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.