Author: Theodore Grask, MD
Co Author #1: Andrew Peterson
Senior Editor: Christian Fulmer, DO, FAMSSM
Editor: Irvin Sulapas, MD

Patient Presentation:
Bilateral lower leg pain for three years.

History:
A 22yo female University ROTC cadet presented to the Sports Medicine clinic with a three-year history of chronic bilateral lower leg pain, left greater than right. Initially, she was treated conservatively for bilateral tibial stress injuries with improvement; however, her symptoms kept recurring.

She has persistent antero-medial leg pain radiating to her calves that is present at rest and acutely exacerbated during activity along with chronic fluctuating swelling that never fully resolves. She also reported neuropathic symptoms including numbness, tingling, peri-incisional sensory changes, and intermittent foot weakness with partial relief from gabapentin. She described the pain as sharp and intermittent, with activity as the only known trigger. She rated her pain 6/10 on average that reaches 8-9/10 at its worst and limited her to walking slowly for three blocks before needing to stop. In addition to walking, she has difficulty sitting for prolonged periods, denied foot ulcers or back pain, and a bone scan was normal. During severe episodes, she used acetaminophen and ibuprofen with minimal relief and has never participated in formal physical therapy.

She underwent evaluation for chronic exertional compartment syndrome (CECS). Although initial compartment pressure testing showed only mild elevations, persistent symptoms prompted repeat testing and ultimately led to bilateral four-compartment fasciotomies. Her postoperative course was complicated by hematoma formation, wound dehiscence, rejection of internal sutures, and delayed closure that required a total of four surgical procedures with no infections documented. Following postoperative improvement, she was released to unrestricted activity.

Physical Exam:
Vital Signs Reviewed and Stable
General: Well-developed, well-appearing, and well-nourished, NAD
HEENT: Normocephalic/Atraumatic, no scleral icterus
CV: Pulse regular
Pulmonary: No increased work of breathing

Bilateral Lower Extremities:
Inspection: No erythema, skin discoloration, swelling noted. Surgical scars present and well healed
Palpation: Tenderness over the middle third of the posterior medial tibia left greater right. No pain anterior tibia. No pain over proximal fibular head. No syndesmotic pain. Pain with compression of the popliteal artery bilaterally. Tenderness to palpation diffusely throughout the gastrocnemius. No Achilles pain, both mid substance and insertional.
Range of Motion (ROM): Full ROM with bilateral knees and ankles. Normal subtalar motion.
Strength: 5/5 with resisted dorsi/plantarflexion and resisted inversion/eversion. 4/5 strength to knee extension and flexion. Fires Flexor Hallucis Longus, Extensor Hallucis Longus, tibialis anterior, gastroc-soleus, peroneals.
Neuro: Reporting decreased sensation in Superficial Peroneal Nerve and Saphenous distributions. She reports pain on assessment of sural distribution. Dorsalis pedis and posterior tibial pulses 2+. Thompson test negative. Fulcrum test negative

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