM
  • Diagnosis
    • Localised POP +/- palpable defect
    • Painful AROM and PROM dorsiflexion (end range)
    • Painful AROM and MMT plantarflexion
    • Measure calf girth for swelling
    • Functional - bilateral heal raise, hop, lunge (if not in acute phase)
    • Complete rupture – limited plantarflexion but still possible
  • Treatment
    • Stage 1 Acute Phase
      • POLICE, analgesics, 6mm heal raise, ? crutches if required
    • Stage 2 Improve ROM +/- flexibility
      • Gentle stretching, swimming, unloaded isometric contractions
    • Stage 3 Power and Endurance
      • Progressive strengthening of both gastroc and soleus, STT, cardio
    • Stage 4 Coordination, agility, sport skills
      • Sport specific training, motor control, agility exercises
    • Stage 5 RTS
      • Simulated game play, coach involvement

Vascular Conditions – Claudicant-type pain

  • Popliteal artery entrapment
    • Presents similarly to posterior compartment syndrome
    • Two categories with 7 types: anatomical and functional (acquired)
    • Signs and Symptoms
      • Claudicant-type pain calf or anterior leg
      • Bought on by exercise
      • Severity typically related to intensity of exercise
    • Diagnosis
      • Examination post exercise preferred
      • Diminished pulse may be unreliable at rest
      • Diminished pulse during active PF or passive DF following exercise (Popliteal Bruit)
      • Ultrasound (Doppler) – inexpensive and real-time
      • MRI or MR angiography
    • Surgical intervention with severe conditions
  • Atherosclerotic vessel disease
    • Atherosclerosis is the deposition of fatty material in the arteries
    • Middle aged sedentary patients with claudicant-type pain
    • Increased symptoms with exercise
    • Progression of disease results in less time to symptoms
    • Diagnosis
      • Thigh or calf pain depending on location
      • Examination post exercise preferred
      • Diminished or absent pulse (depending on severity)
      • Bruit may be heard at rest
      • Ultrasound (Doppler) – inexpensive and real-time
      • MRI or MR angiography
    • Surgical intervention – balloon or stent, or bypass surgery
  • Endofibrotic disease
    • Thickening of the endothelium of the artery
    • Endurance athletes (typically cycling likely due to position)
    • Diagnosis
      • Calf pain but more common resulting in thigh pain
      • Examination post exercise preferred
      • Bruit may be heard at rest over femoral artery with hip in flexion
      • Diminished or absent distal pulse (depending on severity)
      • Ultrasound (Doppler) – inexpensive and real-time
      • MRI or MR angiography
    • Surgical intervention – balloon or stent, or bypass surgery

Neural Entrapment

  • Tibial nerve
    • Posterior knee – tibial nerve entrapment secondary to a Baker’s cyst (rare)
    • Baker’s cyst increases compression on the tibial nerve leading to entrapment
    • Diagnosis
      • Baker’s cyst – palpation/imaging
      • Paraesthesia – into the foot
      • Weakness and atrophy of: plantaris, popliteus, tib post, flex digit longus, flex hallucis longus
      • Nerve conduction tests +/- MRI or ultrasound imaging
    • Treatment of Baker’s cyst – aspiration, CSI, anti-inflammatory medications, surgical intervention… should reduce compression entrapment
  • Sural nerve
    • Compression at the sural aponeurosis where the nerve passes through
    • Increased training  increase calf muscle mass resulting in entrapment
    • Entrapment may result from compression (e.g. casts, ski boots)
    • Diagnosis
      • Baker’s cyst – palpation/imaging
      • Paraesthesia – lateral lower leg and ankle and lateral foot
      • Nerve conduction tests +/- MRI or ultrasound imaging
    • Conservative treatment: neural stretches (sliders and gliders MSK3), fascial massage, CSI, and surgical intervention.